Spinal Cord Injury Flashcards
Etiology
- Trauma (40%)
- cervical
- thoracolumbar - Infection
- Malignancy
Cervical Injury
Upper cervical (C1,C2) - occipital condyle - ring fracture - odontoid process Lower cervical (C3-C7)
Mechanism of upper cervical fracture
Ring fracture: Sudden severe load on head
Hangman’s fracture: Hanging, cause hyperextension
Odontoid process: High velocity accident, fall on forehead or face
Lower cervical injury
Wedge compression fracture: Stable. Middle and posterior column intact
Burst compression fracture: Axial loading? Unstable. Tear drop in anterior column
Fracture dislocation:
- Bilateral
- Unioateral
Whiplash: hyperextension, soft tissue injury
Dennis Classification Thoracolumbar injury
Based on column
- anterior (2/3rd vertebral body)
- middle (posterior 1/3rd, post longlitudinal ligament)
- posterior (distal to lig)
Mechanism
- compression
- burst
- seat-belt
- fracture dislocation
minor
- transverse
- articular
- pars interarticularis
- spinous process
Mechanism of fracture
Compression: Flexion, hyperflexion: Anterior column. Usually no neuro deficits.
Burst: Axial loading: Anterior and middle (Retropulsion into spinal canal, neuro deficits)
Flexion/Distraction: Middle and Posterior column: Hyperflexion and subsequent? (associated with GIT injury)
- one level (Chance fracture)(same with burst)
- two level
Fracture dislocation: All three columns: Severe compression, rotation and tension (associate with spinal cord injury)
- flexion-rotation
- flexion distraction
- shearing
Malignancy
Primary
- intradual, intramedullary
- intradural, extramedullary
- extradural (most common): mets, chordoma
Extradural Metastasis
Batson’s Plexus (valveless) - haematogenous - lymphatics Site: thoracic/thoracolumbar/sacral (rare) More than 55yo
Chordoma
- sacrum, clivus
Categories of spinal cord lesion
- UMNL
- LMNL
- cauda equina syndrome (root)
- conus medullaris syndrome(L2 -S4)(cord and nerve roots)
- above t10: cord
- t10 to L1: cord and nerve roots
- L1: root lesion
Cauda equina
- LMNL
- backpain, saddle anaesthesia, impotence, sensorimotor, incontinence, loss of reflex
Conus mdeullaris
- UMNL, LMNL
- reflex may be preserved
Pathology
Primary: Traumatic structural damage (disrupted spinal cord)
Secondary
- minutes-hours: conduction block
- 4-8 hours: haemorrhage and necrosis, anuerysm, vessel rupture
- more than 8: thrombi in capillary
Shock
Spinal Shock (Neurological)
transcient (46 to 6 weeks) loss of somatic and autonomic reflex below neurological damage
- brady, hypo, poikilo (if symphatetic chain affected)
- absent bulbocavernous reflex
- flaccid paralysis
Neurogenic Shock (Physiological) autonomic-initiated cardiovascular condition in patient with cord lesion above t6 - reflex variable - paralysis variable - hypo, brady
Type of spinal injury
Only after resotaration of bulbo reflex
Complete: Involve s4, s5 (no preserved motor or sensory fx)
Incomplete:
- anterior cord (commonest): spinothalamic, corticospinal, anterior spinal artery (loss of motor, pin prick, temperature)
- posterior cord (rare): loss of light touch, deep pressure, proprioception
- central cord (commonest): cervical spondylosis, hyperextension: loss of motor fx (ul more sever than ll) good prognosis. usually gross preserved, fine may loss)
- brown sequard (rare): penetrating injury (ipsi hemiplegia, conta hemianaesthesia)
- cauda
Frankle Score
A B C D E
History Taking
- Pain:
- back/neck
- sharp or dull
- sudden (fracture) or gradual (malignancy)
- radiating (sciatica)
- relieving factor (by rest mechanical?)
