Cervical Spinal Cord Injury j- Yudi.pptx

Semua ini agar bermanfaat bagi semua

1. CERVICAL INJURY By: Yudi Pranata Tutor: Dr. dr. Ifran Saleh, SpOT (K)-Spine

2. Cervical Spine - Overview The most vulnerable part of the spine to injury The cervical canal is wide from the foramen magnum-lower part of C2 Most patients with injuries at this level who survive to neurologically intact on arrival to the hospital 1/3 of patients with upper cervical spine injuries (i.e., injury above C3) die at the scene from apnea caused by loss of central innervation of the phrenic nerves Below the level of C3 → the spinal canal diameter < spinal cord diameter & vertebral column injuries → cause spinal cord injuries

3. Anatomy

4. Effects of Spinal Injury on Other Organ System Hypoventilation Occur from paralysis of the intercostal muscles (i.e., injury to the lower cervical or upper thoracic spinal cord) or the diaphragm (i.e., injury to C3 to C5). The Inability to Perceive Pain can mask a potentially serious injury elsewhere in the body, such as the usual signs of acute abdominal or pelvic pain associated with pelvic fracture

5. Epidemiology Kim HS, Lim KB, Kim J, Kang J, Lee H, Lee SW, Yoo J. Epidemiology of spinal cord injury: changes to its cause amid aging population, a single center study. Annals of rehabilitation medicine. 2021 Feb 9;45(1):7-15.

6. Mechanism of Injury Motor vehicle crash (35.4%) Falling off (37.3%) Gunshots (12–21%) Sports (6–13%) 1 2 3 4 Kim HS, Lim KB, Kim J, Kang J, Lee H, Lee SW, Yoo J. Epidemiology of spinal cord injury: changes to its cause amid aging population, a single center study. Annals of rehabilitation medicine. 2021 Feb 9;45(1):7-15.

7. Table 1. Mechanistic Classification (Allen-Ferguson)

8. Class IFI cation

9. Injuries of the Upper Cervical Spine

10. Spes IFIC Types of Cervical Injury 1 Atlanto Occipital Dislocation Craniocervical disruption injuries → uncommon & result from severe traumatic flexion & distraction Most patients with destruction & apnea thi s inju r y di e o f b r ainstem or have profound neurological impairment s (e.g. , v entila t o r dependenc e and quadriplegia/tetraplegia) Patients may survive if they are promptly resuscitated at the injury scene Atlanto-occipital dislocation → common cause of death in cases of shaken baby syndrome

11. Spesific Types of Cervical Injury 2 Atlas CI Fracture The atlas is a thin, bony ring with broad articular surfaces. Fractures of the atlas represent approximately 5% of acute cervical spine fractures, and up to 40% of atlas fractures are associated with fractures of the axis (C2). The most common C1 fracture is a burst fracture (Jefferson fracture). The typical mechanism of injury is axial loading, which occurs when a large load falls vertically on the head or a patient lands on the top of his or her head in a relatively neutral position. The fracture is best seen on an open-mouth view of the C1 to C2 region and axial computed tomography (CT) scans

12. Spesi FIC Types of Cervical Injury 3 Axis C2 Fracture The axis is the largest cervical vertebra and the most unusual in shape → susceptible to various fractures, depending on the force & direction of the impact Acute fractures of C2 represent approximately 18% of all cervical spine injuries Axis fractures of note to trauma care providers include odontoid fractures and posterior element fractures.

13. Odontoid Fracture 60% of C2 fractures involve the odontoid process → a peg-shaped bony protuberance that projects upward & is normally positioned in contact with the anterior arch of C1 The odontoid process is held in place primarily by the transverse ligament Type I odontoid fractures typically involve the tip of the odontoid and are relatively uncommon Type II odontoid fractures occur through the base of the dens and are the most common odontoid fracture Normal view Odontoid fracture

14. Hangman’s/Posterior Element Fracture Involves the posterior elements of C2 → the pars interarticularis → caused by an extension-type injury (hyperextension) Ensure that patients with this fracture are maintained in properly sized rigid cervical collar until specialized care is available Fractures and Dislocations (C3-C7) The area of greatest flexion and extension of the cervical spine occurs at C5–C6 and is thus most vulnerable to injury.

