Spinal Trauma PDF

SPINAL TRAUMA Neurosurgery department Tanta faculty of Medicine Contact email: [email protected] Tanta Univ. – Neurosurgery Dep. 2020 Anatomy of the Vertebral Column 7 cervical, 12 thoracic, 5 lumbar vertebrae 4-5...

SPINAL TRAUMA Neurosurgery department Tanta faculty of Medicine Contact email: [email protected] Tanta Univ. – Neurosurgery Dep. 2020 Anatomy of the Vertebral Column 7 cervical, 12 thoracic, 5 lumbar vertebrae 4-5 fused sacral vertebrae 3-5 fused coxygeal vertebrae Cervical Vertebrae Ring of C1 Transverse Foramen Dens (odontoid) of C2 Body of C2 C1-2 Complex Tanta Univ. – Neurosurgery Dep. 2020 Cervical Vertebrae Body Transverse foramen Facet Pedicle Vertebral foramen Lamina Spinous process Thoracic Spine Body Pedicle Facet Transverse Process Spinous Process Attatched to a pair of ribs Lumbar Vertebrae Body Pedicle Transverse process Articulating process Spinous process Intervertebral disc Intervertebral Disc The disc structure is composed of an outer annular fibrosus, a constraining ring primarily composed of collagen The nucleus pulposus consists of proteoglycan and, specifically, hyaluronic long chains, which have an affinity for water molecules and thus hydrate the nucleus Dura of the Spine  Arteries of the Spinal Cord An anterior spinal artery supplies the anterior two-thirds of the cord Two posterior spinal arteries supply the posterior one-third Spinal arteries and radicular arteries form the arterial vasocorona around the cord Artery of Adamkiewicz, provides the blood supply to the inferior two-thirds of the spinal cord Tanta Univ. – Neurosurgery Dep. 2020 Spinous Ligaments Help to provide structural stability. Intrasegmental and intersegmental systems. The intrasegmental system holds individual vertebrae together. The intersegmental system holds many vertebrae together.  Boney and Ligamentous Injury Stability 3 Column Theory Canal Stenosis Cord and nerve root compression 3 Columns of Stability When describing and diagnosing spinal fractures, divide the spinal column into 3 sections: 1. Anterior column :- made up of the anterior longitudinal ligament and the anterior one- half of the vertebral body, disc, and annulus. 3 Columns of Stability 2. Middle column :- made up of the posterior one-half of the vertebral body, disc, and annulus, and the posterior longitudinal ligament. 3. Posterior column :- made up of the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments Stable and Unstable Fractures Generally, a fracture is considered stable if only the anterior column is involved When the anterior and middle columns are involved, the fracture may be considered more unstable. When all three columns are involved, the fracture is by definition considered unstable Tanta Univ. – Neurosurgery Dep. 2020 Mechanism of Injury Compression Flexion and Extension Rotational Injuries Penetrating Injuries Compression Injury Cased by fall to the head and buttocks Increases axial loading Characterized by vertebral body flattening, endplate fractures, retropulsion of boney/disc fragments into the canal with cord compression Injuries occur at the craniocervical , cervicothoracic and thoracolumbar junctions Tanta Univ. – Neurosurgery Dep. 2020 Burst Fracture Downward compressive causes the vertebra to shatter outward Unstable if > 50% compression, >50% canal stenosis, and 30% of angulation Flexion Injury Simple wedge compression fracture without posterior disruption Flexion teardrop fracture Anterior subluxation Bilateral facet dislocation Anterior atlantoaxial dislocation Tanta Univ. – Neurosurgery Dep. 2020  Simple Wedge Fracture With a flexion injury, the l05a anterior vertebral body bears most of the force, sustaining simple wedge compression anteriorly Radiographically, the anterior border of the vertebral body has diminished height and increased concavity The posterior column remains intact, making this a stable fracture  Flexion Teardrop Fracture Flexion of the spine causes a fracture of the anteroinferior vertebral body. This fragment is displaced anteriorly Significant anterior and posterior ligamentous disruption occurs. This injury involves disruption of all 3 columns, making this an extremely unstable fracture  Anterior subluxation Occurs when posterior ligamentous complexes rupture. The anterior longitudinal ligament remains intact. The lateral view shows widening of interspinous processes, and anterior and posterior contour lines are disrupted Considered mechanically stable in extension but potentially unstable in flexion  Extension Injury Hangman fracture Bilateral fractures through the pedicles of C2 due to hyperextension Although considered an unstable fracture, it seldom is associated with spinal injury, since the anteroposterior diameter of the spinal canal is greatest at this level, and the fractured pedicles allow decompression. Odontoid Process Fractures The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture occurs Type I odontoid fracture is an avulsion of the tip of the dens at the insertion site of the alar ligament. Type I fracture is mechanically stable Type II fractures Occur at the base of the dens and are the most common odontoid fractures. This type is associated with a high prevalence of nonunion because of the limited vascular supply and a small area of cancellous bone. Type III Odontoid Fracture Occurs when the fracture line extends into the body of the axis. With types II and III fractures, the fractured segment may be displaced making the prevalence of spinal cord injury is as high as 10% Ligamentous Injury Patients with neck or back pain may be without boney injury, yet remain unstable due to ligamentous disruption Flexion-extension Films and MRI help delineate this pathology Spinal Cord Injury (SCI) Tanta Univ. – Neurosurgery Dep. 2020  The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale using the following categories: Complete: No sensory or motor function is preserved. Incomplete: Some function is preserved below the level of injury Tanta Univ. – Neurosurgery Dep. 2020 Pathophysiology Acute spinal cord injury is usually caused by an initial impact with or without ongoing compression Pathophysiology Pathological changes in the appearance of the lesion during the first few days. This evolution is explained by primary and secondary mechanisms.  