Download - Spinal Injuries
SPINE
RUDI FEBRIANTO, MDOrthopaedic Surgeon
RSUP NTB/FK UNRAM
Curriculum VitaeNama : Rudi FebriantoLahir : Sumbawa, 18 Februari 1975Status : Menikah ( 1 istri, 3 Anak)Pendidikan :
SD 3 MataramSMP 1 MataramSMA 1 MataramPendidikan dokter FK UI 1993 – 1999Pendidikan orthopedi & traumatologi FK UI 2003 – 2008
Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM
Spine Anatomy33 vertebra : 7 cervical, 12
thoracal, 5 lumbal, 5 sacrum, 1 coccygeus
Spinal curves: normal curves - Cervical lordosis - Thoracic kyphosis - Lumbar lordosis - Sacral kyphosis
Cervical C1-C2: unique bones allow stabilization of occiput to spine and rotation of head. Motion: rotation and fl exion/extension.
Thoracic Relatively stiff due to costal articulations. Motion: rotation. Minimal flexion/extension.
ThoracolumbarFacet orientation transitions from semicoronal to sagittal. Segments are mobile. Most common site of lower spine injuries.
Lumbar Largest vertebrae. Common site for pain. Houses caudaequina. Motion: fl exion/extension. Minimal rotation.
Sacrum No motion. Is center of pelvis
Radiologic Evaluation
Spinal ProblemStability : stable or unstable?Location : Cervical or Thoracolumbal?Cause : - Infection- Non-infective inflammatory disease - Tumor- Trauma
Management :- early management
- definitve management
StabilityStable fracture is one in which the
vertebra component will not be displaced by movement. - Wedge compression fracture
Unstable fracture is one in which there is a significant risk of displacement and consequent damage to neural tissue- Burst compression fracture, Fracture-
dislocation
Three Column Stabilty Concept
TREATMENT
Objective :
SPINAL DEFORMITIESScoliosis- Postural scoliosis- Structural scoliosis
Kyphosis
SCOLIOSIS• Lateral curvature of the spine• Postural scoliosis
compensatory to some condition outside the spine, as a short leg, pelvic tiltreversible and curvature without rotation
• Structural scoliosisirreversible and curvatrue with rotation in the primary curveetilogy : idiopathic (85%), osteopathic, neuropathic, myopathic
TreatmentAim of treatment are to prevent the
progression, to correct and stabilize a more severe deformity
Non-operative Spinal braces : curve 20° - 40° and with 2 years ageMilwauke brace, Boston brace, TLSO
Operative Idiopathic scoliosis with curve more than 40°and more than 10 years oldCorrection the curvature by combination of spinal instrumentation and spinal fusion.
SPINAL INFECTIONTuberculosis (Spondylitis TB or
Pott’s disease)Spine is the most common site of skeletal tuberculosis and the most dangerous.
The most common site are the lower thoracic and upper lumbar
Granulomatous inflammation, characteristized by slowly progressive done destruction
TreatmentGeneral treatment
- Antituberculosis drugs for 9 month – 1 years- General rest- Nourishing diet
Debridement and stabilisation-spinal fusion after 1 month of drug therapy
Spondylitis TB L2-3 with posterior stabilization
Surgical Indication- Neurologic Defisit – Acute neurologic deterioration, paraparesis and paraplegia- Spinal deformity with instability or pain- Large Paraspinal abscess- No respone to medical therapy, continuing progression of kyphosis or instabilty
ComplicationPott’s Paraplegia - Paraplegia of active disease : develops
realtively early, may result either from extradural pressure or from direct involvement of spinal cord
- Paraplegia of healed disease : develops late, result either from the gradual development of a bony ridge or from progressive fibrosis.
