Extern conferenceExt. ธนกร เทียมสวุรรณ

Case ผูป้ว่ยหญิงไทยอายุ 48 ปี มา

ด้วยอาการปวดหลัง 30 นาทีก่อนมารพ.

30 นาทีก่อนมารพ. ถกูววัชนจากด้านหลัง 1 ครัง้ มี อาการปวดหลังมาก ขยบัตัวแล้วปวดหลังมาก ไม่

หมดสติ พอขยบัแขนขาได้ ไมม่บีาดแผลภายนอก ไมม่อีาการบาดเจบ็บรเิวณอ่ืน ไมม่แีขนขาชา

ประวัติ

A : Can speak, Full ROM of neck, No neck pain

B : Normal breath sound, Equal both lung, Trachea in mid line, RR 20/min

C : BP 106/56 mmHg, PR 79/minD : E4M6V5, Pupil 3mm RTLBE, Motor grade

V allE : No external bleeding, No deformity,

swelling at low back, normal anal sphincters tone, no bleeding per rectum

Primary survey

A : ปฏิเสธประวติัแพย้าหรอืแพอ้าหารM : ไมม่ยีาทานเป็นประจำาP : ปฎิเสธโรคประจำาตัว, ปฎิเสธการตัง้ครรภ์L : 3 ชม. ก่อนมารพ.E : ถกูววัชนจากด้านหลัง

Secondary survey

ตรวจรา่งกายV/S BP 106/56 mmHg PR 79/min BT 36.1 c

RR 20/minGA : A thai middle age woman, good

consciousnessHEENT : Not pale conjuntivae, An icteric

scleraeHeart : pulse full and regular, normal S1S2,

no murmurLungs : Trachea in midline, normal breath

sound, Equal both lungsAbd. : soft, not tender, normoactive bowel

sound

Ext. : Low back swelling at lumbar level, mark tender, limit movement due to pain, no wound, palpable pulse on both legs, no pelvic pain

Neuro : Grade V all ext., Pain at back on legs movement, Normal sensation to touch and pain, DTR : 1+ both legs

PR : Good sphincter tone, normal perianal sensation

ตรวจรา่งกาย

Problem listBlunt injury to back

X-ray LS spine AP view

X-ray LS spine Lateral view

X-ray Pelvic AP view

Chance Fracture of L3

Diagnosis

AdmitAbsolute bedrestPain control

Management

Thoracic and Lumbar spinal column injury

Anatomy of Thoracic and Lumbar spine

Compression fractureBurst fracturesFlexion-distraction (lap belt) injuriesTranslational spinal column injury

Classification

projections reveal a compression fracture of T5 (arrows) with about 70 percent loss of height of the vertebral body. A second compression fracture of T7 (arrowheads) has resulted in about 15 percent loss of height of the vertebral body. A kyphosis of the thoracic spine of about 30 degrees has resulted.

Compression fracture

Burst fracturesa burst fracture of L1 characterized by loss of height and malposition of the L1 vertebral body with posterior retropulsion into the spinal canal (arrow). The posterior elements are splayed as reflected in the widening of the pedicles (arrowheads)

Flexion-distraction (lap belt) injuries

a transverse fracture of the third lumbar (L3) vertebral body. Chance fracture is often due to seatbelt injury. Note the wide radiolucent gap between the two fracture segments (arrows). Associated fractures of the lamina, pedicles and interspinous ligament has splayed the posterior elements (double arrow)

Translational spinal column injuryreveals a fracture dislocation centered around T11/T12. The arrowheads define the spinous processes on the frontal film and demonstrate the abrupt angulation centered at the dislocated level. The arrows point to the posterior cortices of the vertebral bodies and highlight the extent of abnormal translation.

Injury morpology•Compression = 1 point•Burst = 1 point•Translational/rotational = 3 points•Distraction = 4 points

Neurological Status•Intact = 0 points•Nerve root = 2 points•Cord, conus medullaris:Incomplete = 3 pointsComplete = 2 pointsCauda equina = 3 points

Thoracolumbar Injury Classification and Severity Score (TLICS)

Posterior Ligament Complex•Intact = 0 points•Injury suspected/indeterminate = 2 points•Injured = 3 points

A score ≥5 suggests instability and the need for operative treatment

a score ≤3 suggests stability.A score of 4 is considered indeterminate

Thoracolumbar Injury Classification and Severity Score (TLICS)

Thank you