Primary Injury Refers to the 20040510-neckhematoma mechanical disruption of axons by the initial mechanical injury. Usually a compressive lesion although lacerations occur with open penetrating injuries or with stretch type of injuries. Secondary Injury A cascade of events initiated by the trauma which damages axons secondarily when otherwise they should have survived. Decreased spinal cord blood flow. Vasoactive substances (prostaglandins, phospholipases, lipid peroxidation). Neurotoxic substances. Tanta Univ. – Neurosurgery Dep. 2020 Secondary Injury After a few hours, petechial hemorrhages due to diapedesis of blood cells from capillaries and venules. Occurs in the central region which is the grey matter and the immediately adjacent white matter. Tanta Univ. – Neurosurgery Dep. 2020 Complete Injury Complete loss of motor and sensory function below the level of injury Types of Incomplete Lesions Anterior cord syndrome Loss of motor, pain and temperature Preserved propioception and deep touch Brown-Sequard syndrome Loss of ipsilateral motor and propioception Loss of contralateral pain and temperature Central cord syndrome Weakness : upper > lower Variable sensory loss Sacral sparing Conus medullaris syndrome Conus medullaris syndrome is associated with injury to the conus and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while the sacral segments occasionally may show preserved reflexes (eg, bulbocavernosus and micturition reflexes). Tanta Univ. – Neurosurgery Dep. 2020 Cauda equina syndrome Click to see larger picture Cauda equina syndrome is due to injury to the lumbosacral nerve roots in the spinal canal leading to areflexic bladder, bowel, and lower limbs. SCI Management In the Field Immobilization C-Collar Back Board Maintain BP Pressors IVF Oxygenation Intubate vs O2 Tanta Univ. – Neurosurgery Dep. 2020 Tanta Univ. – Neurosurgery Dep. 2020 ER Management Goal: Preserve Function ABCs No extension with intubation (fiber optic) Keep MAP > 80 (vasopressors) CVP >8 (5% albumin-250 cc Q 6 hrs) Tanta Univ. – Neurosurgery Dep. 2020 Management Resuscitation Fluids Atropine F/C, NG, CVC Body temperature Examination Muscle strengths are graded 5 - Normal power 4+ - Submaximal movement against resistance 4 - Moderate movement against resistance 4- - Slight movement against resistance 3 - Movement against gravity but not against resistance 2 - Movement with gravity eliminated 1 - Flicker of movement 0 - No movement Tanta Univ. – Neurosurgery Dep. 2020 Tanta Univ. – Neurosurgery Dep. 2020 Sensory Exam Dermatomal Chart Use pin-prick Position sense Vibratory sense Tanta Univ. – Neurosurgery Dep. 2020 Sensory testing at the following C6 - Thumb T4 - 4th IS at nipple line T10 - 10th IS or umbilicus L5 - Dorsum of the foot at third metatarsophalangeal joint Tanta Univ. – Neurosurgery Dep. 2020 Spinal shock Transient reflex depression of cord function below the level of injury with associated loss of all sensorimotor functions. An initial increase in blood pressure is noted due to the release of catecholamines, followed by hypotension. Flaccid paralysis, including of the bowel and bladder, is observed, and sometimes sustained priapism develops. These symptoms tend to last several hours to days until the reflex arcs below the level of the injury begin to function again Tanta Univ. – Neurosurgery Dep. 2020 Neurogenic shock Manifested by the triad of hypotension, bradycardia, and hypothermia. Occurs secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone, leading to decrease in vascular resistance with associated vascular dilatation. Differentiated from hypovolemic shock. By absence of tachycardia. Tanta Univ. – Neurosurgery Dep. 2020 Imaging AP/Lat and odontoid x-rays with swimmer’s views Must visualize C7-T1 junction CT if abnormal or pain MRI or CT myelogram if neuro deficit without boney abnormality Flex/Ex for pain with negative imaging Repeat for thoracic or lumbar spine if exam indicates or comatose patient with likely mechanism Tanta Univ. – Neurosurgery Dep. 2020 Tanta Univ. – Neurosurgery Dep. 2020 Pharmaceutical Management Solumedrol – High dose steroid Only effective if given within 3 hrs of injury 30mg/kg bolus followed by 5.4 mg/kg/hr for 24 hours H2 blocker for gastric ulcer risk Accucheck Q 6 hrs Likely to lose “standard of care” status Tanta Univ. – Neurosurgery Dep. 2020 Surgical Management Decompression vs Stabilization Timing Urgent Surgery Incomplete injury secondary to mass effect Progressive neuro deficits with persistant neurocompression Less Urgent Reduced dislocations Complete injuries with unstable fractures Tanta Univ. – Neurosurgery Dep. 2020  Unstable Fractures are fused with pedicle screws Burst fractures are reduced and fused after vertebrectomy Non-Operative Stabilization Reduction Gardener-Wells Tongs Fixation Halo Aspen collar Acute Care Nutrition. Physical and occupational therapy. Emotional support. Acute Care Choice of bed to facilitate nursing care and physiotherapy. Many centers use kinetic therapy beds (Rotabed, Rotarest). Pulmonary care. Adequate hydration, incentive spirometry, avoid aspiration, close monitoring, O2 sat monitoring early on. Bowel routine, antacids and H2 blockers. Tanta Univ. – Neurosurgery Dep. 2020 Acute Care Urinary system. Initially a foley, later replaced by intermittent catheterization. Keep bladder volume