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C5 C6 dislocation

  1. 1. ORTHO CONFERENCE Ext pattraporn
  2. 2. HISTORY Male 43 yr cc: รถชน 3 hr PTA PI : 3 hr PTA รถกระบะชนเสาไฟฟ้า มีอาการปวดต้นคอ มีอาการอ่อนแรงและชาที่แขนและขา ไม่มีแผลตามตัว สลบจา เหตุการณ์ไม่ได้ ไม่มีอาเจียน ไม่หายใจหอบเหนื่อย ไม่ปวดท้อง Past history : no underlying disease
  3. 3. PHYSICAL EXAMINATION Primary survey A : Can talk, tender at neck with limited ROM B : Equal breath sound, CCT -ve, no subcutaneous emphysema C : BP 96/60 mmHg, PR 66 bpm, no active bleeding D : E4V5M6, pupil 3 mm RTLBE E : no external wound
  4. 4. PHYSICAL EXAMINATION Vital sign : BP 96/60 mm Hg PR 90 bpm RR 20 /min Temp 37.2 GA : A Thai man , good consciousness CVS : normal S1 , S2 , no murmur , cap refill < 2 secs Lung : clear , equal both lung , no adventitious sound Abd : soft , not tender , no guarding , no rebound tenderness
  5. 5. PHYSICAL EXAMINATION Can't flexion and extension neck tender posterior Decrease sensation below C6 Bulbocarvernosus reflex -ve Loose sphincter tone RT LT C5 II II C6 II I C7 II II C8 0 0 T1 0 0 RT LT L2 0 0 L3 0 0 L4 0 0 L5 0 0 S1 0 0
  6. 6. INVESTIGATION Film C-spine AP, Lateral Swimming view
  7. 7. SPINOUS PROCESS LINE
  8. 8. Spinolaminar line posterior vertebral body line anterior vertebral body line facet joints appear as stacked parallelograms Prevertebral soft-tissue shadow Disc C2-C3 < 7mm Disc C6-C7 < 21 mm
  9. 9. AP TRANSLATION 3.5 mm of translational deformity is suggestive of mechanical instability
  10. 10. COBB ANGLE >11 degrees suggestive of posterior ligamentous injury and potential instability
  11. 11. CT SCAN • More sensitive for detecting fractures • More consistently enables assessment of the occipitocervical and cervicothoracic junctions
  12. 12. ALLEN & FERGUSON CLASSIFICATION Distraction flexion II
  13. 13. DISTRACTIVE FLEXION
  14. 14. DIAGNOSIS C5-C6 unilateral facet dislocation with complete cord injury
  15. 15. INITIAL MANAGEMENT High dose Methyl- prednisolone Methyl prednisolone 30mg/kg then 5.4 mg/kg over the next 24 hours On skull traction MRI c-spine
  16. 16. HIGH-DOSE METHYL PREDNISOLONE
  17. 17. MRI • Superiority in visualizing the spinal cord, intervertebral disc, and spinal ligaments • Detecting • traumatic disc herniations • epidural hematoma • spinal cord edema or compression • posterior ligamentous disruption
  18. 18. MRI Indication • patients with neurological deficits • patients with injuries in which the integrity of the posterior ligamentous complex is unclear and would directly influence the treatment plan
  19. 19. TREATMENT
  20. 20. SUBAXIAL CERVICAL SPINE INJURY CLASSIFICATION (SLIC) <= 3 : nonoperative >= 5 : operative
  21. 21. TREATMENT 8 point Operative treatment
  22. 22. FACET DISLOCATION Non-operative treatment • Indication : unilateral facet dislocations without any signs of neurological injury • Halo vest immobilization 3 month • Flexion-extension views to confirm stability
  23. 23. FACET DISLOCATION Operative treatment • Closed reduction using cranial tong or halo traction as early as possible in awake, conscious, and able to be serially examined patient • Pre-reduction and post-reduction MRI
  24. 24. FACET DISLOCATION Operative treatment • If there the spinal cord is being indented by a disc herniation, anterior surgery is preferred • Anterior surgery followed by posterior stabilization for patients with highly unstable bilateral facet dislocations
  25. 25. TREATMENT
  26. 26. SPINAL CORD INJURY
  27. 27. ANATOMY
  28. 28. SPINAL CORD
  29. 29. SPINAL CORD INJURY Complete cord injury syndrome Incomplete cord injury syndrome Conus medullaris syndrome Clauda equine syndrome
  30. 30. COMPLETE CORD INJURY SYNDROME After presence of bulbocavernosus reflex : no sensation or voluntary motor function is noted
  31. 31. INCOMPLETE CORD INJURY SYNDROME Some neurological function persist after return of bulbocavernosus reflex Sacral sparing : imply continuity between cerebral cortex and lower sacral motor neuron. Such as 1. Perianal sensation 2. Voluntary rectal motor function 3. Big toe flexor activity
  32. 32. INCOMPLETE CORD INJURY SYNDROME
  33. 33. INCOMPLETE CORD INJURY SYNDROME
  34. 34. ANTERIOR CORD SYNDROME Blood flow is reduced or interrupted in the artery that runs along the anterior portion of the spinal cord. May be the result of bone fragments from traumatic injury to the vertebra, spinal disc herniations or flexion/compression injury. Most poor prognosis : recovery rate 10%
  35. 35. CENTRAL CORD SYNDROME Most common type Characterized by impairment in the arms and hands and, to a lesser extent, in the legs. Spare sacral spine thalamus and corticospinal tracts Recovery from distal to proximal [toe flexion > toe extension > ankle > knee > hip] recovery rate 75%
  36. 36. BROWN SEQUARD SYNDROME Hemisection of the spinal cord Motor paralysis , loss of vibration and proprioception on the ipsilateral side as the lesion and deficits in pain and temperature sensation on the contralateral side of the lesion. The most common cause of Brown- Séquard syndrome is penetrating trauma such as a gunshot wound or stab wound to the spinal cord. Best prognosis : More than 90% of people regain bladder & bowel control and the ability to walk.
  37. 37. POSTERIOR CORD SYNDROME
  38. 38. SPINAL SHOCK Immediate temporary loss of total power , sensation and reflexs below the level of injury Loss of bulbocavernosus reflex Usually recovery in 24-48 hrs

Editor's Notes

  • C,
    Retropharyngeal soft tissue more than 5 mm on midsagittal image (arrow).
    D,
    a : indicates hemorrhage causing widening of soft tissue density at C3 level.
    b : indicates anterior annulus disruption.
    c : indicates disruption of ligamentum flavum.
  • Distractive flexion
    Stage 1: Facet subluxation, gapping of the spinous process ligaments, with or without some blunting of anterosuperior vertebral body (like CF stage 1)
    Stage 2: Unilateral facet dislocation, usually PLC is intact, rotational deformity
    Stage 3: Bilateral facet dislocations, 50% translation of upper vertebral body on lower one
    Stage 4: Close to 100% translation of upper vertebral body on lower one, so-called floating vertebra
  • F,
    Arrow a indicates hemorrhage at C3 level.
    Arrow b indicates disruption through anterior anulus and through the disc space
  • sagittal T2-weighted image of an uninjured cervical spine
    small arrow is pointing to the PLL
    large solid arrow is pointing to the ligamentum flavum
  • ×