Kyphosis Deformity
Non-infection Inflamatoy DiseaseDegerative Disc DiseaseHerniation of intervertebral discSpinal StenosisSegmental instability
Degenerative Disc Disease• The spinal structures most affected by
degenerative disease are– Intervertebral discs– Articular facet joints
• These conditions are similar to osteoarthritis and degenerative disease of the spine, which is often referred to as “osteoarthritis of the spine,” or spondylosis
• Occurs at all levels of the spine• Asymptomatic degeneration in majority of the
population
SymptomsLow back pain and/or buttocks painIf leg pain also exists, there is likely an additional cause, eg, HNP.
DiagnosisPatient examinationCT/MRI
Nonoperative careRest for acute, low back painNSAID medicationPhysical therapy
Exercise/walkingLow-impact aerobicsTrunk strengthening
• Surgical care Failure of nonoperative treatment
Minimum of 6 weeksFusion
Removal of disc and replacement with bone graft, or a cage-filled bone graft, or a bone graft substitute
ArthroplastyArticulating disc replacement
Segmental Instability
• Spondylolisthesisforward shift of the spine in relations to the vertebra segment immediately below
• Spondylolysisdefect in one or both side of the neural arc of lumbar vertebra
• Spondyloloptosiscompletely dislocation
SpondylolisthesisUsually occur in lumbar spine,
paricularly in L5-S1Type :
- Spondylosis spondylolisthesis- degenerative spondylolisthesis- Traumatic spondylolisthesis- Congenital spondylolisthesis
• Gradation of spondylolisthesis– Meyerding’s Scale
• Grade 1 = up to 25%• Grade 2 = up to 50%• Grade 3 = up to 75%• Grade 4 = up to 100%• Grade 5 >100%
(complete dislocation, spondyloloptosis)
SymptomsGradual onset of low back pain that aggravated by standing, walking, running and relieved by lying down Nerve root irritation that cause sciatica
Nonoperative CareRestNSAID medicationPhysical therapySteroid injections
Surgical care Failure of nonoperative
treatmentDecompression and fusion
InstrumentedPosterior approachWith interbody fusion
Spinal StenosisA bony narrowing of the spinal canalBony narrowing may be congenital or may
be acquired
–Central stenosis• Narrowing of the
central part of the spinal canal
–Foraminal stenosis• Narrowing of the
foramen, resulting in pressure on the exiting nerve root
–Far lateral recess stenosis• Narrowing of the
lateral part of the spinal canal
Nonoperative careRestNSAID medicationPhysical therapy
Exercise/walkingSteroid injections
Surgical care Failure of nonoperative
treatmentMinimum of 3-6 months’ duration
DecompressionBone removal to widen area
Laminectomy Foraminotomy
High success rateMay require adjunct fusion
to address instability
Herniation of intervertebral discThe progressive degeneration of a disc,
or traumatic event, can lead to a failure of the annulus to adequately contain the nucleus pulposus
Herniation of intervertebral disc is not synonimus degeneration disc disease, but may be complication of degerative disc disease
Most common sites is L4-5, L5-S1, and L3-4
• Varying degrees• Disc bulge
– Mild symptoms• Usually go away with
nonoperative treatment
– Rarely an indication for surgery
• Extrusion (herniation)– Moderate/severe
symptoms• Nonoperative treatment
Posterolateral herniation: nerve root compression cause sciatica
Medline herniation : cauda equina compression cause cauda equina syndrome
Cauda Equina Syndrome symptoms :Bilateral leg painLoss of perianal sensationParalysis of the bladderWeakness of the anal sphincter
Surgical intervention in these cases is urgent
Nonoperative CareInitial bed restNonsteroidal anti-inflammatory (NSAID) medicationPhysical therapy
Exercise/walkingSteroid injections
Surgical care Failure of nonoperative treatment
Minimum of 6 weeks in duration Can be months
DiscectomyRemoval of the herniated portion of the discUsually through a small incision
