L9: Spinal Trauma Flashcards
(165 cards)
1
Q
Anatomy of Vertebral Column
A
2
Q
Anatomy of Vertebral Column
- Lordosis in ….
A
- Cervical & Lumbar
3
Q
Anatomy of Vertebral Column
- Kyphosis in ……..
A
Thoracic & Sacral
4
Q
Cervical Vertebra
- Characters
A
- Vertebral bodies (lesser weight bearing).
- Extensive joint surfaces allow greater Range of Movement “ROM”
5
Q
Cervical Vertebra
- Movements allowed
A
- Rotation
- Flexion
- Extension
6
Q
Thoracic Vertebra
- Characters
A
- Rib bearing vertebrae.
- Designed to remain stiff
7
Q
Thoracic Vertebra
- Movements allowed
A
- Minimal Flexion & Extension
8
Q
Lumbar Vertebra
- Characters
A
- Weight-bearing vertebrae
- Houses cauda equine
9
Q
Lumbar Vertebra
- Movements allowed
A
Minimal Rotation
10
Q
Sacral Vertebra
- Characters
A
Transmits weight of body to the pelvis
11
Q
Sacral Vertebra
- Movements Allowed
A
No Motion
12
Q
Spinal nerve roots Exit through the intervertebral foramen …….
- C1- C7
A
Above
13
Q
Spinal nerve roots Exit through the intervertebral foramen …….
- C8 - S5
A
Below
14
Q
Spinal cord ends below lower border of …..
A
L1.
15
Q
What is cauda equina formed of?
A
- Formed by lumbosacral nerve root in the spinal canal before exiting.
- Cauda equina is below L1.
16
Q
Level of Cauda Equina
A
17
Q
if the vertebra level is ……, Then the cord Level is ……
A
18
Q
if the vertebra level is C2 - C7, Then the cord Level is ……
A
Add 1+
19
Q
if the vertebra level is T1 - T6 , Then the cord Level is ……
A
Add 2+
20
Q
if the vertebra level is T7 - T9, Then the cord Level is ……
A
Add 3+
21
Q
if the vertebra level is T 10, Then the cord Level is ……
A
L1, L2
22
Q
if the vertebra level is T11, Then the cord Level is ……
A
L3, L4
23
Q
if the vertebra level is T12, Then the cord Level is ……
A
L5
24
Q
if the vertebra level is L1, Then the cord Level is ……
A
Sacrococcygeal Segments
25
Spinal Cord Nucleui
Spinal nerve cells: ventral (motor), dorsal (sensory):
- Sensory cells in dorsal horn.
- Motor cells in Ventral horn.
26
Mid Dorsal Spinal Cord & Neural Canal Space
Complete Lesion
27
Neurlogical Recovery in cauda equina
Unpredictable
28
Denis Column Model
29
Denis Column Model
- Anterior Column
1. Anterior longitudinal ligament.
2. Anterior annular ligament.
3. Anterior half of VB.
30
Denis Column Model
- Middle Column
1. Posterior long. Lig.
2. Posterior annular ligament.
3. Posterior half of VB.
31
Denis Column Model
- Posterior Column
1. Ligamentum flavum.
2. Superior & Interspinous lig.
3. Intertransverse capsular lig.
4. Neural arch.
5. Pedicle & spinous process.
32
What is an **Unstable Fracture**?
Middle column
+
either anterior or Posterior column is damaged.
33
Rupture of interspinous ligament
- Characters
- Associated with avulsion of spinous process.
- Unstable spin
- Further flexion → increase neurological injury
34
Mechanisms (Causes) of Spinal Trauma
- Direct Injury
- Indirect Injury
35
Mechanisms (Causes) of Spinal Trauma
- Direct Injury
- Penetrating injuries to the spine: e.g., firearms and knives.
36
Mechanisms (Causes) of Spinal Trauma
- Indirect Injury
37
- Most common cause of significant spinal damage.
Indirect njury
38
- Most important spinal cord injury indicator is the ......
Mechanism
39
When to suspect Spinal Injury?
40
Sites of spinal cord injury
41
Injuries of the vertebral column tend to cluster in .......
42
Neurological level is at ......
lowest segment with normal motor & sensory function.
