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SPINAL CORD INJURIES

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Title: SPINAL CORD INJURIES


1
SPINAL CORD INJURIES
  • M.R.EHSAEI M.D
  • ASSOCIATE PROFESSOR OF NEUROSURGERY

2
Anatomy of spine
  • Complete spine contains
  • 7 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 4 coccygeal
  • Spinal cord protection
  • Ligaments

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Ligaments of spine
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Vertebra (29) 7 cervical, 12 thoracic, 5
lumbar, 5 sacral Conus medullaris at L1-2
vertebrae 31 spinal cord segments 8 cervical,
12 thoracic, 5 lumbar, 5 sacral, and 1
coccygeal C1 dorsal roots missing in some
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Cerebrospinal fluid Clear 50-200 mm H2O
pressure 0-10 WBC 0 RBC lt 45 mg/100
ml protein glucose 2/3 blood level
50-80 mg/100 ml
Spinal tap done at L3-L4
Dural sac ends at vert. S1-S2
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Cervical Spine
  • C1 Atlas
  • C2 Axis
  • Vertebral canal space for spinal cord
  • Intervertebral foramen nerves exit from canal

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Anatomy of spine
  • Anterior column
  • Half of Vertebral bodies and intervertebral disc
  • Anterior longitudinal ligament
  • Middle column
  • Half of Vertebral bodies and intervertebral disc
  • posterior longitudinal ligament
  • Posterior column
  • Pedicles, facet joints, lamina
  • Supraspnious, interspinous, infraspinous ligaments

13
SPINAL CORD INJURIES
Car Crashes 83 Motorcycle incidents
10 Bicycle accidents 3
Medical/Surgical Complications 38 Hit by
falling Object 30 Pedestrian 22
Gunshot 92 Personal Contact 6
Diving 55 Snow skiing 8 Surfing 6
Source National Spinal Cord Injury Statistical
Center
14
Epidemiology
  • Spinal injury
  • Motor vehicle crashes 41
  • Falling down 21
  • Sporting activity8
  • Human violence22
  • Others8
  • Average age 34yrs
  • MF 41

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Epidemiology
  • Approx. 100,000 new cases/year, 80 male. Age
    group most commonly injured 16-30 years (43)
    and 31-45 (28).
  • Although Vehicle is the leading cause overall,
    Falls become the leading cause in people over 60
    years.

16
Spinal Cord Injuries
  • Traumatic injury of vertebral and neural tissues
    due to compressing, pulling or shearing forces
  • Most common locations cervical (12), cervical
    (4-7), and 12th thoracic 2nd lumbar vertebrae
  • Locations reflect most mobile portions of
    vertebral column and the locations where the
    spinal cord occupies most the the vertebral canal

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Spinal Cord Injuries
  • Vertebral injury can occur due to fracture,
    dislocation, or both.
  • Within minutes after injury, hemorrhages appear
    in the central gray matter, pia, and arachnoid.
  • Local hemorrhages reduce vascular perfusion

18
Cervical spine
19
Spinal Cord Injuries
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General Symptoms Signs
  • Pain Tenderness
  • Skin abrasions or contusions
  • Subcutaneous Hematoma
  • Muscle Spasm
  • Cripitation in Touch
  • Spinal Deformity

22
Neurological Exam
  • Detection Documentation
  • Sensory Level
  • Posterior Column function
  • Sacral Sensory Sparing
  • Muscle Weakness (0 - 5 )
  • Pathological Reflex (BCR Babinski)
  • Rectal Exam for Tone cotracture

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Neurological evaluation
  • Complete inj.no motor or sensory function below
    the zone of inj.
  • Incomplete inj.partial preservation of motor or
    sensory function below the zone of inj.

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Neurological evaluationcervical inj.
  • Incomplete inj.
  • Ant cord syn.
  • Central cord syn.
  • Brown-sequard syn.
  • Post.cord syn.
  • Spinal shock
  • hypotension without tachycardia
    (motor,sensory,and reflexes are absent but cannot
    determine complete inj.until bulbocavernosus or
    other reflexes return within 24 houres.)

