Spinal Cord Injury 2 Flashcards
1
Q
Spinal Cord Injury pathology
A
- Epidemiology
- 10% unstable
- 5% with cord damage
- Damage to vertebral column
- Mechanism of injury
i. Traction
ii. Direct injury
iii. Indirect injury (most common) - Type:
i. stable - normal movements will not cause displacement of vertebral component
ii. unstable - normal movement has significant risk of causing displacement of vertebral component - Stability (Denis classification)
i. anterior column - anterior longlitudinal lig. to half of vertebral body
ii. middle column - posterior half of vertebral body to posterior longlitudinal lig
iii. posterior column - pedicles, facets, post bony arch (lamina, spinous process), interspinous and supraspinous ligament - any fracture of middle column + at least one other column is unstable
- Area of injury
i. upper cervical spine - occipital condyle fracture
- occipito-cervical dislocation
- c1 ring fracture
- c2 pars interarticularis fracture
- c2 odontoid process fracture
ii. lower cervical spine - posterior lig, injury
- tear-drop fracture
- fracture dislocation
- hyperextension injury
- whiplash injury
iii. minor thoracolumbar injury - transverse process fracture
- pars interarticularis fracture
iv. major thoracolumbar injury - flexion-compression fracture
- axial-compression (burst) fracture
- flexion-distraction (jack-knife/chance/seat-belt) fracture
- fracture dislocation
- Damage to spinal cord
- ASIA Impairment Scale (AIS)
i. Complete: No sacral sparing (sensory or motor fx is absent in sacral segments S4,S5). assess by VAC and DAP
ii. Incomplete: sacral sparing - Frankle Scale
A: absent sensory and motor (0/5)
B: sensory present (0/5:
C: sensory present, motor present but not useful (3/5)
D: sensory present, motor present and useful (4/5)
E: normal - Examples
i. Complete neuro deficit: SCI only
ii. Incomplete neuro deficit: - SCI
- Central cord syndrome
- Anterior cord syndrome
- Brown sequard syndrome
- Posterior cord syndrome
- Conus medullaris syndrome
- Cauda equina syndrome
2
Q
Impairment in Spinal Cord Injury
A
- Motor
- paraplegia
- tetraplegia - Sensory
- Neurogenic bowel
i. UMNL: intact anal tone, BCR+ve
- Target: Bristol Stool Type 4 (soft)
- Suppository Bisacodyl
- Daily syrup lactulose
ii. LMNL: lax anal tone, BCR-ve
- Target: Brostol stool Type 3 (hard)
- KY Jelly, Lignocaine gel evacuate using finger
- Syrup lactulose PRN - Neurogenic bladder
i. UMNL:
- hyperactive bladder
- sphincter dysnergia
ii. LMNL:
- underactive bladder (overflow incontinence)
- acontractality - Sexual dysfunction
- Autonomic dysreflexia
- occur in SCI at level T6 and above
- triggered by symphatetic stimulation from below the level of injury: eg bladder, bowel distention, pressure ulcers, ingrown toe nails
- peripheral vasoconstriction below level of injury cause hypertension, detected by baroreceptors
- parasympathetic surge in response unable to be transmitted below level of injury
- CF:
i. hypertension
ii. above lesion: bradycardia, vasodilation, flushing, pupillary constriction, nasal stuffiness
iii. below lesion: pale and cool skin - Orthostatic hypotension
- Neurogenic shock
- loss of symphatetic pathways when injury above T6
- CF: bradycardia, warm periphery, hypotension (low diastolic) - Spinal shock
- physiological temporary shutdown
- primitive anal wink and bulbocavernous reflex return in 48 hours
- motor and sensory loss may up to 6 weeks
- CF: bradycardia, hypotension if symphatetic chain affected
3
Q
Occipital condyle fracture
A
- Mechanism of injury
i. axial loading - Type I
ii. shear force to basal skull - Type II
iii. contralateral bending or rotation - Type III - Anderson-Montesan Classification
I - impacted fracture, comminuted
II - basal skull fracture extending to occipital condyle
III - avulsion fracture by alar ligament
++risk of occipito-cervical dissociation
4
Q
Occipito-cervical dislocation
A
- Mechanism of injury
Type I : Anterior displacement of occiput
Type II - Longlitudinal distraction of occiput from atlas
Type III - Posterior displacement of occiput - X-ray diagnosis
