O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.

Cervical spine injury

Evaluation & Management

Audiolivros relacionados

Gratuito durante 30 dias do Scribd

Ver tudo
  • Entre para ver os comentários

Cervical spine injury

  1. 1. 1 CERVICAL SPINE INJURY PRESENTED BY : Dr MK TIWARI
  2. 2. CERVICAL SPINE ANATOMY
  3. 3. LIGAMENTS OF OCCIPITO- ATLANTO-AXIAL COMPLEX 3
  4. 4. Anatomy • Spinal cord ends below lower border of L1 • Cauda equina is below L1 • Mid dorsal spinal cord & neural canal space are of same diameter hence prone for complete lesion • Mechanical injury - early ischaemia, cord edema - cord necrosis • Neurological recovery unpredictable in cauda equina ie. peripheral nerves 4
  5. 5. STABILITY OF CERVICAL SPINE 6
  6. 6. SIGNIFICANCE • Unstable if middle column + either Anterior or Posterior column is damaged • Rupture of interspinous ligament is : - associated with avulsion of spinous process - Unstable spine - Further flexion increases neurological injury 7
  7. 7. LEVEL OF SPINAL INJURY • Neurological level is at the most lowest segment with normal motor & sensory function • Difficult to determine : - As most muscle efferents receive fibers from more than one level - Closed cord lesions may extend over several cms. - Dermatomes have imprecise boundaries. 8
  8. 8. MECHANISM OF INJURY 1 • Impact with persisting compression • Impact with no persistent compression • Distraction • Laceration/Transection
  9. 9. PATHOPHYSIOLOGY • Primary Neurological damage External compression- Direct trauma, hematoma In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis • Secondary damage Hypoxia Hypo-perfusion Neurogenic shock Spinal shock 11
  10. 10. CLINICAL FEATURES • Pain • Respiratory distress • Sensitivity to stimuli • Loss of reflex • Autonomic disturbances • Paralysis 12
  11. 11. PATIENT ASSESSMENT Any of the following patients should be treated as having a SCI until proven otherwise: 1. all victims of significant trauma 2. trauma patients with loss of consciousness 3. minor trauma victims with complaints referable to the spine (neck or back pain or tenderness) or spinal cord (numbness or tingling in an extremity, weakness) 4. associated findings suggestive of SCI include A. abdominal breathing B. priapism (autonomic dysfunction) 13
  12. 12. RADIOGRAPH IN SPINAL INJURY • Lateral C spine views in diagnostic in 80% • Complete set of C spine xray are 90% diagnostic • CT of the C-spine is 98% diagnostic • 22.50 logrolled view for better views of the facets • 450 view shows the intervertebral foramen & facets 14
  13. 13. 15 SCIWORA • Incidence- 3% - 5% • Higher in pediatric age group (35%) • No radiological incidence of fracture/dislocation • MRI findings: » Intervertebral disc rupture » Epidural hematoma » Cord contusion » Hematomylia
  14. 14. 16 MANAGEMENT • Pre hospital management • Hospital management
  15. 15. PREHOSPITAL TRANSFER • Modified left lateral position at scene • Scoop stretcher slotted together around the patient • Repeated assessment enroute • Head down if they vomit • Remove objects from clothes to avoid pressure sores 17
  16. 16. 1.Spinal pain or tenderness, including any neck pain with a history of trauma 2. Significant multiple system trauma 3.Severe head or facial trauma 4.Numbness or weakness in any extremity after trauma 5.Loss of consciousness caused by trauma 6.If mental status is altered 7. Any significant distracting injury SPINAL IMMOBILISTION
  17. 17. CARE IN ED • Careful manual handling especially if unconscious • Jaw thrust is safer • Intubation if respiratory distress or RR>35 • Ryles tube if abdominal distention causes respiratory distress • Catheterize to avoid over stretching of detrusor • IV fluids – paralytic ileus in first 48hrs. • Passive movements to rule out fractures 19
  18. 18. PRIMARY SURVEY STEP 1. Airway: A. Assess the airway while protecting the cervical spine. B. Establish a definitive airway as needed. STEP 2. Breathing: Assess and provide adequate oxygenation and ventilatory support as needed.
  19. 19. STEP 3. Circulation: A. Differentiate hypovolemic shock from neurogenic shock B. Replace fluids for hypovolemia. C. IV Fluid resuscitation D. DRE 21
  20. 20. STEP 4. Disability—Brief Neurologic Examination: A. Determine level of consciousness and assess pupils. B. Determine Glasgow Coma Scale (GCS) score. C. Recognize paralysis/paresis. 22
  21. 21. SECONDARY SURVEY Step 1.Obtain AMPLE history. A. History and mechanism of injury B. Medical history C. Identify and record drugs given prior to the patient’s arrival and during the assessment and management phases Step 2 Reassess level of consciousness and pupils. Step 3.Reassess GCS score. Step 4.Assess the spine 23
