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Orthopaedics > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q

Etiology

A
  1. Trauma (40%)
    - cervical
    - thoracolumbar
  2. Infection
  3. Malignancy
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2
Q

Cervical Injury

A 
Upper cervical (C1,C2)
- occipital condyle
- ring fracture 
- odontoid process
Lower cervical (C3-C7)
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3
Q

Mechanism of upper cervical fracture

A

Ring fracture: Sudden severe load on head
Hangman’s fracture: Hanging, cause hyperextension
Odontoid process: High velocity accident, fall on forehead or face

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4
Q

Lower cervical injury

A

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

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5
Q

Dennis Classification Thoracolumbar injury

A

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
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6
Q

Mechanism of fracture

A

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

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7
Q

Malignancy

A

Primary

  • intradual, intramedullary
  • intradural, extramedullary
  • extradural (most common): mets, chordoma
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8
Q

Extradural Metastasis

A 
Batson’s Plexus (valveless)
- haematogenous
- lymphatics
Site: thoracic/thoracolumbar/sacral (rare)
More than 55yo
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9
Q

Chordoma

A
  • sacrum, clivus
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10
Q

Categories of spinal cord lesion

A
  1. UMNL
  2. 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
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11
Q

Cauda equina

A
  • LMNL

- backpain, saddle anaesthesia, impotence, sensorimotor, incontinence, loss of reflex

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12
Q

Conus mdeullaris

A
  • UMNL, LMNL

- reflex may be preserved

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13
Q

Pathology

A

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

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14
Q

Shock

A

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
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15
Q

Type of spinal injury

A

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

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16
Q

Frankle Score

A 
A
B
C
D
E
17
Q

History Taking

A
  1. 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)
  2. Neuro deficits
    - motor (loss of power, bilateral/unilateral)
    - sensory (pattern? saddle)
    - bowel, urinary fx
  3. Associated injury
    - brain (loss of consciousness)
    - respiratory (sob)
    - etc
    - cons sx
    - infection
  4. Trauma mechanism
    - flexion
    - hyperextension
    - axial loading
    - rotation
18
Q

Physical Examination

A
  1. General
    - consciousness, gait, posture, vitals
  2. Neck
    - ins: deformity, bruising
    - pal: tenderness, mass, midline tenderness, bogginess, space between interspinous ligament
    - move: no!
  3. 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)
19
Q

ASIA Chart

A
  • 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

20
Q

X-Ray Neck

A
  1. AP: Spinous process alignment, uncovertebral joint, facets
  2. Lateral: Soft tissue line, anterior vertebral, posterior vertebrae, spinolaminar, line of convergence (only up to c5?)
    - soft tissue:
    c2 (6mm)
    c6 (2cm)
  3. Swimmer’s view: Cervico-thoracic junction
  4. Shoulder pull-down/Depression view: If cannot do swimmer’s view
  5. If cannot: ct
  6. 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)

21
Q

X-Ray Thoracolumbar

A
  1. Compression
  2. Burst:
    - lateral: middle, anterior column. Compression more than 50%.
    - AP: sudden widening of interpeduncular width
  3. Chance
    - lateral: all three columns
  4. Osteoporotic insufficiency injury
22
Q

CT-Scan Indication

A
  1. Individual vertebrae
  2. Bone displacement into canal
  3. Fracture pattern
23
Q

MRI Indication

A
  1. Display intervertebral disc, ligamentum flavum, neural tube
  2. Patient with neurological deficit
  3. Decide approach of surgery
24
Q

Aim of management

A
  1. 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
  2. Preserve neurological function
    i. Immobilization (collars, tongs, halo rings, thoracolumbar brace)
    ii. Stabilization and decompression
25
Q

Log-Rolling Technique

A

Person 1: Manual in line, coordinator
Person 2: Cranial position
Person 3: Caudal position
Person 4: Examine

26
Q

Collars

A

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

27
Q

Skull Traction/Tongs Indication

A
  1. Subaxial malalignment
  2. Facet dislocation
  3. Displaced odontoid fracture
  • risk of overdistraction of cervical column
28
Q

Indication stabilization and decompression

A

Unstable fracture

Progressive neurological deficits

29
Q

Cervical Spine

A

Burst fracture: Anterior approach

Facet dislocation: Posterior approach

30
Q

Pharmacological

A
  1. Corticosteroids (improve spinal flow, restore transmission, enhance functional)
    - within 8 hours, iv methyprednisolone
    * controversial
31
Q

Complication of spinal cord injury

A
  1. Neurogenic shock
  2. Temperature regulation
  3. Sweat (hyper/hypo/anhidrosis)
  4. Heterotopic ossification
  5. Thromboembolism
  6. CVS (arrhythmia, orthostatic hypotension)
  7. autonomic dysreflexia (malignant hypertension)
  8. Respiratory (Atelectasis, pneumonia)
  9. GUT (Neurogenic bladder)
  10. GIT (UMN or LMN bowel syndrome)
  11. Spasticity
  12. Pain syndromes (Nociceptive, Neuropathic)
  13. Musculoskeletal (Atrophy)
  14. Pressure ulcers

Orthopaedics (47 decks)

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