TRAUMA MEDULA

SPINALIS
Dr. Rendra leonas SpOT
ORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY
MOH. HOESIN PALEMBANG

Introduction
Most common
age and high speed level
traffic accident >>
80% spinal inj not assoc SI
more important preliminary care

At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.

Introduction

Trauma spine can cause damaged :

Hard tissue : bone
Soft tissue : ligament
discus
spinal cord

Introduction

Careful Physical Examination is potentially

the most valuable service a physician can
provide to the patient. ( OKU Spine : 2004 )

Complete exam :

Correct diag nosis

Mag nitude of the problem
D eterm ine appropriate Treatm ent

Anatomy and Physiology

33 bones comprise the spine

Function

Skeletal support structure

Major portion of axial skeleton
Protective container for
spinal cord

Vertebral Body

Major weight-bearing
component
Anterior to other
vertebrae components

Anatomy and Physiology

Characteristic of the
Vertebrae
Cervical
C-1 & C-2 no
v ertebral body
Support head
A llow for turning
of head
Vertebral body siz e
increase inferiorly
they becom e

Anatomy and Physiology

Characteristic of
theVertebrae
Lumbar spine has
strongest and
largest
weight bearing of
the body
Sacral & Coccyx
vertebrae are fused
No vertebral body

Anatomy and Physiology

Components of
Vertebrae

Spinal Canal

Opening in the
vertebrae that the
spinal cord passes
through

Pedicles

Thick, bony structures

that connect the
vertebral body to the
spinous and
transverse processes

Anatomy and Physiology

Components of Vertebrae

Laminae

Spinous Process

Posterior prominence on vertebrae

Intervertebral Disks

Posterior bones of vertebrae that make up foramen

Cartilagenous pad between vertebrae

Serves as shock absorber

Transverse Process

Bilateral projections from vertebrae

Muscle attachment and articulation location with ribs

Intervertebral Disc
nucleus
pulposus
annulus
fibrosus
hyaline cartilage
end plates

Facet Joints

Act to limit shear and torsion

motions between vertebrae
Orientation of facet changes
along length of spine
Cervical : couple lateral
bending and torsional
motion
Thoracic : coronal plane
orientation of joint surfaces
Lumbar : sagital plane
orientation of joint surfaces
Facets carry 10-20% of
compressive load in upright
standing, >50% of anterior
shear load in forward fexion

Anatomy and Physiology

SPINAL NERVES
31 pairs of spinal nerves :
8 cervical
12 thoracic
5 lumbar
5 saccral
1 coccygeal

Each has both motor and sensory fibers

Motor fibers = anterior or ventral root
Sensory fibers = posterior or dorsal root

OVERVIEW

LOOK

FEEL

inspection
palpation

MOVE

active & passive

movements

EXAMINATION : STANDING
Look :
bruise
hematom
wound : gun shoot wound
stab wound
Deformity

EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral
Bony prominence or steps
spinous processes

using C7 &/or L4-5

as landmarks

facet joints

approx. 2cm lateral to spinous processes

EXAMINATION : STANDING
Feel :
assess alignment, mobility &
tenderness of:
transverse processes of vertebrae
lateral to spinous processes

EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral
Bony prominence or steps
spinous processes

using C7 &/or L4-5

as landmarks

facet joints

approx. 2cm lateral to spinous processes

EXAMINATION : STANDING
Feel :
assess alignment, mobility &
tenderness of:
transverse processes of vertebrae
lateral to spinous processes

Signs of nerve root

compression
Standard full neurological examination of
both lower limbs :

tone, power (MRC grading)

sensation (light touch, pinprick &
proprioceptive if indicated)
reflexes (physiologic and patologic)
an anatomical distribution [dermatome(s) or
myotome(s)]

Neurological Examination

Objectives :
Determine if defect is present
Localize the level of the deficit

Include :
Sensory
Motor
Reflex

Neurological Examination
Sensory examination

Explain, eyes closed

Examine : touch, 2 point discrimination,
proprioceptive.
Sensory dermatomes, compare each
opposite

Sensory Dermatome

Muscle Power Grading

0 - complete paralysis
1 - flicker of contraction possible
2 - movement is possible when gravity is
excluded
3 - movement is possible against gravity
4 - movement is possible against gravity + some
resistance
5 - normal power