  22. 22. NEUROLOGICAL EXAMINATION 24
  23. 23. LEVEL OF NEUROLOGICAL IMPAIRMENT 25
  24. 24. NEUROGENIC SHOCK • Lesions above D6 • Minutes – hours (fall of catecholamines may take 24 hrs) • Disruption of sympathetic outflow from D1 - L2 • Unopposed vagal tone • Peripheral vasodilatation • Hypotension, Bradycardia & Hypothermia • BUT consider hemorrhagic shock if – injury below D6, other major injuries, hypotension with spinal fracture alone without neurological injury. 27
  25. 25. SPINAL SHOCK • Transient physiological reflex depression of cord function – ‘concussion of spinal cord’ • Loss of motor and sensory and reflexes below the lesion • Loss anal tone, reflexes, autonomic control within 24- 72hr • Flaccid paralysis bladder & bowel and sustained Priapism • Lasts till reflex neural arcs below the level recovers. 28
  26. 26. 29 PHASES OF SPINAL SHOCK Phases Physical findings Underlying mechanism Phase-1 0-1 day Areflexia Loss of descending facilitation Phase-2 1-3 days Initial reflex return Denervation supersensitivity Phase-3 1-4 weeks Hyper reflexia Axon supported synapse growth Phase- 1-12 months Hyper reflexia, spasticity Soma supported synapse growth
  27. 27. 30 RADIOLOGICAL ASSESSMENT Awake asymptomatic- discontinuance of cervical immobilization without cervical spinal imaging. Awake symptomatic-continue cervical immobilization , CT imaging Awake symptomatic - normal CT normal X ray Obtunded- CT imaging, if CT unavailable 3 series Xray
  28. 28. C-SPINE XRAY ASSESSMENT 31
  29. 29. LATERAL VIEW 32
  30. 30. ODONTOID VIEW • 33
  31. 31. AP VIEW 34
  32. 32. NORMAL CERVICAL SPINE • Peg & lateral mass distance <2mm and symmetrical • Peg & arch of atlas distance <2mm in adults < 4mm in kids • Above C4 the width is <half of the VB width below C4 its equal to one VB width • Pseudosubluxation of C2 on C3 is normal in young kids& it disappears on extension • C1 and C2 interspinous space <10mm wide • Distance between occiput and atlas <3.5mm • Anterior compression of VB >40% suggest burst fracture 35
  33. 33. ABNORMAL CERVICAL SPINE • Unilateral facet dislocation < half of the vertebral body shifted on the lateral view • Bilateral facet dislocation > half shifted forwards • Wide interspinous gap is unstable (crush fracture or subluxation) suggestive of rupture of the posterior cervical ligament rupture and haematoma formation. • Severe flexion injury – fractures the anteroinferior margin of the vertebral body • Severe extension injury – fractures the anterosuperior margin of the VB. 36
  34. 34. PRINCIPLES OF DEFINITIVE TREATMENT The objectives of treatment are: • To preserve neurological function; • To minimize a perceived threat of neurological compression; • To stabilize the spine; • To rehabilitate the patient 37
  35. 35. ANTERIOR CORD SYNDROME • Flexion rotational force to spine • Due to compression fracture of vertebral body or anterior dislocation • Anterior spinal artery compression • Loss of power, reduced pain and temperature below the lesion. 38
  36. 36. POSTERIOR CORD SYNDROME • Hyperextension injuries • Posterior vertebral body fracture • Loss of proprioception and vibration sense • ataxia 39
  37. 37. CENTRAL CORD SYNDROME • Older age with cervical spondylosis • Hyperextension with minor trauma • Cord is compressed by osteophytes from vertebral body against thick ligamentum flavum. • Damages the central cervical tract • UMN lesion to legs (spastic) • LMN to arms (flaccid paralysis) 40
  38. 38. BROWN SEQUARD SYNDROME • Hemisection of the cord • Stab injury and lateral mass fractures • Uninjured side has good power but absent pinprick and temperature. • Spinothalamic tracts cross to opposite side of the cord three segments below. 41
  39. 39. 42 CERVICAL SPINE FRACTURE 1. hyperextension fracture-dislocations • Posterior fracture-dislocation of the dens • Traumatic spondylolisthesis of the axis (hangman's fracture • hyperextension sprain (momentary dislocation) with fracture • Hyperextension fracture-dislocation with fractured articular pillar • Hyperextension fracture-dislocation with comminution of the vertebral arch
  40. 40. 43 2. HyperfIexion fracture-dislocations • Anterior fracture-dislocation of the dens • HyperfIexion sprain: rare. Occurs when posterior ligaments are disrupted but locking of articular facets does not occur • Locked articular facets with fracture • "Teardrop" fracture-dislocation
  41. 41. 44 CLASSIFICATION AOD
  42. 42. 45 . ATLANTO-OCCIPITAL DISLOCATION
  43. 43. 46