- intermittent claudication (resolve by sitting, hip flexion. release compress nerve) - Neuro deficits
- motor (loss of power, bilateral/unilateral)
- sensory (pattern? saddle)
- bowel, urinary fx - Associated injury
- brain (loss of consciousness)
- respiratory (sob)
- etc
- cons sx
- infection - Trauma mechanism
- flexion
- hyperextension
- axial loading
- rotation
Physical Examination
- General
- consciousness, gait, posture, vitals - Neck
- ins: deformity, bruising
- pal: tenderness, mass, midline tenderness, bogginess, space between interspinous ligament
- move: no! - Back
- ins: superficial landmarks (t1, t7, L1)
- palpation: bony tenderness, steps, gaps
- move: straight leg raise test (30 to 70 degree) compress sciatic nerve. (if more than 70 hamstring)
* Lasegue’s sign (same like slr, recreate sxiatica)
* bow string
* femoral atretch test
* sciatic stretch test (dorsiflex when no sciatica pain)
ASIA Chart
- Diagnostic
- Prognostic
Autonomous region (more representative for respective dermatome) c2- occipital protuberance c3- supraclavicular fossa c4- acromion process c5- lateral cubital fossa c6- thumb c7- middle finger c8 - little finger T1- medial xubital dossa axillary 3rd ics to 9 T4- nipple area T10-umbilicus
0
1
2
Muscle fradinf
0-5
Francle
A-E
A- 15 regain fx (bt only 3% full)
B- 50% regain fx
C,D,E- majority regain fx
X-Ray Neck
- AP: Spinous process alignment, uncovertebral joint, facets
- Lateral: Soft tissue line, anterior vertebral, posterior vertebrae, spinolaminar, line of convergence (only up to c5?)
- soft tissue:
c2 (6mm)
c6 (2cm) - Swimmer’s view: Cervico-thoracic junction
- Shoulder pull-down/Depression view: If cannot do swimmer’s view
- If cannot: ct
- Open mouth view: symmetrical c1, c2 lateral mass normal alignment, odontoid (gap must be similiar)
++Jeffersons (open mouth)
++ Odontoid (open mouth)
++ Hangmans (lateral)
++ Burst (lateral)
X-Ray Thoracolumbar
- Compression
- Burst:
- lateral: middle, anterior column. Compression more than 50%.
- AP: sudden widening of interpeduncular width - Chance
- lateral: all three columns - Osteoporotic insufficiency injury
CT-Scan Indication
- Individual vertebrae
- Bone displacement into canal
- Fracture pattern
MRI Indication
- Display intervertebral disc, ligamentum flavum, neural tube
- Patient with neurological deficit
- Decide approach of surgery
Aim of management
- Preserve life
i. resuscitation
ii. spine immobilization
- cervical (manual in-line, apply collar, quadruple immobilization)
- thoracolumbar (move without flexion or rotation, scoop stretcher, spinal board, log rolling - Preserve neurological function
i. Immobilization (collars, tongs, halo rings, thoracolumbar brace)
ii. Stabilization and decompression
Log-Rolling Technique
Person 1: Manual in line, coordinator
Person 2: Cranial position
Person 3: Caudal position
Person 4: Examine
Collars
Soft Collar
- Little support
- for minor sprain
Semi-Rigid Collar
- limit motion effectively
- for acute injury
- inadequate for unstable injury
- venous obstruction (increase ICP if size not suitable)
Rigid/Four Poster Brace
Skull Traction/Tongs Indication
- Subaxial malalignment
- Facet dislocation
- Displaced odontoid fracture
- risk of overdistraction of cervical column
Indication stabilization and decompression
Unstable fracture
Progressive neurological deficits
Cervical Spine
Burst fracture: Anterior approach
Facet dislocation: Posterior approach
Pharmacological
- Corticosteroids (improve spinal flow, restore transmission, enhance functional)
- within 8 hours, iv methyprednisolone
* controversial
Complication of spinal cord injury
- Neurogenic shock
- Temperature regulation
- Sweat (hyper/hypo/anhidrosis)
- Heterotopic ossification
- Thromboembolism
- CVS (arrhythmia, orthostatic hypotension)
- autonomic dysreflexia (malignant hypertension)
- Respiratory (Atelectasis, pneumonia)
- GUT (Neurogenic bladder)
- GIT (UMN or LMN bowel syndrome)
- Spasticity
- Pain syndromes (Nociceptive, Neuropathic)
- Musculoskeletal (Atrophy)
- Pressure ulcers
