1. A 17-year-old Thai male presented to the emergency department with an abrasion wound on his left face and left shoulder following a motorcycle accident 5 hours prior. 2. Imaging revealed a T3-T4 fracture-dislocation with spinal cord compression. He was diagnosed with a spinal cord injury and underwent treatment including methylprednisolone and surgical stabilization of his spine. 3. His injury resulted in lower extremity weakness and loss of sensation. He will require long-term rehabilitation for his spinal cord injury.

1. Extern conference
20/06/61
อรณิช บำรุงวุทธิ์

2. • Case : ผู้ป่วยชำยไทย อำยุ 17 ปี ไม่มีโรคประจำตัว
• Chief complaint : มีแผลที่สีข้ำงซ้ำย 5 hr PTA

3. Primary Survey at COMH
• A : patent airway , not tender along C-spine ,
can flex+extend
• B : normal breath sound equal both lung , CCT
negative
• C : BP 117/58mmHg PR 81/min abdomen –
soft , not tender , PCT negative
• D : E3V5M6 , pupil 2 mm RTLBE
• E : abrasion wound Lt. Face , Lt. Shoulder

4. Second survey at COMH
• AMPLE : -
• Neuro :
– Motor : upper at least gr.IV , Lower gr.0
– Sensory : decrease pinprick sensation both legs
– PR : loose sphincter tone
• Diagnosis at COMH : R/O Spinal cord injury

5. Management at COMH
• 00.00 NSS 1000ml IV rate 80ml/hr , Cefazolin 1g
IV stat , On hard collar, Retain Foley’s cath
• 00.20 Pulse เบำ วัดBPไม่ได้ ให้ Load IV
• 00.35 Dopamine (2:1) 10μd/hr
• 00.45 BP 70/30mmHg ↑Dopamine (2:1)
20μd/hr + Load NSS IV 2000ml then 60ml/hr x 2
เส้น
• 00.55 ได้ IV 1400 BP 88/33 ↑ Dopamine (2:1)
30μd/hr
• จำกนั้น refer มำ รพ. มหำรำชนครรำชสีมำ

6. Primary survey at MNRH
• A : patent airway , on hard collar
• B : normal breath sound equal both lungs ,
CCT positive
• C : BP 129/96mmHg PR 86/min FAST negative
• D : E4V5M6 , pupil 3mm RTLBE
• E : abrasion wound at Lt. Face, 2 degree burn
at Lt. thoracoabdomen

7. Second survey at MNRH
• A : no history of food and drug allergy
• M : no current medication
• P : no underlying disease
• L : 23.00
• E : 5 hr PTA ขับMCล้มเอง สลบ จำเหตุกำรณ์ไม่ได้ มีแผลที่
สีข้ำงซ้ำย ขยับขำสองข้ำงไม่ได้ กู้ภัยนำส่ง

8. Head to Toe examination
• GA: A Thai young man, normosthenic build, good
consciousness, well-cooperated
• HEENT: not pale conjunctivae, anicteric sclerae,
laceration wound
size 3 cm at right forehead, no active bleed
• Heart: normal S1 S2, no murmur
• Lungs: normal breath sounds, equal both lungs
• Abdomen: soft, not tender, normoactive bowel
sounds
• Extremities: no rash, no edema, no deformity

9. Head to Toe examination
• Neurological: E4V5M6, pupil3mm RTLBE
• PR : absent sphincter tone, absent perianal
sensation, bulbocavernosus reflex negative

10. Motor power
Key Muscles Level Right Left
Shoulder abductor C5 V V
Wrist extensors C6 V V
Elbow extensor C7 V V
Fingers Flexors C8 V V
Fingers acductors T1 V V
Hip flexors L2 0 0
Knee extensors L3 0 0
Ankle dorsiflexors L4 0 0
Long toe extensors L5 0 0
Ankle plantar flexor S1 0 0

11. Sensory

12. Management at COMH
• CXR
• Film C-spine, TL spine, LS spine AP/Lateral
• Film pelvis AP
• Film Lt. Shoulder AP
• CT brain non-contrast

22. Film
• Fracture T3-4 dislocate with cord compression
with spinal shock
• Fracture C6 Rt facet , no dislocation
• Closed fracture Lt. Clavicle
• Increase haziness of Lt. Lung >>> Hemothorax