  44. 44. 47 ATLANTO AXIAL DISLOCATION Clinical findings • Patients are usually young. • Neurologic deficit is rare. • Neck pain, headache, torticollis (~ 20° lateral tilt to one side, 20° rotation to the other, and slight (~ 10°) flexion, • Reduced range of motion, dislocation can increase with head rotation towards the subluxed joint with potential injury to the high cervical cord.
  45. 45. 48 IMAGING
  46. 46. 49
  47. 47. 50
  48. 48. 51 . ATLAS (C1) FRACTURE Sudden severe load on the top of the head may cause a ‘bursting’ force which fractures the ring of the atlas (Jefferson’s fracture). Classification Type I: fractures involving a single arch (31-45% of C1 fractures) Type II: burst fracture (37-51%) Type III: lateral mass fractures of the atlas (13-37%)
  49. 49. 52
  50. 50. 53 Landells Atlas Fractures Classification Type-1 Isolated anterior or posterior arch fracture. A "plough fracture is an isolated anterior arch fracture caused by a force driving the odontoid through the anterior arch. Stable. Treat with hard collar. Type-2 Jefferson burst fracture with bilateral fractures of anterior and posterior arch resulting from axial load. Stability determined by integrity of transverse ligament. If intact, hard collar. If disrupted, halo vest (for bony avulsion) or C1-2 fusion (for intrasubstance tear). Type-3 Unilateral lateral mass fx. Stability determined by integrity of transverse ligament. If stable, treat with hard collar. If unstable, halo vest. Dickman Transverse Ligament Injuries Classification Type-1 Intrasubstance tear. Treat with C1-2 fusion. Type-2 Bony avulsion at tubercle on C1 lateral mass. Treat with halo vest (successful in 75%)
  51. 51. 54 HANGMANS FRACTURE
  52. 52. 55 Levine and Edwards Classification Tpe-1 Axial compression and hyperextension • < 3mm horizontal displacement C2/3 • No angulation • C2/3 disc remains intact • stable fx pattern • Rigid collar x 4-6 weeks Type-2 Hyperextension and axial load followed by rebound flexion • > 3mm of horizontal displacement • Significant angulation • Vertical fracture line • C2/3 disc and PLL are disrupted • unstable fracture pattern • If < 5mm displacement, reduction with traction then halo immobilization x 6-12 weeks • If > 5mm displacement, surgery or prolonged traction • Usually heal despite displacement (autofuse C2 on C3 Type-2A Flexion-distraction • No horizontal displacement • Horizontal fracture line • Significant angulation • Avoid Traction in Type IIA. • Reduction with gentle axial load + hyperextension, then compression halo immobilization for 6-12 weeks. Type-3 Flexion-distraction followed by hyperextension • Type I fracture with associated bilateral C2-3 facet dislocation • Rare injury pattern • Surgical reduction of facet dislocation followed by stabilization required.
  53. 53. 56 MANAGEMENT
  54. 54. 57 ODONTOID FRACTURES
  55. 55. 58
  56. 56. 59
  57. 57. 60
  58. 58. 61 CLASSIFICATION Anderson and D'Alonzo Classification Type -I Oblique avulsion fracture of tip of odontoid. Due to avulsion of alar ligament. Although rare, atlanto-occipital instability should be ruled out with flexion and extension films. Type -II Fracture through waist (high nonunion rate due to interruption of blood supply). Type -III Fracture extends into cancellous body of C2 and involves a variable portion of the C1-C2 joint.
  59. 59. 62
  60. 60. 63 TREATMENT Type I fractures Isolated fractures of the odontoid tip are uncommon. • They need no more than immobilization in a rigid collar until discomfort subsides.
  61. 61. 64 Type II fractures- often unstable and prone to non- union, especially if displaced more than 5 mm. Undisplayed fractures- held by fitting a halo vest or in elderly patients a rigid collar. Displaced fractures- traction and can then be held by operative posterior C1/2 fusion, a drawback is that neck rotation will be restricted
  62. 62. 65
  63. 63. 66 POSTERIOR LIGAMENT INJURY
  64. 64. 67 WEDGE COMPRESSION FRACTURE
  65. 65. 68 TEAR DROP FRACTURE
  66. 66. 69
  67. 67. 70
  68. 68. 71
  69. 69. WHIPLASH INJURY • Sudden hyperextension and flexion • Increasing neck pain for the first 24hours • Associated headache, pain radiating to both shoulders and paraesthesia in hands • Reduced lateral flexion • Anterior longitudinal ligaments are torn causes dysphagia • Forward flexion against resistance is painful • 90% are asymptomatic after 2years • 10% still have pain • Some still claim money hence the need for proper documentations. 72
  70. 70. 73 WHIPLASH INJURY
  71. 71. 74
  72. 72. 75
  73. 73. 76 TAKE HOME MESSAGE • Over half of spinal cord injury occurs in cervical spine region • Cervical spine immobilization(hard collar+spinal board) • Neurogenic shock is triad of hypotension, bradycardia & peripheral vasodilatation

×