Neurological Examination
Motor examination

Muscle grading
Compare each side

Cervical :
Scapular

C4

Deltoid & Biceps

C5

Wrist extension & supination

C6

Wrist flexion & Pronation

C7

Neurological Examination
Motor
examination

Lumbo-sacral

Hip flexor
Hip extensor

L 1,2,3
S1

Knee flexor
Knee extensor

L 4,5, S1,2
L 2,3,4

Ankle flexor
Ankle extensor

S1
L5

Denis 3 Column Theory

Denis, F.: The Three-Column Spine and its Significance in the

Classification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)

Basic Types of Spine Fractures

1.
2.

Compression fracture
Burst fracture

Denis
Classification

Basic Types of Spine Fractures

3.

Seat-belt injury (Flexion-distraction

injury)

Bony Chance fracture

Soft tissue Chance injury

Basic Types of Spine Fractures

4.

Fracture-dislocation

Anterior posterior shear

Flexion-rotation

Flexion-distraction

Classification spine fracture

Stable injury :

compression fracture
burst fracture

Unstable injury : dislocation

fracture dislocation
chance fracture

Classification spine fracture

Location :
1. Jefferson fracture
2. Dens fracture
3. Hangmans fracture
4. Clay shovelers fracture
5. SCIWORA

Compression fracture

Failure of the anterior column

Mechanism anterior or lateral flexion
Normally Stable or unstable fracture
Rarely involved neurologic comprimise

Criteria unstable

Loss of 50% of vert body height

Angulation of thoracolumbar junct > 20
deg
Mutiple adjacent column of spine
Failure of 2/3 of column of spine

Chance fracture

Anterior column falls in tension (along w/

the middle and posterior columns)
Three columns rupture in distraction
(tension)
Seldom assc w/ neurologic comprimise
unless
Unstable

Burst fracture

Compressive failure of vert body both

anteriorly & posteriorly , w/ failure of both
anterior & middle columns
Axial loading applied to intravertebral disc
results in increased nuclear pressure and
hoop stresses in the annulus

Burst frx location

Cervical burst fix
Lumbar burst fix
Thoracic burst fix
Thoracolumbar burst fix

Classification :
Stable frx
- neurologically intact
- poterior arch remains intact : pedicl
widening implies post arch disruption
- less than 50% anterior body height
- compression fracture

Unstable frx
- neurologic defisit
- loss of 50% vertebral body height
- fracture dislocation
- thoracolumbar burst frx

Jefferson Fracture

Pediatric frx fraktur lateral C1

- frx proceeds thru open synchondroses,
and may occur w/ minimal trauma/
- posterior synchondroses fuses at age 4
- anterior synchondroses fuses at age 7

Mechanism
- original description in 1920 noted role of
axial compression
- may also be caused by hyperextension,
causing a posterior arch fracture

Associated injuries
- approx 1/3 of these fractures are
associated with a axis fracture
- approx 50% chance that some other
C-spine injury is present
- low rate of neurologic deficits is due to
large breadth of C1 canal

Radiographs
Odontoid view
Lateral view
Flexion and extension views
CT scan

Dens Fracture

Odontoid fractures are the most common

upper cervical spine fratures C2
Remember rule of thirds cervical cord
occupies a 1/3 of canal, dens occupies a
1/3 and the remaining 1/3 is empty
Mechanism
Flexion loading
Extension loading

Classification
Type I
Type 2 Dens frx
Type 3

Associated Injury
Atlas frx
Transverse ligament rupture
Pharangeal injury

Hangmans frx/Traumatic
Spondylolisthesis of the Axis

Fix of pars interarticularis of C2 & disruption of C2-C3

junction
Type of traumatic spondylolisthesis Hangmans frx
Term Hangmans fracture is not accurate for the majority
of cases, because mechanism of injury for clinically
encountered frx often lacks large traction force present in
judicial hangings

In cases in which there is neurologic

injury, there will usually be significant
horizontal translation w/ accompanying
damage to the posterior longitudinal
ligament w/ or w/o damage of the C2 C3
interspace