15. Hangman’s/Posterior Element Fracture In adults, the most common level of cervical vertebral fracture is C5, and the most common level of subluxation is C5 on C6. Other injuries → subluxation of the articular processes (unilateral or bilateral locked facets) & fractures of the laminae, spinous processes, pedicles, or lateral masses. Rarely, ligamentous disruption occurs without fractures or facet dislocations The incidence of neurological injury increases significantly with facet dislocations and is much more severe with bilateral locked facets.

16. Table 2. Levine Classification of Traumatic Spondylolisthesis of The Axis (Hangman’s Fracture)

17. Lower Cervical ( Subaxial ) Spine Injuries (C3 to C7) Etiology (types): 1. Compression fracture 2. Burst fracture

18. Flexion Teardrop Fracture characterized by: anterior column failure in flexion/compression posterior portion of vertebra retropulsed posteriorly posterior column failure in tension Typically affect C5-C6 Prognosis → associated with SCI Treatment → unstable and usually requires surgery Extension Teardrop Avulsion Fracture characterized by: small fleck of bone is avulsed of anterior endplate usually occur at C2 must differentiate from a true teardrop fracture Mechanism → Extension Prognosis → stable injury pattern and not associated with SCI Treatment → cervical collar Lower Cervical ( Subaxial ) Spine Injuries (C3 to C7)

19. Flexion Teardrop Fracture

20. Extension Teardrop Avulsion Fracture

21. Subaxial Spine Injury Classification Allen and Ferguson classification(of subaxial spine injuries) typically used for research and not in clinical setting based solely on static radiographs appearance and mechanisms of injury 6 groups represent a spectrum of anatomic disruption: 1. flexion-compression vertical compression flexion-distraction extension-compression extension-distraction lateral flexion Radiographic Description Classification Radiographic description classification (of subaxial spine injuries) more commonly used in clinical setting I ncludes compression fracture burst fraction flexion-distraction injury facet dislocation (unilateral or bilateral) facet fracture

22. P r esentation Symtoms → incomplete vs. complete cord injury Imaging Must determine if there is a posterior ligamentous injury so MRI often important T r eatment Nonoperative collar immobilization I ndications → stable mild compression fractures (intact posterior ligaments & no significant kyphosis), anterior teardrop avulsion fracture external halo immobilization Indications → only if stable fracture pattern (intact posterior ligaments & no significant kyphosis) · Radiographic Description Classification Ope r ati v e A nterior decompression, corpectomy, strut graft, & fusion with instrumentation Indications: compression fracture with 11 degrees of angulation or 25% loss of vertebral body height unstable burst fracture with cord compression unstable tear-drop fracture with cord compression minimal injury to posterior elements early decompression (< 24 hours) has been shown to improve neurologic outcomes compared with delayed (>/ 24 hours) decompression posterior decompression, & fusion with instrumentation Indications → significant injury to posterior elements & anterior decompression not required

23. External halo immobilization

24. Airway Maintenance - Cervical Spine Motion Restriction

25. Spinal Motion Restriction - Four Person Logroll

26. Airway Management - Helmet Removal

27. Many trauma patients have a c-collar placed by emergency medical services (EMS) in the field Current guidelines for spinal motion restriction in the prehospital setting allow for more flexibility in the use of long spine boards and cervical collars With the use of clinical screening decision tools such as the Canadian C-Spine Rule and the National Emergency X-Radiography Utilization Study → c-spine collars and blocks may be discontinued in many of these patients without the need for radiologic imaging Radiographic Evaluation

28. THANK YOU!