Mini Symposium: Introduction, Spinal Injuries and Cases Flashcards
what are the different areas of the spine?
what are the vertebra like in different regions?
basic block of the bony
- 3 main types of vertebrae
- similar
- viewed from above
1. vertebral body – WB surface
2. spinal formamen – conating the cord and later the spinal nerve roots
3. posterior elements, lamina superior and inferior articular procsess
4. Pedicles
5. spinous prcess and trasverese prcoess- allow muscle attachments
Spinal canal in the lumbar is smaller so there is less space for the cord
Laminar long and thin in the cervical region and small and thick in the lumbar region
The transverse processes in lumbar are nearly horizontal but in thoracic area they are oblique and in the cervical region they don’t have them
All vertebra have spinous process, bifid in the cervical region
Facet joints – synovial joints linking the vertebra in the posterior elements, coronal plane in the thoracic region to allow lateral tilting, in lumbar region they are more in sagittal plane which allows forwards flexion and extension
Foramen for the vertebral artery in the cervical region
each individual vertebrae _________ with the level below and above
articulates
thoracic spine is a rigid structure much less flex/ext. but allows _______
rotation
what is the shape of the spine?
7 cervical segments, t12 thoracic 5 lumbar , 5 sacral and variable coccygeal
charcetertistic s shape in sagital plane
cervical and lumbar lordosis balanced by t spine kyphosis
In the coronal plane
what are the muscles around the spine?
Abdominal muscles also act on spine
Nerve emerges at the _________ foramen at each level and if it is compressed it can cause pain that distribution of the spinal nerve
intervertebral
what is a dermatome?
A dermatome is an area of skin that is mainly supplied by a single spinal nerve
what is a myotome?
A myotome is the group of muscles that a single spinal nerve innervates
how are the dermatomes of the arms different form the legs?
In trunk horizontal distribution but in lower limb more vertical distribution
what are the myotoms of the upper limbs?
C5 - Shoulder abduction (deltoid)
C 6 - Elbow flexion/ Wrist extensors (biceps)
C 7 - Elbow extensors (triceps)
C 8 - Long finger flexors (FDS/FDP)
T 1 - Finger abduction (interossei)
what are the myotomes of the lower limbs?
L2 - Hip flexion (iliopsoas)
L3,4 - Knee extension (quadriceps)
L4 - Ankle dorsiflexion (tib ant)
L5 - Big toe extension (EHL)
S1 - Ankle plantar flexion (gastroc)
spinal inuries
what are different spinal injuries
fracutres (left)
spincal cord injuries - SCI (right)
(C5 translated on C6 on the left picture)
how many people with fractures/dislocation will also have SCI?
- 15% of people with a fracture/dislocation will have SCI
- Majority of people with SCI will have an accompanying column injury
how many spinal cord injuries occur and in who?
- 1000 SCI / year in the UK
- 50 000 people in the UK living with paralysis
- Male > Female
- Peak 20-29yrs
what is the most common causes of SCI?
what symptoms and signs would be seen in a complete SCI?
no motor or sensory function distal to lesion
no anal squeeze
no sacral sensation
ASIA Grade A (most severe group)
no chance of recovery
what symptoms and signs would be seen in a incomplete SCI?
Some function is present below site of injury
More favorable prognosis overall
can you determie acutley if it is complete or incomplete?
NOT ABLE TO DETERMINE ACUTELY AS PATIENT MAY BE IN SPINAL SHOCK
what are the different ASIA Classification?
in ASIA Classification, is grade A or E worse?
A
what are the different patterns of injury that may be seen?
- Tetraplegia/Quadriplegia (above innervation of arms)
- Paraplegia (injury level below innervation of arms)
- Central Cord Syndrome
- Anterior Cord Syndrome
- Brown-Sequard Syndrome
Depends on where injury caused
Bottom 3 are incomplete injury
what is tetraplegia?
- AKA Quadriplegia
- Partial or total loss of use of all four limbs and the trunk
- Loss of motor/sensory function in cervical segments of the spinal cord
how is tetraplegia caused?
- Cervical fracture
- Respiratory failure due to loss of innervation of the diaphragm
- Phrenic nerve C3-5
- ‘C5 keeps you alive’
- Spasticity (in all 4 limbs)
what is Spasticity and its cause?
- Increased muscle tone
- Upper motor neuron lesion
- Spinal cord and above (CNS)
- Injuries above L1
(Peripheral nerves not damaged)
what is Paraplegia and its effects?
- Partial or total loss of use of the lower-limbs
- Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
- Arm function spared
- Possible impairment of function in trunk
what causes paraplegia?