24. MRI OF CERVICAL AND THORACIC SPINE
• IMPRESSIONS:
1. Fracture-dislocation of T3-T4 with T3/4 disc
injury and anterior epidural hematoma at T3,
causing spinal cord compression and spinal cord
contusion/ edema along C7-T6 levels.
2. Fracture right C6 superior facet and minimal
anterolisthesis of C5 over C6.
3. C5/6 traumatic anterior disc protrusion is
observed.
4. Marrow edema of the T2, T5-T7 vertebral
bodies, possible mild compression fracture or
marrow contusion

25. Impression
• Fracture-dislocation of T3-T4 with Spinal cord
compression with neurogenic shock with
spinal shock
• Mild head injury moderate risk
• Close fracture Lt. Clavicle
• Lt. Hemothorax
• 2 degree burn Lt.thoracoabdomen

26. Management at MNRH
• Methylprednisolone 2400mg + 5 DW 100ml IV
drip in 30min
• Methylprednisolone 9936mg + 5 DW 1000ml
IV drip rate 45ml/hr
• On ICD Lt. Side
• NSS 1000ml IV rate 80ml/hr
• Dopamine (2:1) IV rate 30ml/hr
• Admit

27. Vertebral Fracture

28. Denis Three-Column classification (1983)
• ส่วนหน้ำ (anterior column): คือกำยวิภำคที่อยู่หน้ำและ
ครึ่งหนึ่งของกระดูกส่วนหน้ำ (1/2 ของ anterior vertebral
body) และ Anterior longitudinal ligament
• ส่วนกลำง (middle column): คือ ส่วนของกระดูกครึ่งหนึ่งของ
กระดูกสันหลังส่วนหลัง (1/2 posterior vertebral body)
และ posterior longitudinal ligament
• ส่วนหลัง (posterior column): ประกอบด้วย pedicle
lamina transverse precess และ posterior
ligamentous complex

30. Compression fracture
• Compression force to anterior column from
flexion injury
• Patent middle and posterior column
• percent height loss > 50% and kyphotic angle >30°
>>> unstable injury
• Might found interspinous gap widening
• AP view found decreased anterior vertebral
height
• lateral view found anterior wedging of vertebral
body

32. Burst fracture
• Fracture of anterior column and middle
column from axial loading and flexion injury
• Associated with retroperitoneal hematoma
• AP view found decreased vertebral body
height, widening of interpedicular distance
• Lateral view found anterior vertebral body
wedging, widening of spinousprocess
• percentage of height loss > 50%, kyphotic
angle>30°

34. Flexion-distractioninjuries
(Seat-belt, Chance Fractures)
• Uncommon
• flexion and distraction force tear posterior
column to middle column and anterior column
• Injury might affect either bone or ligament
• lateral view might found fracture of posterior
column, pedicles to vertebralbody (bony
chance fracture) or interspinous widening
• CT scan are recommened especially in
ligament injury

36. Fracture-Dislocation
• Fracture of all 3 columns and all spinal ligaments
from flexion, rotation and translation injuries
• Found stepping deformity or interspinous
widening including ecchymosis on skin
• AP view found fracture
• Lateral view found fracure and dislocation
• CT scan could evaluate fracture displacement,
joint dislocation, canal compromise
• MRI found ruptured spinal ligament
• Need surgical treatment

39. Thoracolumbar Injury Severity Score (TLIC)
• Injury morphology
• Disco-ligamentous complex injury
• Neurologic status

41. Spinal Cord Injury

42. Spinal Cord Injury
• Primary spinal cord injury
– Blunt injury
– Penetrating injury
• Secondary spinal cord injury
– Inflammatory process

43. American Spinal Injury Association (ASIA)

44. Functional Classification Of Spinal Cord
Injury (Frankel)
• A : complete loss of motor and sensory
function
• B : sensation present, motor absent
• C : sensation present, motor useless
• D : sensory present, motoruseful
• E :normal neurological examination

45. Anatomical classification of spinal cord injury
• Complete spinal cord injury >>> ASIA A
• Quadriplegia
• Paraplegia
• Incomplete spinal cord injury
• Central cord syndrome
• Anterior cord syndrome
• Brown – Sequard syndrome
• Posterior cord syndrome
• Conus medullaris syndrome
• Cauda equina compression syndrome

