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ORTHO CONFERENCEExt pattraporn
HISTORY
Male 43 yr
cc: รถชน 3 hr PTA
PI : 3 hr PTA รถกระบะชนเสาไฟฟา้ มอีาการปวดต้นคอ มอีาการอ่อนแรงและชาท่ีแขนและ ขา ไมม่แีผลตามตัว สลบจำาเหตกุารณ์ไมไ่ด้ ไมม่อีาเจยีน ไมห่ายใจหอบเหนื่อย ไมป่วดท้อง
Past history : no underlying disease
PHYSICAL EXAMINATION Primary survey
A : Can talk, tender at neck with limited ROM
B : Equal breath sound, CCT -ve, no subcutaneous emphysema
C : BP 96/60 mmHg, PR 66 bpm, no active bleeding
D : E4V5M6, pupil 3 mm RTLBE
E : no external wound
PHYSICAL EXAMINATION
Vital sign : BP 96/60 mm Hg PR 90 bpm RR 20 /min Temp 37.2
GA : A Thai man , good consciousnessCVS : normal S1 , S2 , no murmur , cap refill < 2
secsLung : clear , equal both lung , no adventitious
soundAbd : soft , not tender , no guarding , no rebound
tenderness
PHYSICAL EXAMINATION Can't flexion and extension neck tender posterior
Decrease sensation below C6
Bulbocarvernosus reflex -ve
Loose sphincter tone
RT LT
C5 II II
C6 II I
C7 II II
C8 0 0
T1 0 0
RT LT
L2 0 0
L3 0 0
L4 0 0
L5 0 0
S1 0 0
INVESTIGATION
Film C-spine AP, Lateral
Swimming view
SPINOUS PROCESS LINE
Spinolaminar line
posterior vertebral body lineanterior vertebral body line
facet joints appear as stacked parallelograms
Prevertebral soft-tissue shadow Disc C2-C3 < 7mmDisc C6-C7 < 21 mm
AP TRANSLATION
3.5 mm of translational deformity is suggestive of mechanical instability
COBB ANGLE
>11 degrees suggestive of posterior ligamentous injury and potential instability
CT SCAN• More sensitive for detecting fractures
• More consistently enables assessment of the occipitocervical and cervicothoracic junctions
ALLEN & FERGUSON CLASSIFICATION
Distraction flexion II
DISTRACTIVE FLEXION
DIAGNOSIS
C5-C6 unilateral facet dislocation with complete cord injury
INITIAL MANAGEMENT High dose Methyl-prednisolone Methyl prednisolone 30mg/kg then 5.4 mg/kg over the next 24 hours
On skull traction
MRI c-spine
HIGH-DOSE METHYL PREDNISOLONE
MRI• Superiority in visualizing the spinal cord, intervertebral
disc, and spinal ligaments
• Detecting
• traumatic disc herniations
• epidural hematoma
• spinal cord edema or compression
• posterior ligamentous disruption
MRIIndication
• patients with neurological deficits
• patients with injuries in which the integrity of the posterior ligamentous complex is unclear and would directly influence the treatment plan
TREATMENT
SUBAXIAL CERVICAL SPINE INJURY CLASSIFICATION (SLIC)
<= 3 : nonoperative
>= 5 : operative
TREATMENT
8 point
Operative treatment
FACET DISLOCATIONNon-operative treatment
• Indication : unilateral facet dislocations without any signs of neurological injury
• Halo vest immobilization 3 month
• Flexion-extension views to confirm stability
FACET DISLOCATIONOperative treatment
• Closed reduction using cranial tong or halo traction as early as possible in awake, conscious, and able to be serially examined patient
• Pre-reduction and post-reduction MRI
FACET DISLOCATIONOperative treatment
• If there the spinal cord is being indented by a disc herniation, anterior surgery is preferred
• Anterior surgery followed by posterior stabilization for patients with highly unstable bilateral facet dislocations
TREATMENT
SPINAL CORD INJURY
ANATOMY
SPINAL CORD
SPINAL CORD INJURY
Complete cord injury syndrome
Incomplete cord injury syndrome
Conus medullaris syndrome
Clauda equine syndrome
COMPLETE CORD INJURY SYNDROME
After presence of bulbocavernosus reflex : no sensation or voluntary motor function is noted
INCOMPLETE CORD INJURY SYNDROME
Some neurological function persist after return of bulbocavernosus reflex
Sacral sparing : imply continuity between cerebral cortex and lower sacral motor neuron.
Such as 1. Perianal sensation 2. Voluntary rectal motor function 3. Big toe flexor activity
INCOMPLETE CORD INJURY SYNDROME
INCOMPLETE CORD INJURY SYNDROME
ANTERIOR CORD SYNDROMEBlood flow is reduced or interrupted in the artery that runs along the anterior portion of the spinal cord.
May be the result of bone fragments from traumatic injury to the vertebra, spinal disc herniations or flexion/compression injury.
Most poor prognosis : recovery rate 10%
CENTRAL CORD SYNDROMEMost common type
Characterized by impairment in the arms and hands and, to a lesser extent, in the legs.
Spare sacral spine thalamus and corticospinal tracts
Recovery from distal to proximal [toe flexion > toe extension > ankle > knee > hip]
recovery rate 75%
BROWN SEQUARD SYNDROMEHemisection of the spinal cord
Motor paralysis , loss of vibration and proprioception on the ipsilateral side as the lesion and deficits in pain and temperature sensation on the contralateral side of the lesion.
The most common cause of Brown-Séquard syndrome is penetrating trauma such as a gunshot wound or stab wound to the spinal cord.
Best prognosis : More than 90% of people regain bladder & bowel control and the ability to walk.
POSTERIOR CORD SYNDROME
SPINAL SHOCK
Immediate temporary loss of total power , sensation and reflexs below the level of injury
Loss of bulbocavernosus reflex
Usually recovery in 24-48 hrs