Muhammad Iqbal, SpOT

Medical problems:
 initial immobilization
 prolonged rehabilitation
 significant readjustment in lifestyle
 potential complications in the chronic stages
Internal fixation: early mobilization &
rehabilitation, more thorough decompression
Goals of SCI treatment: early aggressive tx &
prevention of secondary injury
Primary Survey
 Airway (with C-spine protection)
 Breathing and ventilation
 Circulation (with hemorrhage control)
 Disability - neurologic status
 Exposure and environment
Resuscitation
Other studies and monitors
Secondary survey
Injuries to the spine must be excluded after
trauma:
55% involve the cervical spine
15% involve the thoracic spine
15% involve the thoracolumbar region
15% involve the lumbosacral region
Primary injury
Initial insult to
cord

Local deformation

Energy
transformation
 Secondary injury

Biochemical
cascade

Cellular
Most acute therapies aim to
processes
limit secondary injury
cascade
1970’s: free radicals

1980’s: Ca, opiate receptors

lipid peroxidation

1990/2000’s: apoptosis
intracellular protein
synthesis glutaminergic
mechanisms
In U.S. : 11,200
 Death before hospital : 4,200
 Death in hospital : 1,150
 Survive :  50%

In Dr. Sardjito hospital: 5-6 cases / month

Quadriplegia : 50%
Paraplegia : 50%

80% < 40 y.o.

( 15-35 y.o.)

10% paralysis increase during staying

in the hospital

Cerebral concussion : 20% with

cervical fracture
CERVICAL VERTEBRAE :
• More often
• Especially C 5 - C6
• Wider mobility
• Spinal canal 30% wider than spinal cord

THORACAL VERTEBRA

• Trauma  Not so often

• Trauma  • Complete paralysis
• Irreversible
VERTEBRAE LUMBAL :
• The most cases fracture  T 12- L1
• Paraparese Paraplegi

NEUROLOGIC DISTURBANCES :
• Compression of the spinal cord
• Disruption of the vascularization

Death neuron in 4 hours

Dysfunction of the spinal cord
 Based on key muscle strength & key sensory points
 Useful for following improvement or deterioration
PREHOSPITAL CARE
1. ABC evaluation, B6 evaluation
2. Vital sign
3. Seeking for painful, consciousness evaluation
4. Cervical palpation – neurologic evaluation
5. Examination the others trauma
6. Splinting stabilization
7. Medication
 SPINAL CORD INJURY
Bowel
PRESSURE
Distension SORES
WEAK SPASM
RESPIRATION
BLADDER
DYSFUNCTION CONTRACTURES
RESPIRATORY
INFECTION PSYCOLOGICAL
FACTORS
ACUTE
URINARY
INFECTION
PROTEIN LOSS
AND ANAEMIA
DEATH

PYELONEPHRITIS

POOR RESISTANCE LOSS OF

TO INFECTION APPETITE
CACHEXIA
SUSPECTED CERVICAL FRACTURE

• Keep unmoving of the head

• Apply cervical collar
• Fixing sand-bag pillow beside the head
• Traction: Glisson, Crutch field traction
• Lifting the patient in a unite: 4 persons
VERTEBRAE FRACTURE WITH PARALYSIS

SPINAL SHOCK
• Paralysis + sensibility disturbances
• Areflexia
• Micturation and defication disturbances
• Unsweating
• No perianal sensation
• No Bulbocavernous reflex
• Lasting < 24 hours
INCOMPLETE LESION

• Paralysis (+) / (-)

• Perianal sensation (+)
• Moving voluntary finger of the foot (+)
• Anal contraction voluntary (+)
• Bulbocavernous reflex (+)

After recovery of the spinal shock

COMPLETE LESION

• Paralysis : Total
• Sensibility (-)
• Bulbocavernous reflex (+)
• Plantar moving big-toe – stimulation: slowly
• Priapismus

After recovery of the spinal shock

Fracture C3 - C4 : Fracture C7 - T1:
Horner syndrome
Abdominal
 Ptosis
respiratory
 n. intercostal  Enopthalmus
 Lesion respiratory  Anhidrosis
distress  death  Miosis
MANAGEMENT

• Bed rest - spinal board

• Collar brace
• Infus maintenance
• Fasting
• Catheter
• Gastric distension evaluation – gastric cube
• Dexamethason / metil prednisolon inj., if < 8 hours
• Vital sign & neurologic Evaluation
• If : spinal shock: T, P, HR
 Limitation fluid management
 Sympatomimetic
- Two column concept:
- Anterior – posterior column
- Disruption posterior column: unstable

- Three column concept:

- Anterior-middle-posterior column
- Disruption of two column : instability

- Neurologic dysfunction: instability

TREATMENT

1. Operation : Unstable
• Neurologic deficit
• Kyphosis > 30o (thoraco-lumbal),
cervical > 11o
• Translation vertebrae / Dislocation
• 2 columns fracture
• Vertebrae body height collapse > 50%
• Protrusion to spinal canal > 30%

• Release spinal cord compression

• Stabilization : Plate + Screw + Wire, Nail + Wire
Continuity of
the
Ligamentum
Flavum
Anterior
Alone vs.
Combined
A/P
TREATMENT

2. Conservative
• Bed rest
• Traction
• Collar brace
• Minerva cast (cervical)
• Body jacket brace / cast (thoraco-lumbal)
• Hemi-spica cast (> L3)
If must be operated,
but not to be operated :

• Paralysis after few years

• Painful

• Hyper kyphosis
I