43
Why is level of spinal injury level hard to determine?
1. Muscles receive motor nerve supply from more than one level.
2. Dermatomes have imprecise boundaries.
44
Dx of **Spinal Injury**
- Clinically
- Radiologically
45
Dx of **Spinal Injury**
- Clinically
46
Dx of **Spinal Injury**
- Inspection & Palpation
**Occiput to Coccyx**
A. Tenderness.
B. Gap or Step.
C. Edema and bruising.
D. Spasm of associated muscles.
47
Dx of **Spinal Injury**
- Neurological Assessment
A. Sensation.
B. Motor function.
C. Reflexes.
D. Rectal examination.
48
**Sensory Assessment in Spinal Trauma**
- C5
49
**Sensory Assessment in Spinal Trauma**
- C6
50
**Sensory Assessment in Spinal Trauma**
- C7
51
**Sensory Assessment in Spinal Trauma**
- C8
52
**Sensory Assessment in Spinal Trauma**
- T1
53
**Sensory Assessment in Spinal Trauma**
- T3
54
**Sensory Assessment in Spinal Trauma**
- T4
55
**Sensory Assessment in Spinal Trauma**
- T8
56
**Sensory Assessment in Spinal Trauma**
- T10
57
**Sensory Assessment in Spinal Trauma**
- T12
58
**Sensory Assessment in Spinal Trauma**
- L2
59
**Sensory Assessment in Spinal Trauma**
- L3
60
**Sensory Assessment in Spinal Trauma**
- L4
60
**Sensory Assessment in Spinal Trauma**
- L5
61
**Sensory Assessment in Spinal Trauma**
- S1
62
**Sensory Assessment in Spinal Trauma**
- S2
63
**Sensory Assessment in Spinal Trauma**
- S3
64
**Sensory Assessment in Spinal Trauma**
- Grading
65
**Motor Assessment in Spinal Trauma**
66
**Motor Assessment in Spinal Trauma**
- C5
Deltoids / biceps
67
**Motor Assessment in Spinal Trauma**
- C6
Wrist extensors
68
**Motor Assessment in Spinal Trauma**
- C7
Elbow extensors
68
**Motor Assessment in Spinal Trauma**
- C8
Finger flexors
68
**Motor Assessment in Spinal Trauma**
- T1
Finger Abductors
68
**Motor Assessment in Spinal Trauma**
- L2
Hip flexors
69
**Motor Assessment in Spinal Trauma**
- L3
Knee extensors
70
**Motor Assessment in Spinal Trauma**
- L4
- Knee extensors
71
**Motor Assessment in Spinal Trauma**
- L5
- Ankle Dorsiflexion
- Long toe extensors
72
**Motor Assessment in Spinal Trauma**
- S1
- Ankle Plantar Reflex
- Long Toe Plantar Reflex
73
**Motor Assessment in Spinal Trauma**
- Grading
74
**Rectal Assessment in Spinal Trauma**
75
**Rectal Assessment in Spinal Trauma**
- Tone
the presence of rectal tone in itself does not indicate an incomplete injury.
76
**Rectal Assessment in Spinal Trauma**
- sensation
....
77
**Rectal Assessment in Spinal Trauma**
- Bulbocavernous Reflex
78
Stimulus for **Bulbocavernous Reflex**
- Squeezing the glans penis or clitoris.
- Tugging on an indwelling Foley catheter
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Center of **Bulbocavernous Reflex**
S2 - S4
80
Response of **Bulbocavernous Reflex**
Anal Sphincter Contraction
81
Significance of Present **Bulbocavernous Reflex**
82
Significance of Absent **Bulbocavernous Reflex**
83
**Sacral Sparing** in complete Spinal Cord Injury
- Right or Wrong?
Wrong, Absence of sensory and motor functions in the lowest sacral segments.
84
**How to Evaluate Sacral Sparing**?
85
**Sacral Sparing** in Incomplete Spinal Cord Injury
- Right or Wrong?
- Preservation of sensory or motor function below the level of injury, including the lowest sacral segments
86
Sacral sparing may include the triad of
1. Perianal sensation.
2. Rectal tone.
3. Great toe flexion.
87
Recoveryt of **Spinal Shock**
Lasts even days till reflex neural arcs below the level recovers.
