Hyperextension Injury

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Hyperextension Injury

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

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