- Ratio between distance of BP/AO normally is equal to 1
B: Basion (mid anterior margin of foramen magnum)
P: Posterior C1
A: Anterior C1
O: Opisthion (mid posterior margin of foramen magnum)
BP/AO > 1 : Type I injury
BP/AO < 1 : Type III injury
Widening space: Type II
5
Q
C1 Ring Fracture (Jefferson)
A
- Mechanism of injury: axial loading
- Classification
Type I : bony injury with intact transverse ligament
Type II : bony injury with transverse lig. tear - Diagnosis
i. Hx: Axial loading
ii. X-Ray:
Type I:
- atlantodental interval (ADI) less than 3mm
- lateral mass displacement less than 7mm (between lateral border of C1, C2)
Type II:
- ADI more than 3mm
- lateral displacement more than 7mm
6
Q
C2 Pars Interarticularis Fracture (Hangman’s)
A
- Mechanism of injury:
- hyperextension - Levine and Edwards Classification:
Type I : Less than 3 mm displacement, stable, no angulation
Type II : More than 3mm displacement, unstable with angulation
Type III : C2, C3 facet dislocation
7
Q
C2 Odontoid Process Fracture
A
- Mechanism of injury:
- hyperflexion (II, III)
- lateral bending, rotation (I) - Anderson and D’Alonzo Classification
Type I - Avulsion fracture tip of odontoid (alar ligament)
Type II - Base of odontoid
Type III - Body of C2
8
Q
Posterior ligament complex injury of lower cervical
A
- Mechanism of injury: hyperflexion
- X-Ray
- posterior translation and angulation
- loss of 50% anterior column height
9
Q
Tear Drop Fracture
A
- Definition: Fracture of anterior inferior aspect of vertebral body (aka wedge compression fracture)
- Mechanism of injury: flexion-compression
- Associated injury:
- posterior spinous ligaments injury
- vertebral body forward displacement cause spinal cord injury
10
Q
Burst fracture of lower cervical
A
- Definition: Compression >40% of vertebral body height affecting anterior and middle column
- Mechanism of injury: axial loading
11
Q
Facet Dislocation
A
- Mechanism of injury: flexion rotation
- Type:
i. Unilateral:
- less than 50% translation (25% of its width)
- neurological involvement rare
ii. Bilateral:
- more than 50% translation
- neurological involvement common
12
Q
Whiplash injury
A
- Mechanism of injury:
- neck hyperextension followed by hyperflexion (accident) - Common associated injury:
- intervertebral disc tear
- nerve root impingement
- muscle tear
- posterior ligament complex injury
13
Q
Cervical Injury Imaging
A
- AP
- lateral outline intact
- spinous process
- tracheal shadow midline - Open mouth view
- C1, C2 - Lateral view:
- must include all 7 cervical vertebrae and upper half of T1 (if fail, do swimmer’s view)
- lordotic curve
- four parrallel lines: anterior vertebral body, posterior vertebral body, transverse process, spinous process
- displacement
- loss of vertebral height
- soft tissue shadow
14
Q
Flexion-compression fracture (Compression)
A
- Epidemiology
- most common vertebral fracture - Mechanism of injury
- high energy: spinal flexion
- low energy: osteoporosis - Prognosis
- stable fracture
- neurological impairment is rare - Diagnosis
i. Hx
- hyperflexion thoracolumbar
- fracture sx
ii. Pe
- same as fracture
iii. X-ray
- Lateral: loss of anterior vertebral height - Treatment
i. minimal wedging (<20% loss of vertebral height): bed rest until pain subsides. no support needed
ii. moderate (<40% loss of vertebral height): bed rest until pain subsides, later support with body cast or thoracolumbar brace. repeat x-ray at 3 months
iii. severe (>40% loss of vertebral height): posterior ligament disruption expected. surgical intervention
15
Q
Axial-compression fracture (Burst)
A
- Mechanism of injury
- axial loading - Prognosis
- usually unstable - Diagnosis
i. Hx
- axial loading
- fracture sx
ii. Pe
- same as fracture
iii. X-ray
- AP: increase interpedicular distance
- Lateral: fracture involving anterior, middle column. retropulsion of posterior fragment into spinal canal
iv. CT
- If retropulsion is suspected - Treatment
i. Conservative:
- if no neurological sx
- cast or brace for 12 weeks
ii. Surgery
- anterior decompression and stabilization