87
CP of **Spinal Shock**
1. Loss anal tone, reflexes, autonomic control within 24-72 hr.
2. Flaccid paralysis bladder & bowel.
3. Priapism.
4. Lasts even days till reflex neural arcs below the level recovers.
87
Def of **Spinal Shock**
- Loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes.
- Transient physiological reflex depression of cord function
'concussion of spinal cord'.
88
**Neurogenic Shock** Causes ......
Hemodynamic instability.
89
**Neurogenic Shock**
- Etiology
- Rostral cord injuries related to the loss of sympathetic tone to the peripheral vasculature and heart.
- Lesions above D6 → Disruption of sympathetic outflow from D1-L2 → Unopposed vagal tone → Peripheral vasodilatation.
90
**Neurogenic Shock**
- CP
- Bradycardia
- Hypotension
- Hypothermia
91
Every patient with:
- blunt injury above the clavicle.
- head injury.
- Loss of consciousness.
Should be considered to have a cervical spine injury until proven otherwise.
92
Every patient who is involved in:
- a fall from a height.
- a high-speed deceleration accident.
Should similarly be considered to have a thoracolumbar injury.
93
All patients with multiple injuries ......
- Consider the presence of a vertebral column injury.
94
Lesser injuries if they are followed by:
- Pain in the neck or back.
- Neurological symptoms in the limb.
Arouse Suspicion
95
Degrees of **Spinal Trauma**
- Complete
- Incomplete
96
Degrees of **Spinal Trauma**
- Complete
- Flaccid paralysis
- total loss of sensory & motor functions.
97
Degrees of **Spinal Trauma**
- Incomplete
Incomplete - Mixed loss:
1. Anterior cord syndrome.
2. Posterior cord syndrome.
3. Central cord syndrome.
4. Brown Sequard's syndrome.
5. Cauda equina syndrome.
98
Etiology of **Anterior Cord Syndrome**
- Flexion rotational force to spine.
- Due to Compression fracture of vertebral body or anterior dislocation.
- Anterior spinal artery compression.
99
CP of **Anterior Cord Syndrome**
- Loss of power
- reduced pain and temperature below the lesion.
100
Etiology of **Posterior Cord Syndrome**
1. Hyperextension injuries.
2. Posterior vertebral body fracture.
101
CP of **Posterior Cord Syndrome**
1. Loss of proprioception and vibration sense.
2. Severe ataxia.
102
Etiology of **Central Cord Syndrome**
- Older age with cervical spondylosis.
- Hyperextension with minor trauma.
- Cord is compressed by osteophytes from vertebral body against thick ligamentum flavum.
- Damages the central cervical tract.
103
CP of **Central Cord Syndrome**
1. UMN lesion to legs (spastic).
2. LMN to arms (flaccid paralysis).
**(NB: It affects Upper limbs more than lower limbs)**
104
Etiology of **Brown Sequard Syndrome**
1. Hemisection of the cord
2. Stab injury and lateral mass fractures.
105
CP of **Brown Sequard Syndrome**
- Contralateral (Uninjured) side has good power but absent pinprick and temperature 2-3 segments below the lesion.
- Ipsilateral side has motor paralysis below the lesion.
106
Spinothalamic tracts cross to opposite side of the cord 3 segments below.
...
107
Pathophysiology in **1ry Neurological Damage**
- Direct trauma, haematoma and SCIWORA < 8 yrs old.
- In 4hrs - Infarction of white matter
- In 8hrs - Infarction of grey matter and irreversible paralysis.
108
Pathophysiology in **2ry Neurological Damage**
1. Hypoxia.
2. Hypoperfusion.
3. Neurogenic shock.
4. Spinal shock.
109
SCIWORA
Spinal Cord Injury Without Radiographic Abnormality
110
Radiological Tool of Choice in **Spinal Trauma**
111
Radiological Tool of Choice in **Spinal Trauma**
- Suspectimg Level
Suspect the level from
- Examination
- Mode of trauma.
112
Radiological Tool of Choice in **Spinal Trauma**
- What to Start With?
X-Ray
113
Radiological Tool of Choice in **Spinal Trauma**
- If Suspicious
CT
114
Radiological Tool of Choice in **Spinal Trauma**
- Indications of MRI
1. Positive CT.
2. high suspicion even with negative CT.