Spinal TumorMost spinal tumor are metastase
and malignancie20 – 40% primary spinal tumors
are benignTypically, benign lesion are in
posterior elements, and most anteriorly located lesions are malignant
Posterior Element TumorOsteoid TumorOsteoblastomaOsteochondromaAneurysma bone cyst
Vertebral Body TumorsHemangiomaEosinofilic GranulomaGiant cell tumorPrimary Malignat tumor
- Osteosarcoma- Ewing Sarcoma- Multiple myeloma
Metastatic tumor- Breast, lung, prostat, kidney, GIT, and thyroid cancer
TreatmentIrradiation
indication : pain, slowly progressive neurological symptoms in the presence of a radiosensitive tumor, spinal canal compromise Instability is a relative contraindication, because of the potential collapse and progression of deformity that could occur with tissue necrosis
OperativeIndication : decompression and stabilization, radioresistan tumor
Spinal TraumaCervical injury
- Jefferson’s fracture- Odontoid fracture- Hangman’s fracture- Subaxial cervical fracture
Thoracolumbal injury- Compression fracture
wedge and burst fracture- Fracture – dislocation
Cervical InjuriesCervical spine
injuries must be suspected in patient with :unconsciousmaxilofacial traumaneck pain
CevicalC1 Fracture
(Jefferson’s Fracture)
Sudeen load on the top of headUsually no neurologis damage
C2 fracture (odontoid fracture)
UncommonFlexion injury after high-velocity or severe fallNeurological symptoms occur in about 20% cases
Fracture of pedicle C2 (Hangman’s Fracture)
Associated with C2/3 facet dislocation, need open reduction and stabilization.
Lower Cervical Injury (Fracture from C3 – C7)Wedge fracturePosterior ligament injuryBurst fractureHiperextension injuryFracture-dislocation Tear drop injurySubaxial cervical fracture
Tear drop fracture C7
Fracture Dislocation C7 – T1
Thoracic & Lumbar injuryRelatively common, particularly in
thoracolumbar regionMost common fracture are
compression fracture, wedge and burst.
Less common but more serious are fracture-dislocation.
Wedge Compression FractureVertebral body
crushed anteriorly, posterior ligament remain intact.
Stable injuriesClinically symptoms
relative mild, but may be there is local tenderness
Burst Compression FractureFailure of both anterior
and middle column Posteior column and
intervertebral disc may be displaced into spinal canal.
May be stable but usually unstable
Neurologic defisit (+) unstable ]]
Fracture-DislocationSegemental
displacementAll three column
distrupted, posterior ligament torn, posterior facet joint fracture, and spinal column dislocated.
Completely unstable
ManagementEarly management
Rescucitation (Airway & cervical control, Breathing, Circulation)Immobilization (Rigid Collar Neck, Long Spine Board) Neurologic AssesmentInj. Methylprednisolone 30 mg/kgBB bolus, and 5,4 mg/kgBB/hour for 23 hours.
Definitive Management1. Cervical Spine
-Cervical collar- Halo ring- Fixation
2. Thoracolumbal
- Bed rest- Brace- Decompression and stabilization
Subaxial Cervical Spine Injury Classification System
(SLIC)
Components Points
Morphology No abnormality Compression Burst Distraction Rotation/translation
01
+1 = 234
Disco-ligamentous complex (DLC) Intact Indeterminate Disrupted
012
Neurological Status Intact Root injury Complete cord injury Incomplete cord injury Continuous cord compression in setting of neurological deficit
0123
+1
Subaxial Cervical Spine Injury Classification System (SLIC)
Subaxial Cervical Spine Injury Classification System
(SLIC)
Fracture dislocation C7-T1 with decompression and posterior stabilization
Nama : Rudi FebriantoLahir : Sumbawa, 18 Februari 1975Status : Menikah ( 1 istri, 3 Anak)Pendidikan :
SD 3 MataramSMP 1 MataramSMA 1 MataramPendidikan dokter FK UI 1993 – 1999Pendidikan orthopedi & traumatologi FK UI 2003 – 2008
Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM
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