TRAUMA SPINAL

Dr Bambang Priyanto, SpBS

 Kasus
 Laki-laki usia 19 tahun, dibawa ke
UGD karena tidak bisa
menggerakkan kedua kaki setelah
mengalami kecelakaan lalu lintas
naik sepeda motor ditabrak truk 2
jam sebelumnya.
ACUTE SPINAL
CORD INJURY
 Outlined
1. Anatomy and Physiology
2. Epidemiology
3. Clinical Sign and Symptoms
4. Radiolographic Investigation
5. Diagnosis and Management
6. Prognosis and Rehabilitation
1. Anatomy and Physiology
31 pairs of spinal
nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
 Dermatomes
 Area of skin innervated by sensory
axons within a particular segmental
nerve root
 Knowledge is essential in

determining level of injury

 Useful in assessing improvement or

deterioration
Dermatomes
 Myotomes :
 Segmental nerve root innervating a muscle
 Important in determining level of injury

Upper limbs: Lower Limbs :

C5 - Deltoid L2 - Hip flexors
C 6 - Wrist extensors L3,4 - Knee extensors
C 7 - Elbow extensors L4,5 – S1 - Knee flexion
C 8 - Long finger flexors
L5 - Ankle dorsiflexion
T 1 - Small hand muscles
S1 - Ankle plantar flexion
 Pathophysiology
 Primary injury
• directly disrupts axons, blood vesseles
and cell membranes
 Secondary injury
• Vascular dysfunction, edema, ischemia,
excitotoxicity, electrolyte shifts, free
radical production, inflammation and
delayed apoptotic cell death.
2. Epidemiology
 Epidemiology of SCI
 15-40 cases/million  severe physical,
psychological, social and economic problems pts
and families
 Predominantly young, healthy and workers (15-
24 yrs)
 Male : Female = 4 : 1
 Common causes :
• Motor vehicle accidents (50%)
• Falls and work-related (30%)
• Violent (11%)
• Sport (9%)
Spinal Injuries

15
3. Cinical Sign and Symptoms
 Suspicion of
Neurologic Injury
 History
• Pain/paresthesias
• Transient or persistent motor or
sensory symptoms
 Physical Examination
• Abrasions/hematoma
• Tenderness
• Interspinous process widening
 Spine Injury PE Pearls
 Suspect Spinal Cord Injury in:
• Patients with Altered Mental Status
 Secondary to trauma or toxin (ETOH)
• Patients with unexplained hypotension
and bradycardia
• Elderly patients with OA or spondylosis
• Children, especially <8 years old.
 SCIWORA – Normal XR with Neuro
abnormality
 Spinal Cord Injury PE Findings
 Flaccid arreflexia
 Loss of sphincter tone

 Diaphragmatic abdominal breathing

 Priapism

 Hypotension + Bradycardia

 Facial reaction to painful stimulus

above (but not below) the clavicle

 Spinal Cord Injury PE Findings
 A COMPLETE HISTORY AND PE a MUST
• INCLUDING a thorough NEURO EXAM!!

 Sensory/Motor Dermatomes
ROOT MOTOR SENSORY
C3 Diaphragm, Trap Lower neck
C4 Diaphragm Clavicular area
C5 Biceps, Deltoid Below clavicle
C6 Biceps Thumb & Lat. Forearm
C7 Triceps Index & Middle Fingers
C8 Finger Flexors Little Finger
T1 Hand Intrinsics Medial Arm
Complete:
i) Loss of voluntary movement of
parts innervated by segment, this
is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:

i) Some function is present below

site of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury,
although they are rarely pure and
variations occur
 ASIA (American Spinal Injury Association)
Impairment Scale
 Class A : Complete, no motor or sensory
preserved in sacral segment S4-5
 Class B : Incomplete, sensory but no motor
function preserved below lesion
 Class C : Incomplete, motor function preserved
below lesion (lebih dari separuh otot
mempunyai kekuatan motorik< 3)
 Class D : Incomplete, motor function preserved
below lesion (lebih dari separuh otot
mempunyai kekuatan motorik ≥3)
 Class E : Normal, Sensory and Motor function
4. Radiographic Investigation
 Radiographic Investigation

 Trauma series includes: lateral cervical,

chest, lateral thoracic, A/P and lateral
lumbar and A/P pelvis

 Obtunded patients require further skeletal

survey
• Mackersie et al J Trauma 1988
 Additional Imaging
 CT scan – bony injuries