26
Incomplete Spinal Cord Lesions
  • The anterior cord syndrome
  • cervical flexion injuries causing cord contusion
  • protrusion of a bony fragment or herniated
    intervertebral disk into the spinal canal
  • laceration or thrombosis of the anterior spinal
    artery
  • rarely, systemic embolization or prolonged
    cross-clamping of the aorta during resuscitation
    or surgery

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Incomplete Spinal Cord Lesions
  • central cord syndrome (m/c)
  • affects the central gray matter and the most
    central portions of the pyramidal and
    spinothalamic tracts
  • a greater neurologic deficit in the upper
    extremities than in the lower extremities

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Incomplete Spinal Cord Lesions
  • The Brown-Séquard syndrome, or hemisection of the
    spinal cord
  • a penetrating lesion such as a gunshot or knife
    wound
  • ipsilateral motor paralysis and contralateral
    sensory hypesthesia distal to the level of injury

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Neurologic status frankel scale
  • a) no motor or sensory function
  • b) sensation but no motor function
  • c) motor function present but useless
  • d) motor function present but useful
  • e) normal motor and sensory

30
Neurologic exam cervical inj.
  • C4(spont.breathing),C5(deltoids and biceps)
    C6(wrist ext.),C7(triceps and wrist ext.),C8
    (finger flex.),T1(intrinsics).
  • SensoryC5(upper outer arm),C6(thumb),C7 (long
    finger),C8(little finger),T1(medial forearm).

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Prognosis of spinal cord inj.
  • Complete inj usually remains complete,but one or
    two level recovery is expected.
  • Incomplete inj.have potential for significan t
    recovery, particlarly in bronwn-sequard and
    central cord syn.

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Prognosis of spinal cord inj.
  • Gunshot wound to the spine with spinal cord
    inj.carry a poor prognosis for recovery.
  • Spinal cord recovery is better if bony impingment
    is removed for incomplete type.
  • Patients with congenital C1-C2 instability and
    congenital stenosis have higher incidence of
    spinal cord inj.

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Prognosis of spinal cord inj.
  • Patient with ankylosing spondylitis often sustain
    unstable three-column inj.,even with minor
    trauma.
  • High dose corticosteroid is administrated early
    to patient within 8 hours of inj. to improve the
    prognosis.

34
RADIOLOGICAL studies
  • Plain x-ray
  • Ap--LAT--Open mouthOblique- Pillar
    view--Stretch test--Flexion/Extension view
  • Tomography
  • C.T scan best modality for bony lesion.
  • Myelography
  • C.T myelography
  • M.R.I best for soft tissue and give prognosis
    after inj.

35
RADIOLOGICAL studies cervical inj.Plain X-Ray
LATERAL
  • must see C7-T1(obtain swimmers view if
    necessary)
  • soft tissue ant. to the cervical spine 10mm at
    C1,4-5mm at C2-C4, up to 15mm at C4-C7.
  • Loss of lordosis may be an important sign.
  • Vertebral alignment more than 3.5mm
    displacement, and 11degree angulation are
    significant for instability.
  • spinal canal diameter17mm (N),less than
    14mm(Abnor).

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RADIOLOGICAL studies cervical inj.Plain X-Ray
  • Obliques intervertebral and pedicles.
  • Pillar view(hyperextention and 35 rotation)
    lateral masses between facets.
  • Stretch testgt1.7mm and 7.5angulation on
    rotation signifies post. instability.
  • Flexion/Extension viewLig.inj.(usually preformed
    3 weeks later.

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Upper cervical inj.
  • occipital condylar fx.
  • occiput-c1 dislocation.
  • C1-C2 subluxation.
  • fracture of C1.
  • frature of odontoid.
  • fracture through the pedicle of C2.