3. Planning of surgery.
115
Immobilization in **Spinal Trauma**
116
Def of **Whiplash Injury**
Sudden hyperextension and flexion.
117
CP of **Whiplash Injury**
- Increasing neck pain for the first 24 hours.
- Anterior longitudinal ligaments are torn causes dysphagia.
- Forward flexion against resistance is painful.
118
Recovery in **Whiplash Injury**
90% are asymptomatic after 2 years.
119
Types of **Vertebral Fractures**
- Compression Fractures
- Burst Fractures
- Seatbelt Type Fracture
- Dislocation Fracture
120
**Compression Fractures**
121
**Compression Fractures**
- Types
122
**Burst Fractures**
- Types
123
Seatbelt Type Injury
124
Dislocation Fracture
125
Compare between Stable & Instable Injury in terms of
- Displacment of vertebral components by normal movements
- Risk of neural damage
126
Treat as unstable until proven otherwise.
...
127
Def of **Spinal Instability**
- The loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae
- in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots.
128
How to Suspect Spinal instability?
- SLICS
- TLICS
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SLICS
130
SLICS
- Morphology (Immediate Stability)
131
SLICS
- Discoligamentous Complex (DLC)
(Long-term Stability)
132
SLICS
- Neurological status
133
SLICS
- Interpretation
134
**TLICS**
- Morphology (Immediate Stability)
135
**TLICS**
- Posterior Ligamentous Complex (PLC)
**(Integrity Long-term stability)**
136
TLICS
- Neurological Status
137
TLICS
- Interpretatiion
138
Objectives of **Defenitive TTT of Spinal Trauma**
1. To preserve neurological function.
2. To stabilize the spine.
3. To rehabilitate the patient.
139
indications for **urgent surgical stabilization in spinal Trauma**
- An unstable fracture with Progressive neurological deficit
and/or
- MRI signs of likely further neurological deterioration.
140
Emergency TTT in **Spinal Trauma**
141
Emergency TTT in **Spinal Trauma**
- ABCDE
...
142
Emergency TTT in **Spinal Trauma**
- Methylpednisolone
**Loading:**
- 30mg/kg iv bolus over 15 min immediately.
**Maintainence:**
- 5.4 mg/kg/h infusion over 23 hrs.
143
**Acute Management of Spinal Cord Injury**
- Immobilization
144
Emergency TTT in **Spinal Trauma**
- Immobilization
Cervical & Thoracolumbar
145
Emergency TTT in **Spinal Trauma**
- Cervical Immobilization
146
Indications of **Cervical Immobilization**
- Known or suspected cervical spine injury
- Comatose or intoxicated at the scene of injury
147
Methods of **Cervical Immobilization**
- Cervical Orthrosis (Or Sandbags)
- Gardber-Wells Tongs
148
Methods of **Thoracolumbar Immobilization**
- Backbord
- Logrolling
149
**Thoracolumbar Immobilization**
150
Objectives (Indications) of surgical Intervention in **Spinal Trauma**
1. Stabilization of fractures not likely to heal.
2. Decompression of neural elements.
3. Early mobilization:
151
Objectives (Indications) of surgical Intervention in **Spinal Trauma**
- Stabilization
of fractures not likely to heal.
152
Objectives (Indications) of surgical Intervention in **Spinal Trauma**
- Decompression
of neural elements.
153
Objectives (Indications) of surgical Intervention in **Spinal Trauma**
- Early Mobolization
154
Early surgical stabilization of the unstable spine may help to ......
A. Prevent prolonged bed rest complications (atelectasis, pneumonia, DVT, etc.)
B. It also allows the patient to begin rehabilitation earlier.
155
Surgical Intervention in **Spinal Trauma**
- techniques
156
Surgical Intervention in **Spinal Trauma**
- Fusion
...
157
Surgical Intervention in **Spinal Trauma**
- Internal Fixation
(instrumentation).
* Internal fixation is not a substitute for fusion.
* Screws, hooks, cages.
158
Surgical Intervention in **Spinal Trauma**
- Decompression
of spinal canal
(Laminectomy)
159
Done
...