Mechanism of injury in adults

Judical lesion : hyperextension and distraction
Hyperextension w/ vertical compression of
posterior column, & translation of C2 and C3
Forceful extension of already extended neck
is most commonly described mech of injury,
but other causes include flexion of flexed neck
& compression of an extended neck
A blow on the forehead forcing the neck into
extension is a classic mechanism of injury
producing fractures thru the pedicles of C2
known as traumatic spondyloslishthesis of C2

SCIWORA Syndrome

Occurs may often in pediatric population

Accounts for up to 2/3 of severe cervical
injuries in children < 8 years of age
Inherent elasticity in pediatric cervical
spine can allow severe spinal cord injury
to occur in absence of x-ray findings

Radiographs
Diagnosis of exclusion
MRI may give a more anatomic diagnosis by
showing hemorrage or edema of the spinal
cord
Pseudosubluxation : anterior displacement
may be up to 4 mm

Clasification spinal cord

injury

Complete kehilangan seluruh sensasi dan fungsi otot pada

bagian tubuh di bawah level injuri
Incomplete fungsi masih baik (S+m) terdapat pada daerah di
bawah level injuri
Anterior cord syndrome Paralisis di ekstremitas bawah>atas
Central cord syndrome kehilangan kekuatan motoris pada
ekstremitas atas lebih besar disbanding ekstremitas bawah, dengan
tambahan adanya kehilangan sensasi yang bervariasi
Brown sequad hemiseksi dari medulla spinalis dengan kerusakan
pada spinotalamikus dan kortikospinal paralisis otot ipsilateral
(dari lesi taktus kortikospinal) dan hiperestesia terhadap nyeri dan
suhu kontralateral (dari lesi pada traktus spinothalamicus)
Cauda equina retensi urin, pipis terganggu

Anatomy
crossection spinal cord
Ascending Tract
Tracts of Goll and Burdach
(fasc gracilis and cuneatus

Proprioception,vibration,dis
crimination

uncrosssed

Dorsal and ventral

spinocerebellar tract

Proprioception, light touch

uncrossed

Lateral spinothalamic tract

Pain, temperature

crossed

Spinal olivary tract

Tendon and muscle

proprioception

crossed

Ventral spinothalamic tract

Deep tactile and pressure

sensation

crossed

Lateral corticospinal tract

(pyramidal)

Motor control

uncrossed

Rubrospinal tract

Cerebellar reflexes

crossed

Lateral reticulospinal tract

Inhibits locomotor conytrol

crossed

Reticulospinal tract
Vestibulospinal tract

Facilittes locomotor control

Postural control

uncrossed
Uncrossed

Tectospinal tract

Eye and ear reflleces

Descending Tract

crossed

Complete / incomplete Spinal

Cord Lession

Complete cord injury : there is complete loss of

sensation and muscle function in the body below
the level of the injury

An injury to the upper portion of the spinal cord

in the neck can cause quadriplegia-paralysis of
both arms and both legs. If the injury to the
spinal cord occurs lower in the back it can cause
paraplegia-paralysis of both legs only.

Incomplete lesion : there is some

remaining function below the level of the
injury. In most cases both sides of the
body are affected equally.

Present when there is any distal sparing of

motor or sensory function along with
sparing of perirectal sensation

Diff dx of incomplete lesions

Central cord syndrome
Brown sequard syndrome
Anterior cord syndrome
Posterior cord syndrome
Isolated nerve root injury
Cauda equina syndrome (w/ or w/o root
escape)
Conus medullaris injury

Anterior Cord Syndrome

Damage is primarily in the

anterior 2/3 of cord and is
related to vascular insuffiency
There is sparing the posterior
columns
Syndrome is manisfested by
complete motor paralysis
(corticospinal func) and
sensory anesthesi
(spinothalamic func)
Patient demonstrates greater
motor loss in the legs than
arms

Prognosis

anterior cord syndrome has the worst prognosis

of all cord syndromes
prognosis is good if recovery is evident &
progressive during first 24 hours
after 24 hrs, if no signs of sacral sensibility to
pinprick or temp are present,
prognosis for further functional recovery are
poor; only 10 to 15% of patients demonstrate
functional recovery;

Central Cord Syndrome

most common incomplete cord lesion

frequently associated w/ extension injury
to osteoarthritic spine (cervical
spondylosis) in middle aged person who
sustains hyperextension injury
cord is injured in central gray matter, &
results in proportionally greater loss of
motor function to upper extremities than
lower extremities w/ variable sensory
sparing;

