Hyperextension Injury
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Hyperextension Injury

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Hyperextension Injury Hyperextension Injury Presentation Transcript

  • Dr. Ahmed Mirza Al-Shammasi, MB ChB 2031040009 KFHU – Saudi Arabia
  • Outlines
    • Introduction
    • Definition of Traumatic Central Cord Syndrome
    • Correlative Anatomy, Pathogenesis, Pathology
    • Diagnosis
    • Management
      • Consevative vs. Operative
      • Timing of Surgery
  • Introduction
    • First reported by Thorburn in 1887, popularized by Schneider in 1954.
    • TCCS is related to Hyperextension of the cervical spine without concomitant fracture of sublaxation.
    • TCCS compromises 44% of clinical syndrome following traumatic SCI.
    • 35-58% of patients with TCCS had underlying Cervical Canal Stenosis.
  • Introduction
    • General trend since 1954 has been reluctance to undertake aggressive treatment:
      • Lack of # or sublaxation on imaging studies.
      • Spontaneous functional recovery.
      • Comorbidities.
      • Risk of Intraoperative worsening of neurological condition.
    • Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.
  • TCCS
    • Partial SCI with disproportionate:
      • Motor loss in the distal upper extremities.
      • Significant involvement of bladder function.
      • Variable degrees of sensory impairment below the level of skeletal injury.
    • Middle-aged men are mostly affected.
    • In several recent series the proportion of men ranged from 56.2-88%.
    • 35-58% of patients with TCCS had underlying Cervical Canal Stenosis.
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  • Pathogenesis
    • Foerster and Schneider:
      • Buckling of Ligamentum flavum + disc protrusion.
      • Compression of the spinal cord.
      • Formation of a hematoma at the center of the cord (Hematomyelic cavity).
      • Fibers subserving the upper extremities, concentrated medially, are involved.
      • Fibers subserving the lower extremities, concentrated laterally, are spared.
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  • Pathogenesis
    • Recent lines of evidence contradict that assumption.
    • Pappas and Marchi, Coxe and Landau, Barnard and Woolsey studies in monkeys
      • No somatotopic organization of the Corticospinal tract at the level of pyramids or cervical spinal cord.
    • Studies of Nathan and colleagues in human patients tend to confirm this finding.
  • Pathogenesis
    • Jimenez, Martin and Quencer:
      • Correlating autopsy with MRI imaging of TCCS patients.
      • Majority of patients with TCCS had no evidence of hematomyelia or significant injury to the centeral gray matter.
      • Axonal disruption and swelling is widespread in the white matter of the lateral funiculi and to lesser extent the posterior columns.
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  • Alternative hypothesis
    • Proposed by Levi and Collignon:
      • TCCS may result from pathological entities affecting the CST anywhere from the pyramids to the cervical spine.
      • CST primarily subserve fine motor movements to the distal musculature, especially upper limbs.
      • Preservation of leg movement is mediated by other descending motor pathways important to locomotion.
  • Pathology
    • Lesion of TCCS seem to comprise 3 main categories:
      • Cervical Spondylosis associated with spinal canal stenosis
      • Fracture sublaxation
      • Sequestrated disc without evidence of spinal stenosis.
    • The proportion of each is different in every case.
  • Diagnosis
    • CT, MRI, and when indicated, dynamic studies will essentially rule out skeletal damage, DLC injuries and hidden fractures.
    • New technology even enables the measurement of the degree of canal compromise and cord compression. (MCC, LL)
  • i b a MSCC (%) = [1-i/(a+b)/2] x 100 Maximum spinal canal compression
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  • Management Surgical vs. Conservative
    • Factors that discourage urgent surgery, experience of Schneider and colleagues:
      • Lack of # or sublaxation on imaging studies.
      • Spontaneous functional recovery.
      • Comorbidities.
      • Risk of Intraoperative worsening of neurological condition.
  • Management
    • In 1984, Bose review of patients with TCCS showed better motor scores in patients treated surgically.
    • In 2005, Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.
  • Timing of Surgery
    • In 2002, Guest review of patients with TCCS and disc herniation or skeletal injury:
      • Patient underwent Early surgery (<24 hours) had better motor recovery than Late surgery.
      • The timing of surgery did not affect motor recovery in cases with spinal canal stenosis.
    • Preliminary result of prospective multicenter trial, reported by Fehlings, indicate better functional recovery with early decompression.
  • Surgical Objectives
    • Spinal Cord decompression
    • Restoration of normal spinal alignment and internal fixation
    • Prevent and/or interrupt of further secondary injury.
  • Conclusion
    • TCCS is most frequent syndrome after incomplete SCI.
    • 50% is due to hyperextension injury.
    • Until now, no standard algorithm of treatment.
    • Further research should be multicenter, prospective and analytical rather than descriptive.
  • Thank you for listening