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Occipital condylar fx.
  • diagnosis with tomogram or C.T scan.
  • lig.inj, I.c.hematoma,and neurological deficit
    may accompany this inj.
  • treatment
  • usually rigid orthosis or halo vest for 3 m.
  • flex/ext film is obtained at 3 m.
  • occiput to c2 fusion if resultant instability.

41
occiput-c1 dislocation
flex/ext force on the head. disruption of all
lig. unstable and always fatal. treatmentoccipu
t-c1 fusion.
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C1-C2 subluxation
  • Rupture of transverse lig.
  • Atlantodens interval
  • 3-5mm indicate rupture of transverse lig.
  • gt7-8mm indicate all lig.disruption.
  • gt10mm causes spinal cord compression.
  • Treatment
  • if instability 3-5mmgthalo for 2-3 m then
    dynamic study repeated.if instability gt4mm then
    needs fusion c1-c2.
  • if instability gt5mm then early fusion c1-c2.

43
C1-C2 subluxation
  • Atlantoaxial rotatory fixation the head is
    tilted toward the side of fixation and the chin
    and c2 spinous process is pointed toward the
    opposite direction.
  • Type 1 rotatory fixation with no ant.
    displacement.
  • Type 2 rotatory fixation with 3-5mmant.displacem.
  • type3 rotatory fixation withgt5mm ant
    displacement
  • Type4rotatory fixation with post.displacement.
  • tratment reductionc1-c2 fusion if unstable.

44
Stable Upper cervical Injuries
  • Atlas fractures
  • ant. arch fx.
  • post. arch fx.
  • lat. mass fx.with less displacement.
  • Axis fractures
  • type 1 odontoid fx.
  • hangman fx.without angulation.

45
Fracture of C1
  • Axial loading usually with breaks at two sites.
  • gt7mm widening of lat.massgttrnsverse lig.rupture
    .gtfirst immobilization with hallo for 2-3m and
    C1-C2 fusion may be performed if instability is
    greater than 5mm.

46
Fracture of C1
  • TREATMENT
  • Cervical orthosis for 3 m if nondisplaced.
  • Halo vest for 3m if displaced or delayed union.
  • Posterior C1-C2 fusion if nonunion.
  • If C1-C2 instability with gt7mm lat.mass displa.
    halo traction for 4-6w and halo vest for 6w. if
    unable to tolerate prolonged trction,early C1-C2
    fusion is recommended.

47
Fractures of odontoid
  • Type 1rare,avulsion fracture of the tip. stable
    and treatment is cervical collar.
  • type 2 fracture at the base of the odontoid.
  • ant .displ.(flex.inj.) is more common than post
    displ.(ext.inj.).
  • nonunion rate is 20-80 especially age gt50 y.
  • Type 3fracture through the body.
  • nondisplaced cervical orthosis or halo.
  • displaced halo jacked for 3m.

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ODONTOID FX
  • FIXATION OF ODONTOID

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Fractures through pedicle of C2
  • Mechanism of Hangman fracture ext.inj.
  • Types
  • type 1 minimal displacement(less than 3mm)
  • type 2 significant displacement (gt3mm) and
    angulation(gt11 deg.)
  • type 2A minimal displacement(lt3mm) and
    angulation(gt11 deg.)
  • type 3 associated facet dislocation.

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Fractures through pedicle of C2
  • Treatment
  • type 1 halo jacket for 12 w.
  • type 2traction for 2-3w for reduction halo for
    10-12w.
  • type 2A no traction,extention,and
    compression,halo for 3m.
  • type 3 or late instability or nonunion ant.C2-C3
    fusion or post pedicular screw fixation(C2-C3
    plating.

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FRACTURE AND DISLOCATIONS OF LOWER CERVICAL SPINE
  • CLASSIFICATION

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CLASSIFICATION(ALLEN)
  • Distructive flexionperched facet,unilateral or
    bilateral facet dislocation.
  • Vertical compressionburst fx.
  • Compressive flex. comp.fx.tear drop fx.
  • Compressive ext.fx of post element body
  • Lat.flexion uncommon.
  • Distractive ext.widening of disc or
    retrolisthesis.