46. Incomplete Cord Syndromes
Central Cord
• Hyperextension
• Cervical cord
• Distal > Proximal
• Upper > Lower
• Elderly (but all ages)
• Dysesthesias
Anterior Cord
• Anterior spinal artery
• Anter cord compression
• Complete motor loss
• Incomplete sensory loss
• Touch and proprio intact

47. Incomplete Cord Syndromes
Brown Sequard
• Hemisection of cord
• Hemiplegia
• Penetrating trauma
• Ipsilateral paralysis
• Ipsilateral proprio
• Contra pain & temp
Posterior Cord
• Injury to posterior column
• Good motor function
• Pain and temperature
sensation remain intact
• Propioception loss > ataxia

48. Conus medullaris syndrome
• The tapered, lower end of the spinal cord. It
occurs near lumbar vertebral levels 1 (L1) and
2 (L2)
• Causes back pain with radicular pain and
bowel and bladder dysfunction
• Saddle anesthesia and lower extremity
weakness

49. Cauda equina compression Syndrome
• Damage to the bundle of nerves below the
end of the spinal cord known as the cauda
equina
• Low back pain, pain that radiates down the
leg, numbness around the anus, saddle
anesthesia , and loss of bowel or bladder
control

50. Cauda Equina and Conus Medullaris Syndromes

51. Treatment
• Oxygenation
• High-dose methylprednisolone
• Surgical treatment

52. High-dose methylprednisolone
• National Acute Spinal Cord Injury Study
(NASCIS) III
– bolus dose : methylprednisolone 30 mg/kg IV in
15min
– maintenance dose : methylprednisolone 5.4
mg/kg/hour if start within 3hr >> maintenance for
24hr , 3-8hr >> maintenance for 48hr

53. Surgical treatment
• Indication for surgical treatment
– Unstable fracture-dislocations withspinal
cordinjury
– Progressive neurologic deficit with persistent
fracture and/or dislocation, not correctedby
closed methods
– Persistent of incomplete spinal cord injury with
continued impingement on neural tissue
– Late instability or deformity with continued cord
percussion and neurologic deficitor chronic pain

54. Surgical treatment
• Decompression (กำรระบำยควำมกดดันต่อระบบประสำท)
– Spinal cord, Nerve roots
– Anterior, Posterior, Anterior + Posterior
• Fusion (กำรเชื่อมข้อ, กำรเชื่อมกระดูกสันหลังให้อยู่นิ่ง)
– Without instrumentation
– With instrumentation : Cervical plate, Pedicle
screw

55. Surgical treatment
• Cervical spine surgery (กำรผ่ำตัดกระดูกสันหลังส่วนคอ)
– Anterior : ACDF, Corpectomy, Cervical plating
– Posterior : C1-2 fusion, Laminoplasty, Posterior
fixation
• Thoracic spine surgery (กำรผ่ำตัดกระดูกสันหลังส่วนอก)
– Anterior : Open thoracotomy & Instrumentation
– Posterior : Laminectomy, OYL removal, Pedicle screws
• Lumbar spine surgery (กำรผ่ำตัดกระดูกสันหลังส่วนเอว)
– Anterior: Retroperitoneal approach, Instrumentation
– Posterior : Laminectomy, Pedicle screws, MIS

56. Neurogenic shock
• Distributive type of shock that is attributed to
the disruption of the autonomic pathways
within the spinal cord
• Hypotension
• Bradycardia
• Warm, flushed skin due to vasodilation and
inability to vasoconstrict

57. Treatment
• Dopamine (Intropin) is often used either alone
or in combination with other inotropic agents
• Vasopressin (antidiuretic hormone [ADH])
• Certain vasopressors (ephedrine, norepinephri
ne) , Phenylephrine may be used as a first line
treatment, or secondarily in people who do
not respond adequately to dopamine
• Atropine is administered for slowed heart rate

58. Spinal Shock
• Temporary loss of all neurological activity
below the level of the cord injury =>
motor,sensation, includes reflexes (e.g.
bulbocavernosus reflex)

59. Spinal Shock
Phase Time Physical exam finding
Underlying
physiological event
1 0–1d Areflexia/Hyporeflexia
Loss of descending
facilitation
2 1–3d Initial reflex return
Denervation
supersensitivity
3 1–4w Hyperreflexia (Initial)
Axon-supported
synapse growth
4 1–12m Hyperreflexia, Spasticity
Soma-supported
synapse growth