 MRI – images spinal cord, intervertebral discs,

ligamentous structures
CERVICAL SPINE
Normal Cervical Spine – 3
views
 Cervical Spine Injuries
 Injuries classified by mechanism of injury and
stability.
 Unstable C- Spine fractures:
• Remember “ Jefferson bit off a hangmans
thumb”
• Jefferson Fracture ( burst Fx of C1)
• Bilateral facet dislocation
• Odontoid fracture
• Any fracture with sublux
• Hangmans fracture
• Teardrop fracture
Jefferson Fx / Bilateral Facet
Odontoid Fx / Any Fx with Sublux
Hangmans Fx / Teardrop FX
Thoracolumbar Fracture
 A : Compression
• A1 : Wedge
• A2 : Split/Coronal
• A3 : Burst
 B : Distraction
• B1 : posterior soft tissues
(subluxation)
• B2 : posterior arc (Chance
fracture)
• B3 : anterior disc
(extension spondylolysis)
 C : Rotational/Translasi
• C1 : Anteroposterior
(dislocation)
• C2 : Lateral (lateral shear)
• C3 : Rotational (rotational
burst)
 Thoracolumbar Injury
Classification and Severity (TLICS) Scale
 Morphology trauma
• Compression :1
• Translational/rotational : 3 Treatment
• Distraction :4  Non Operative :<4
 Neurological status  Op/non op :4
• Intact : 0  Operative :>4
• Nerve injury : 2
• Spinal cord injury :
 complete 2/incomplete 3

• Cauda equina :3
 Posterior ligamentous integrity
• Intact :0
• Suspected/undetermined :2
• Disrupted :3
 Examples
Flexion Compression Fx
Flexion compression (morphology) - 1
Intact (neurology) - 0

PLC (ligament) no injury - 0

Total 1 points- Non Op

 Compression
Burst-Complete injury
 Axial compression burst-2
 Complete (neurology)-2

 PLC (ligament) Intact-0

Points 4-Non Op vs Op
 Translational/Rotation Injury

Distraction, Translation/rotational,
compression injury - 4
Complete (neurology) – 2

PLC injury - 3

Total 9 points-
Surgery
5. Diagnosis and Management
 Spine Injury Diagnosis
 Assume Injury

 Spine Xray
• ANY abnormality
 Keep in immobilisation
 Xray entire spine
 Consider CT scan

 CT SCAN of Spine
• Indications:
 Inadequate or suspicious plain films
 “Normal” films in patient with abnormal neuro exam
 Fracture/dislocation, Posterior arch Fx, Burst Fx

 MRI of Spine
• Spinal cord injury
• Soft tissue injury
 Spine Injury Management

 As always ABC’s with Spine immobilization

 IV, O2, Monitor
 Neurological evaluation
 Steroid Protocol:
• Indications:
 High dose steroids beneficial in patients with blunt cord
injury who present < 8 hours
 Methyprednisolone 30mg/kg bolus, then start infusion
@ 5.4mg/kg/hr for 23 hours
 Treatment of Spinal Injuries
 No Current Effective Treatment

 Prevention is Key
all current medical and surgical
treatments aimed to prevent further
injury to the spinal cord

 Goals
• Stabilisation and Decompresion
 Immediate Management-
Goals:

 Resuscitation according to ATLS

guidelines
 Determination of neurological injury

 Prevention of neurological deterioration

 Ongoing ID & Tx of assoc injuries

 Prevention of complications

 Initiation of definitive management for

vertebral column injury or SCI

 Airway
 Risk Associated  Ventilatory Function
with Level of • C1 - C7 = accessory
Injury muscles
• C3 - C5 = diaphragm
 Decision to
“C3-4-5 keeps the
Intubate diaphragm alive!”
 Airway • T1 - T11 =
Intervention  intercostals
• T6 - L1 = abdominals
INTUBATE
 Breathing
Cough Function Vital Capacity (acute phase)
 C1-C3 = 0 - 5% of
 C1-C3 = absent

