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CME Orthopedic.pptx
- 1. PRESENTED BY : VENUSYA MENTOR : DR AIDIL
- 2. SPINE INJURIES -Spine injuries STABLE INJURY Vertebral components will not be displaced by normal movements UNSTABLE INJURY Significant risk of displacement and consequent damage- or further damage to neural tissues
- 3. Pathophysiology Primary changes -Physical injury limited to vertebral column including its soft-tissue components and varies from ligamentous strains to vertebral fractures and fracture-dislocations Spinal cord and or nerve roots may injured, either by initial trauma or by ongoing structural instability of a vertebral segment Secondary changes -During the hours and days following a spinal injury biochemical changes may lead to more gradual cellular disruption and extension of initial neurological damage
- 6. 3 COLUMN THEORY (DENIS) :>1 COLUMN INJURED =UNSTABLE
- 7. CERVICAL SPINE INJURIES History and examination •History of fall from height , motor vehicle accident. If patient unconscious, assumed a fractured cervical spine, until proved otherwise •Abnormal position of neck •Tenderness over affected area X ray •Ap view : •-Lateral outlines •-spinous processes •Tracheal shadow in midline •An open mouth view to show c1 and c2(for odontoid and lateral mass fractures) •Lateral view , four parallel lines traced. •Lateral view include all seven cervical vertebrae and upper half T1 (to view cervico-thoracic junction) Findings •Forward shift of the vertebral body d f the optentd by 25 percent sugeests a unilateral facetr dislocation and by 50 percent a bilateral facet dislocation
- 13. Standard view Open Mouth view
- 14. Pathogenetic mechanism of thoracolumbar injuries Low-energy insufficiency fractures Mild compressive stress osteoporotic bone Minor fractures of vertebral processes Compressive, tensile or tortional strains High energy fractures or fracture dislocations Motor vehicle collisions, falls or diving from heights, sporting events Thoracolumbar injuries
- 17. COMPRESSION FRACTURE • Typically caused by osteoporosis • Defined as a vertebral bone in the spine that has decreased at least 15 to 20% in height due to fracture • Most commonly in the upper back (thoracic spine), particularly in the lower vertebrae of that section of the spine (T11-L2)
- 19. WEDGE COMPRESSION FRACTURE • Flexion injury • A stable injury as the middle and posterior elements remain intact. • Acute back pain, and may lead to chronic pain, deformity (thoracic kyphosis, commonly referred to as a dowager's hump.
- 20. Burst and Compression-flexion (tear-drop )fractures • If vertebral body is crushed in neutral position, results in burst fracture • “Burst” implies that the margins of the vertebral body spread out in all directions • When combined axial compression and flexion, an antero-inferior fragment of vertebral body sheared off, producing “tear drop” on lateral x ray
- 21. AXIAL COMPRESSION OR BURST INJURY IN THORACOLUMBAR • Severe axial compression may”explode” the vertebral body, causing failure of both the anterior and middle columns. • AP xrays spreading of vertebral body with an increase of the interpedicular distance • Lateral view posterior displacement of bone into spinal canal(retropulsion) difficult t view, thus CT is essential.
- 24. CHANCE FRACTURE • Referred as seatbelt fractures, are flexion-distraction type injuries of the spine that extend to involve all three spinal columns • Unstable injuries and have a high association with intra-abdominal injuries • A flexion injury of the vertebral body and distraction type injury of the posterior elements
- 26. PRINCIPLES OF DIAGNOSIS AND INITIAL MANAGEMENT -Early management : Airway with cervical spine control, breathing, circulation and hemorrhage control) Adequate oxygenation, ventilation and circulation will minimize secondary spinal cord injury. -Slightest possibility of a spinal injury in a trauma, spine must be immobilized until patient is resuscitated. Immobilization abandoned once excluded by clinical and radiological assessment
- 27. METHODS OF TEMPORARY IMMOBILIZATION • Cervical spine : In line immbolization ( head and neck supported in neutral position) • Thoracolumbar spine : Moved without flexion or rotation of thoracolumbar spine . A scoop stretcher and spinal board are very useful.
- 28. DIAGNOSIS i) Xray • can detect instability or misalignment of the spinal column, but do not give very detailed images and can miss injuries to the spinal cord or displacement of ligaments or disks that do not have accompanying spinal column damage ii) CT Scan • reserved for delineating bony abnormalities or fracture • some studies have suggested that CT scanning with sagittal and coronal reformatting is more sensitive than plain radiography for the detection of spinal fractures iii) MRI • best for suspected spinal cord lesions, ligamentous injuries, or other soft-tissue injuries or pathology • should be used to evaluate nonosseous lesions, such as extradural spinal hematoma; abscess or tumor; disk rupture; and spinal cord hemorrhage, contusion, and/or edema
- 29. •Thank you
- 31. SYMPTOMS • Dermatome- pain, numbness, or a loss of sensation in the related areas, Paresthesia • Myotome - problems with movements that involve those muscles (contract uncontrollably/spasticity), become weak, or completely paralysed • Spinal shock - loss of neural activity including reflexes below the level of injury (occurs shortly after the injury and usually goes away within a day)
- 33. CLASSIFICATION American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification) Grade Description A Complete: No sensory or motor function is preserved in sacral segments S4-S5 B Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5 C Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 D Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3 E Normal: Sensory and motor functions are normal
- 34. Muscle strength 0 No muscle contraction 1 Muscle flickers 2 Full range of motion, gravity eliminated 3 Full range of motion, against gravity 4 Full range of motion against resistance 5 Normal strength Complete Incomplete Tetraplegia 18.5 % 29.5 % Paraplegia 27.9 % 21.3 % The percentage of spinal cord injuries as classified by the American Spinal Injury Association (ASIA) is as follows:
- 35. SCI CLASSIFICATION The International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI) • Tetraplegia (replaces the term quadriplegia): Injury to the spinal cord in the cervical region, with associated loss of muscle strength in all 4 extremities • Paraplegia: Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris
- 36. American Spinal Injury Association (ASIA) Impairment Scale
Editor's Notes
- The spine is made of 33 vertebraes. This spinal column provides main support for your body, allowing to srtand upright, bend twist. Vertebrae are the 33 individual bones that interlock with each other to form spinal column. Each vertebrae consist of spinous process , transverse process , pedicle , nerve Facet joints allow back motion. Each vertebrae consist four facet joints, one pair connects above (superior facets, one pair coneects vertbr below.