- Thoracic/Lumbar fractures
- Associated chest or abdominal Injuries
- Spasticity if injury of spinal cord (i.e. above L1)
- Bladder/ Bowel function affected (as it would be in quadrapaliga)
what are some partial cord syndromes?
- Central cord syndrome
- Anterior cord syndrome
- Brown-Sequard syndrome
who and how does central cord syndrome occur in?
- Older patients (arthritic neck)
- Hyperextension injury
- Centrally cervical tracts more involved
what ar ethe effects of Central Cord Syndrome?
- Weakness of arms > legs
- Perianal sensation & lower extremity power persevered
how is anterior cord syndrome caused?
- Hyperflexion injury
- Anterior compression fracture
- Damaged anterior spinal artery (area in grey)
what are the effects of anterior cord syndrome?
- Fine touch and proprioception preserved
- Profound weakness
poor prognois of recovery
Corticospinal tract damaged so loss of motor function, spinothalamic tract damaged so lose pain but posterior column still in tact
what is Brown–Sequard Syndrome and how is it caused?
- Hemi-section of the cord
- Penetrating injuries
what are the effects of Brown–Sequard Syndrome?
- Paralysis on affected side (corticospinal)
- Loss of proprioception and fine discrimination (dorsal columns)
- Pain and temperature loss on the opposite side below the lesion (spinothalamic)
what is the management of patients with a SCI?
- Key to the management of a patient with SCI is to prevent a secondary insult
- Particularly in patients with incomplete injuries
- ABCD
- ATLS (advanced trauma life support)
what is A in the ABCD manage of a SCI?
Airway (C spine control)
Don’t want further damage, stop movement
Give oxygen
what is B in the ABCD manage of a SCI?
Breathing
- Ventilation and Oxygenation
- Concomitant chest Injuries
how is circulation managed?
- IV fluids
- Consider Neurogenic Shock
- low BP and HR
- Loss of sympathetic tone (High injuries above T6 to the spinal cord the sympathetic outflow to the heart and blood flow is reduced)
- Vasopressors (maximize blood supply and improve circulation to the cord)
Most people with spinal cord injuries have other injuries
Most shock in trauma is due to loss of blood
what are the features of spinal shock?
- Transient depression of cord function below level of injury
- Flaccid paralysis (no tendon reflexes)
- Areflexia
- Last several hours to days after injury
what are the features of Neurogenic Shock?
When you lose sympathetic tone
Hypotension
Bradycardia
Hypothermia
Injuries above T6
Secondary to disruption of sympathetic outflow
how is disability managed in SCI?
- Asses Neurological Function
- Including PR and Perianal sensation
- Log Rolling
- Document
what imaging is done?
- X Rays
- CT Scanning- bony anatomy
- MRI – if neurological deficit or children
how is surgical fixation done?
(Can be managed conservatively or surgically)
- Unstable fractures
- Vast majority fixed from posteriorly
- Pedicle screws preferred method
what is the long term management of SCI?
- Spinal Cord Injury Unit - intermediate term
- Physiotherapy
- Occupational therapy
- Psychological support
- Urological/Sexual counseling
Summary:
- Although spinal fractures are common ___ is rare
- Complete injuries have no ________ below trauma
- Incomplete injuries have _______ function
- Preventing secondary insult is key - ____
- Assessment involves testing ________ and _________
- Important to understand the difference between _________ and spinal shock
SCI
function
variable
ABCD
myotomes
dermatomes
neurogenic
cases
Case 1:
- 56 year old lady
- Neck pain
- 6 months of worsening numbness in the hand
- Difficulty doing buttons
- Wide based gait
What would you do?
What could be the diagnosis?
What would you do? - History and Exam
What could be the diagnosis? - Cervical myelopathy
This effects gait, weakness in lower limbs and spasticity
Definitive diagnosis made by MRI
(Between 4 and 5 in picture)
Case 2:
- A 70 year old man presents with a “tired feeling” in both thighs which is precipitated by walking and relieved by rest
- He has a long history of backache
What are the main differentials?
How could you tell between the two?
What are the main differentials?
Spinal stenosis
Peripheral Vascular Disease
How could you tell between the two?
History: distribution, risk factors
Examination: pulses
Case 3:
- A 70 year old lady presents with severe, worsening thoracic and lumbar back pain over several moths.
- No history of trauma, pain worse on standing but still present when lying in bed at night.
- History of weight loss
What are the important diagnosis to include?
What are the important diagnosis to include?
- Infection- disctis
- Metastatic Malignancy to the spine