 C4 = non-functional
normal
 C4 = 10-15% of normal
 C5-T1 = non-
 C5-T1 = 30-40% of
functional
 T2-T4 = weak
normal
 T2-T4 = 40-50% of
 T5-T10 = poor
normal
 T11 & below =
 T5-T10 = 75-100% of
normal normal
 T11 and below = normal
 Breathing
 Intervention
• O2 therapy
• Assisted ventilation PRN
• Medications (bronchodilators)
• Positioning and mobilizing
• Chest physio
• Assisted Cough
 Circulatory
Spinal Shock Neurogenic Shock
 Temporary suppression
of all reflex activity
 The body’s response
below the level of to the sudden loss
injury of sympathetic
 Occurs immediately control
after injury
 Intensity & duration
vary with the level &  Distributive shock
degree of injury
 Once BCR returns,
spinal shock is over  Occurs in people
who have SCI above
T6 (> 50% loss of
 SYOK TD <90
SYOK HIPOVOLEMIK SYOK NEUROGENIK
(PERDARAHAN)
NADI ↑ NADI ↓
KERINGAT ↑ TIDAK BERKERINGAT
AKRAL DINGIN BIASA
Hb ↓ Hb NORMAL
PCV ↓ PCV NORMAL

TERAPI : TERAPI :
CAIRAN  DARAH VASOPRESSOR
SULFAS ATROPIN
ANALGETIK
 GI System
 Risk of aspiration is high d/t:
• cervical immobilization
• local cervical soft tissue swelling
• delayed gastric emptying
 Parasympathetic reflex activity is altered,
resulting in:
• decreased gut motility and
• often prolonged paralytic ileus.
 GI Intervention

 Minimizing Risk for Aspiration:

• Nasogastric tube

 Minimizing Risk of Gastric Ulceration:

• IV Ranitidine 50mg IV q8h
 GU System

 All ASCI patients initially managed with

indwelling urinary catheter

Skin Care: Common Sites of Pressure
Sores

Occiput
Sacrum

Trochanter

Ischium

Ankle

Heel
 Skin Intervention

 Remove spine board

 Turn or reposition individuals with SCI

initially every 2 hours in the acute phase if
the medical condition allows.

Consortium
 Pain Management
 Nociceptive: Musculoskeletal and
Visceral
Responds well to opioids and
NSAIDS
 Neuropathic: Above Injury/At Injury
Level/Below Injury Level
• Somewhat sensitive to Morphine
• More sensitive to anticonvulsants
(gabapentin) and tricyclics (nortryptiline)

www.iasp-pain.org
 Pharmacologic Therapy
 Option:
Methylprednisolone Neurosurgery

 Others:
• Antioxidants
• NSAIDs
• Antagonis Calcium, Nimodipine
• Analgetics
• Antibiotics
MethylPrednisolone :

• 30mg/kg IV loading dose + 5.4 mg/kg/hr

(during 23hrs)
• effective if administered within 8 hours of
injury
NASCIS II (1992)

• If initiated < 3hrs continue for 24 hrs, if 3-

8 hrs after injury, continue for 48hrs
(morbidity higher - increased sepsis and
pneumonia)
NASCIS III (1997)
 Transfer Checklist
Spinal immobilisation
NG insitu


 Airway risk is identified
 Foley catheter
ETT if PaCO2 =
 Skin is protected
50mmHg or
greater
 Level of SCI
 Supplemental O2 documented
 Assisted ventilation PRN  X-rays, CT, MRI
 MPSS in progress if accompany
appropriate
patient
 Family contacts
documented
6. Complication and Rehabilitation
 Complication
 Ulcus decubitus
 Contractur/Spasticity

 Deep vein Thrombosis

 Atelektasis and Pneumonia

 Orthostatic Hypotension

 Neurogenic Bladder

 Gastrointestinal Problem
 Rehabilitation
 Ulcus Decubitus
• Proper positioning
• Turning position every 2 hours
• Nutrition
• Skin care
• Decubitus matrass/Padding
 Contractur/Spasticity
• Positioning
• ROM Exercise
• Surgery
 Rehabilitation
 DVT
• Passive movement
• Ankle pumping  plantar dorsoflexion and
ankle rotation
• Stocking/pneumatic compression intermitten
 Atelektasis and Pneumonia
• Turning position
• Chest percussion and vibration
• Cough and breath exercise
 Rehabilitation
 Orthostatic Hypotension
• Lesion above T6-8
• Decreased blood pressure when mobilisation
• Headache, dizzines, sweating, anemis
• Bandages of extremity, table tilting, mobilisation
gradually
 Neurogenic Bladder
• Overflow incontinentia
• Intermitten catheterization
 GI Problem
• Ileus, constipation
• NGT
• Enema