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M.R.I of cervical
  • At C4-C5 , Disruption and Widening of the
    intervertebral Disc, compression fracture of C5,
    anterolisthesis of C4-C5

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Facet fracture/dislocation
  • UNILATERAL OR BILATERAL.
  • MAY BE WITH DISC HER. CORD COMP.
  • IN UNILATERAL DISPLACEMENT IS ABOUT 25
  • IN BILATERAL DISPLACEMENT IS ABOUT 50 .

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Stable Lower Cervical Injuries
  • unilateral facet dislocation
  • compression fx.
  • hyperextension injuries
  • clay shoveler,s fx. (fx of s.p)
  • SCIWORA

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Instability defined by
  • X -rays
  • plain ,C.T.S , M.R.I
  • Clinical
  • neurologic deficits
  • persistant pain

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White diagnostic checklistgt5 is unstable
  • ant element2
  • post element2
  • sagital translationgt3.5 mm or20 vertebra2
  • sagital plan rotation gt 11deg.2
  • poitive stretch test2
  • cord damage2
  • root damage1
  • abnormal disc narrowing 1
  • dangerous loading anticipated 1

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  • Myelogram

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  • C.T SCAN

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  • C.T Myelogram

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Medical anagement
c.s.inj.
  • Acute care
  • prehospital management
  • emergency room manangement
  • Spinal orthoses

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prehospital Management
c.s.inj
  • 1

All accident victims of any sort must be assumed
to have an unstable spine until prove otherwise.
immidiate immobilization of head and neck is
important
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prehospital Management
c.s.inj
  • Check airway
  • Mouth check for debrids and cleared.
  • Oropharyngeal or nasopharygeal airway.
  • Gentle intubation if indicated.
  • Indication of intubation
  • hypoventilation due to paralysis of the
    intercostal muscles.
  • loss of conscious level with spinal injury.

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prehospital Management
c.s.inj
  • Respiratory and circulatory manageme- nt at the
    scene of accident is critical.
  • Because aspiration and shock are the primary
    cause of death in spinal cord injury victims.
  • Supplemental oxygentherapy.
  • Maintenace of B.P within normal limits.
  • Foly catheter for output monitor.

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prehospital Management
c.s.inj
  • Method of intubation
  • Gentle manual traction
  • Blind nasal intubation advocated
  • In the presence of basilar skull fracture nasal
    intubation is contra -indicated.

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prehospital Management
c.s.inj
  • assessment of circulation
  • hypotension in a spinal cord injured patient may
    be result of loss of sympathetic tone with
    decreased periphera vascular resista- nce
    secondary to the neurological injury.
  • this results in venous pooling and decrea -sed
    cardiac preload,which is exacerbated by lack of a
    reflex, sympathetically mediat -ed tachycardia.

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Transport of patient
c.s.inj
  • patient should be placed in a supine position on
    a long backboard as soon as possible.
  • immobilization of neck with sanbags.
  • fixation of head with tape across the forehead.

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Acute evaluation and management in the
  • Emergency room

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Emergency Room Manageent
_at_Respiratory function should be control
_at_
if the blood pressure remaine low despite
resu- scitation with intravenous fluids then a
pressor such as dopamine should be started and
titrat- rated to effect.
_at_Full skeletal x-ray chest-pelvis-spine in
patient with low GCS c.t scan should be
taked. 11 incidence of head and spine injury.
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Emergency Room Managememt
c.s.inj.
  • Hypothermiadisruption of sympathetic nerve
    function at T8 or above that.
  • If patient need life saving surgery ap and lat
    x-ray of cervical should be taked. if possible
    thoracolumbar area should also be imaged.

