ORTHO conference

1. ORTHO
CONFERENCE
Ext pattraporn

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. 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. 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. 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. INVESTIGATION
Film C-spine AP, Lateral
Swimming view

8. SPINOUS PROCESS LINE

10. 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

11. AP TRANSLATION
3.5 mm of translational deformity is suggestive of mechanical
instability

13. COBB ANGLE
>11 degrees suggestive of posterior ligamentous injury
and potential instability

15. CT SCAN
• More sensitive for detecting fractures
• More consistently enables assessment of the
occipitocervical and cervicothoracic junctions

18. ALLEN & FERGUSON
CLASSIFICATION
Distraction flexion II

19. DISTRACTIVE FLEXION

20. DIAGNOSIS
C5-C6 unilateral facet dislocation with complete cord injury

21. 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

22. HIGH-DOSE METHYL
PREDNISOLONE

23. 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

24. 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

26. TREATMENT

27. SUBAXIAL CERVICAL SPINE INJURY
CLASSIFICATION (SLIC)
<= 3 : nonoperative
>= 5 : operative

28. TREATMENT
8 point
Operative treatment

29. 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

30. 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

31. 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

32. TREATMENT

34. SPINAL CORD INJURY

35. ANATOMY

36. SPINAL CORD

37. SPINAL CORD INJURY
Complete cord injury syndrome
Incomplete cord injury syndrome
Conus medullaris syndrome
Clauda equine syndrome

38. COMPLETE CORD INJURY
SYNDROME
After presence of bulbocavernosus reflex : no sensation or
voluntary motor function is noted

39. 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

40. INCOMPLETE CORD INJURY
SYNDROME

41. INCOMPLETE CORD INJURY
SYNDROME

42. 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%

43. 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%

44. 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.

45. POSTERIOR CORD
SYNDROME

46. 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