Anatomy:
fibers responsible for lower extremity
motor and sensory functions are located in
the most peripheral part of the cord
whereas fibers controlling the upper
extremity and voluntary bowel and bladder
function are more centrally located
sacral tracts are positioned on the
periphery of the cord & are usually spared
from injury;

Mechanism of Injury:
hyperextension injury
central cord injury and hemorrhage occur
with compression of adjacent white-matter
tracts
more peripheral positioning of lower
extremity axons within the spinal cord
tracts accounts for the injury pattern

damage to central portion of corticospinal

and spinothalamic long tracts in white
matter produces upper motor neuron
spastic paralysis of trunk and lower
extremity

Examination
central cord syndrome is remarkable for
more cord involvement in the upper
extremities than in the lower extremities
manifests w/ loss of distal upper extremity
pain & temperature sensation and
strength, w/ relative preservation of lower
extremity strength & sensation

upper extremities:
mixed upper and lower-motor-neuron lesion, w/
partial
flaccid paralysis of upper extremities
(indicative of involvement of lower motor neurons)
prognosis is variable w/ poor hand function
lower extremities:
spastic paralysis of lower extremities (indicative of
involvement of upper motor neurons)
bladder and bowel function may also be lossed;

Brown Sequard Syndrome

type of incomplete cord syndrome

injury to either side of spinal cord
produces ipsilateral muscle paralysis
(from corticospinal tract injury) and
contralateral hypersthesia to pain and
temperature (from spinothalamic injury)

syndrome results from hemitransection of

spinal cord w/ unilateral damage to the
spinothalamic & corticospinal tracts and
resultant loss of ipsilateral motor & dorsal
column function & of contralateral pain
and temperature sensation
often due to penetrating trauma or
unilateral facet fracture or dislocation;

Prognosis:
this syndrome has a good prognosis for
recovery
more than 90% of pts regain bladder &
bowel control & ability to walk
most patients will regain some strength in
lower extremities and most will regain
functional walking ability;;

Cauda Equina Syndrome

urinary retention is the most consistent

finding
in spinal cord injuries, the caudal equina
may sustain considerable initial trauma
in any potential cauda equina syndrome it
is important to examine for saddle
anesthesia, rectal tone, bulbocaverosus
reflex, and sacral sparing;

Initial Evaluation

ABC
Airway, Breathing, Circulation and C-spine
Back board with C-spine immobilization
C-spine lateral x-ray

Management of neurogenic shock

Vascular hypotension with bradycardia
Volume replacement, vasopressor
Avoid pulmonary edema from fluid overload

Associated life-threatening injuries

Spinal Shock
Usually < 24 hrs
Check for BulboCavernosus reflex!!!

Image Study

Plain x-ray
Vertebral height
Focal kyphosis
Level and type of injury

Above T9 spinal cord injury

T10 to L1 spinal cord or root
injury
Below L2 root injury

Computed tomography

Canal compromise

Myelography, MRI

Neurologic Deficits1

Complete vs. Incomplete Injury?

Sacral sparing Incomplete injury

Frankel Classification
A. Absent motor and sensory function
B. Sensation present, motor function
absent
C. Sensation present, motor function
active but not useful (grade 2-3/5)
D. Sensation present, motor function
active and useful (grade 4/5)
E. Normal motor and sensory function

ASIA Classification

Neurologic Deficits

High dose methylprednisolone

30 mg/kg bolus IV injection in 1st hour
5.4 mg/kg/hr continuous IV infusion since 2 nd
hour

Given in 3 hours after injury: maintain 24-hr

therapy
Given beyond 3 hours after injury: maintain 48-hr
therapy
Given beyond 8 hours after injury: no benefit!!!

Surgical Treatment
Indications:
Neurological deficits (+)
Neurological deficits (-)
Fracture-dislocations
Burst fractures

Anterior vertebral height collapse >50%

Focal kyphosis > 30
Canal compromise > 50%
Sagittal index (SI) > 25

Surgical Treatment
Goals:

To create an optimal environment for

neural recovery
To ensure stabilization and early
mobilization
To minimize further neurological
compromise from late deformity

Thank you

http://sejutabacklink.blogspot.com/2011/11
/frakturcedera-medulaspinalis.html