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Emergency Room Managememt
c.s.inj.
  • Old method of treatment
  • Hypothermia
  • Hyperbaric oxygen
  • Electomagnetic feilds
  • DRUGS
  • Steroids I.v (dexa-methylprednisolon)
  • Lidocain I.v
  • Opiate antagonist Naloxone

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Emergency Room Managememt
c.s.inj.
  • High dose of methylprednisolon improve
    neurological outcome in spinal cord injury
    patients. (compared with placebo and naloxone)
  • Adminestration dose within 4-8 h bolus
    dose 30 mg/kg/in 15min continue with 5.4 mg/h
    for next 23 h.

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Emergency Room Managememt
c.s.inj.
  • other protecols
  • calcium channel blockers----gt nimodipine
  • medulators of exitotoxicity----gt
    phencyclidine ,dextrophan.
  • blockers of lipid peroxidation and membrane
    destruction----gt 21-amino steroids and GN1
    gangliocyte.

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Emergency Room Managememt
c.s.inj.
  • After diagnostic cervical spine films are
    obtained,unstable or displaced spinal column
    injuries should be initially treated wit cervical
    traction.
  • Most common type of traction is Gardner- wells
    tongs.
  • The amount of weight5 pound per vertebral level
    above the fx/dis.

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Emergency Room Managememt
c.s.inj.
  • Complication of traction
  • overdistraction
  • tong dislocation
  • pin site infection
  • skull penetration

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Management with spinal orthses
  • GOALS of immobilization by s.ort
  • reduce motin in unstable segment.
  • reduce pain .
  • correct deformity.
  • protect the spinal cord.

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Who is the best orthoses for?
  • _at_Less rigide orthoses
  • _at_More rigide orthoses

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Four type of cervical orthoses
  • Collars
  • soft collar and philadelphia collar
  • Poster-type orthoses
  • gliford and somi
  • Cervicothoracic devices
  • minerva body jaket
  • Halo orthoses halo vest

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  • Miami-Jackson collar
  • For cervical stabilization

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  • Guilford brace

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  • Occipitoatlantoaxial fusion with the Luque
    rectangle

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  • CERVICAL PLATE

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  • Ant. Odontoid
  • Scrow
  • fixation

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Thoracic Thoracolumbar
Spine Fx.
Compression Fx. Burst Fx. Seat
belt Fx. Fx. dislocation
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Compression Burst Fx.
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FOUR SUBTYPE OF WEDGE COMPRESSION FX.
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Burst fractures
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seat belt-type injuries
One level
  • Chance fx.
  • Through the bone

Two level
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Decreasing of body height (D E / D ) .
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Shearing Fracture
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Burst Fx. With Rotation
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Flexion-rotation type inj.
  • Through the bone (slice fx.)
  • Through the disc

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LISTHESIS
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Sacrum Fx.
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  • Tkank you

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Clinical Paraclinical Presentation in
Thoracolumbar Injury
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General Symptoms Signs
  • Pain Tenderness
  • Skin abrasions or contusions
  • Subcutaneous Hematoma
  • Muscle Spasm
  • Cripitation in Touch
  • Spinal Deformity

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Neurologic Injury
  • 10 - 38 all TL Injuries
  • 50 Fracture-Dislocations
  • Trauma between T5 - T9 has more chance for N.D.

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Neurological Exam
  • Complete or Incomplete
  • Frankel Classification
  • ASIA Motor index Score
  • Repeated Examination

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Frankel Classification
  • A Complete loss(motor sensory)
  • B ,, motor loss,some sensory
  • C Motor useless, Sensory good
  • D Motor useful , but weak
  • E Neurologically Intact

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ASIA motor index score
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ASIA motor index score
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Neurological Exam
  • Dtection Documentation
  • Sensory Level
  • Posterior Column function
  • Sacral Sensory Sparing
  • Muscle Weakness (0 - 5 )
  • Pathological Reflex (BCR Babinski)
  • Rectal Exam for Tone cotracture