- -Avulsion injuries or fractures occur where the joint capsule, ligament, tendon or muscle attachment site is pulled off from the bone, usually taking a fragment of cortical bone. In lumbar spine resisted muscle effort may avulse transverse process. In cervical spine, the 7th spinous process can be avulsed (clay-shoveller’s fracture) Miners in Australia back in 1930’s sometimes sustained fracture when they tossed clay over shoulder, stuck at shovel, causing flexion force on the neck -Direct injury : penetrating injury to the spine -Indirect injury : -common cause as it occurs typically in a fall from a height when the spinal clumn collapses in vertical axis Variety of forces may applied to sine :L axial compression, flexion, lateral compression, flexion-rotation, shear, flexion distraction and extension
- Under the Denis classification system, three-column concept divides a spinal segment into three parts: anterior, middle, and posterior colums. Anterior Column The anterior column comprises of Anterior longitudinal ligament (ALL) Anterior two-thirds of the vertebral body and annulus Middle Column comprises of Posterior one-third of the vertebral body and annulus Posterior vertebral wall Posterior longitudinal ligament (PLL) Posterior Column comprises : All structures posterior to the PLL including the posterior bony arch and the posterior ligamentous complex (supraspinous ligament, interspinous ligament, capsule, and ligamentum flavum
- Blue line connects the spinous processes, they should lie mid-line and have an equal amount of space between. Red-line should smoothly connect the lateral masses of the vertebrae.
- A – alignment and adequacy, B – bone abnormalities, C – cartilage space assessment and S for soft tissues. To check for proper alignment, look for a normal smooth lordotic curve and imagine two lines, each running along the anterior and posterior margins of vertebral bodies. Additionally, a third line (spino-laminar line), running along the base of spinous processes and up to the posterior aspect of the foramen magnum, must be visualized (Figure 4). Bone: Bony outline of the vertebras and bone density. Areas with decreased bone density which may be found in patients with rheumatoid arthritis, osteoporosis or metastatic osteolytic lesions, are more prone to breaking under stress. C – Cartilage space assessment: Inspection of a good quality lateral view x-ray in a healthy person should show uniform intervertebral spaces.
- Retro-pharyngeal soft tissue, narrows down from C1 to C4, and should not exceed more than 7mm (less than third of the vertebral body). Bellow the C4 soft tissue starts widening, but should not exceed 22mm (for easier thinking, should not exceed the width of the body of the vertebrae.
- Figure 5: Disruption in the shape of the AV line, that indicates injury, and in this case a fracture of the body of C7
- Xray of lumbar spine Check whether it is adequate or not Able to see T11/12 L1-L5 and sacrum Vertebral bodies, facet joint and pedicle can be viewed from lateral view
- Xray Thoracic spine Check adequate and exposure Check vertebral bodies and spinous process align Check of loss in body height In the thoracic spine, the vertebral bodies (and the disc spaces) should gradually increase in size as you get further down the spine Look for widened inter-spinous or inter-pedicle distance and check the processes Translation or rotation is displacement in horizontal plane; and distraction is displacement in the vertical plane. Translation/rotation is due to a side-to-side motion (can be left-to-right or front-to-back). It is a serious injury and always involves the posterior ligamentous complex. 7) Distraction is where the vertebrae are pulled apart and carries a high risk of cord injury. Often there is compression at the other side
- Burst Fracture. Frontal radiograph demonstrates decreased height of the L2 vertebral body (arrow) and widening of the interpediculate distance (white line in comparison with levels above and below) . The lateral radiograph shows the L2 vertebral fracture to be comminuted (arrows) along with compression of both the superior and inferior endplates. There is retropulsion of a fragment of bone (P) from the posterosuperior aspect of L2, which causes spinal canal narrowing. The normal anteroposterior dimension of the spinal canal is depicted between the arrowheads at L1 and L3.
- There is a comminuted burst 3 column fracture involving the L1 vertebra, including a large retropulsed fragment causing significant stenosis of the central canal. Bilateral L1 transverse process fractures. Associated kyphosis with subluxation of the left T12/L1 facet joint. Minimally displaced fracture through the T12 spinous process is also noted.