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Prognostic Signs
  • Spinal shock
  • Bulbocavernosus Anal Reflexes
  • Some return of Motor or Sensory function

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Clinical Syndromes
  • mixture of Cord Root Syndromes. (T11 - L2
    ) complete sacral cord Damage variable
    sparing of the lumbar roots.
  • (the most common syndrome) incomplete sacral
    cord lesions (less common)

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Clinical Syndromes
  • solitary or multiple Radiculopathies
  • Cauda equina syndrome

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Imaging
  • X- Ray
  • 5-20 F are multiple
  • 5 at noncontaguious level
  • Lateral View
  • Oblique Views
  • A-P View
  • Flexion Extension Views (CI)
  • A-P View of Pelvis

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Abnormalities in X-Ray
  • Abnormalities of Alignment
  • Kyphotic angulation
  • loos of lumbar lordosis
  • Vertebral disruption

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Abnormalities in X-Ray
  • Disc space Narrowing
  • Naked Facets
  • interspinous distance Widening
  • Paraspinal soft tissue mass
  • Loss of the psoas stripe

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Imaging
  • CTScan
  • on areas suspected
  • bone soft tissue windows
  • 4 - 5- mm -thick
  • Sagital re-formation

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Imaging
  • MRI
  • Adventages
  • better visualization of the cord Ligaments
  • Multiple plan of images
  • Disadventages
  • restriction for life support Equipments
  • motion artifact
  • marginal bony detail

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Complications of Spinal Cord Injury
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All Organs will be involved
  • 2 Main cause1 - Immobility2- loss of central
    control ( paralysis )

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Skin
  • Decubitus Ulcer
  • Sacrum
  • Occiput
  • Heel
  • Shoulder
  • Trochanter

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Skin Ulcers
  • Prevetion
  • Roto-Rest table
  • Skin Hygiene

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Skin Ulcers
  • Treatment
  • Cost 75000

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Respiratory
  • Most common complications in quadriplegic
    Patients in ICU

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Respiratory
  • Cause of Complications
  • Paralysis of Muscle
  • Secretions Stasis
  • Atelectasis
  • Direct trauma to lung

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Respiratory Complications
  • Pneumonia
  • Pneumothorax
  • Plural efusion
  • Lung abscess

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Respiratory Complications
  • Treatment
  • Profilactic Intubation
  • nasotracheal Route
  • above C4 Elective Tracheostomy
  • Periodic monitoring Exam X-Ray Ultasound

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Cardiovascular
  • Arrhythmias
  • Phlebitis
  • Deep vein thrombous
  • Pulmonary emboli
  • Fatal Type 3 - 13

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Cardiovascular
  • Prevention
  • Constant EKG monitoring
  • CVP Swan-Ganz catheter
  • prophilactic Heparin
  • Compression leg devices
  • Kinetic therapy

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Urinary System
  • frequent Infectinos
  • Calculus Formation
  • Incotinance
  • Retention

158
Urinary Complications
  • Prevention
  • maintain good urinary output 400 ml/4h
  • Culture from Foley/ per 4 days
  • Intermittent Catheterization /per 4 h

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Gastrointestinal
  • Ileus
  • Acid hypersecretion
  • GI Ulcerations
  • GI Hemorrhage
  • chronic Constipation
  • Pancreatitis

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GastrointestinalComplications
  • Prevention
  • H2 blocker or similar drugs
  • Gastric secretion drainage
  • central Hyperalimentation
  • start feeding after good bowel sound

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Skeletal System
  • Massive Ca moblization
  • urinary stones
  • heterotopic Bone
  • osteoporosis
  • high risk of Pathological fr

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Psycological complications
  • Denial Phase
  • Anger phase
  • Depression phase
  • Coping Phase

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Miscellaneous complications
  • Sepsis
  • Most common cause of Morbidity in Spinal injury
  • urinary or bed sore
  • Catabolic state
  • Neurogenic Hypotension

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  • Burst Fx L1

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  • Burst Fx

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