Spine surgeon Dr Arun L Naik Bangalore india
-
Upload
dr-arun-l-naik -
Category
Health & Medicine
-
view
44 -
download
5
description
Transcript of Spine surgeon Dr Arun L Naik Bangalore india
Dr. Arun L NaikSenior Consultant Neurosurgeon
Apollo HospitalBannerghatta Road
Bangalore
Annual cases: 2000055 cases per day2 persons per minutesCost per year : INR 5400
cr
MVA 56% Falls 16% Gunshot Injuries 11% Blunt Assault 6% Diving Accidents 5% Stab Wounds 4% Sport Injuries 2%
Flexion: bilateral facet dislocations wedge fractures of anterior vertebrae,
Disruption of the disc with forward bilateral facet dislocations, and fracture of the pedicle.
Flexion with rotation: Causes unilateral facet dislocation fracture of the vertebra, rupture of supporting ligaments.
Vertical compression/axial loading These usually stable injuries "burst" fracture
Trauma to the cord itself Vertebral columnDistractional forces associated with flexion,
extension, dislocation, or rotationStretching or shearing of the neural elementsCompression and contusion from bone
fragments, ligaments, and hematoma within the spinal canal
EdemaIntramedullary hemorrhageAxonal degenerationDemyelination Ischemia
ParamedicsIntubation?Immobilization
Prolonged time spent in transport
Respiratory compromise
Pain and discomfort in conscious patient
Pressure sore in prolonged use
Airway with attention to spinal protectionBreathingCirculationDisability: NeurologicalExposure of the entire patient for signs of
injury
Nasotracheal intubation (ATLS ): Fallen out of practice
Cricothyroidotomy has also become less common
Intubating laryngeal mask airwayLighted styletElastic bougie devices
• Diminished or absent airway protective mechanisms: intracranial injury or other pathology
• Evidence of airway obstruction in the multiple trauma
• Acute respiratory failure in patients with injuries at C4
• Thoracoabdominal trauma• Inability to cough, clear secretions
The ideal MAP: 80 to 100 mmHgHypertension: Risk of intramedullary
hemorrhage and edemaAdequate volume resuscitationVasopressor therapy
Spinal Shock• Temporary
suppression of all or most reflex activity below the level of injury
• Occurs immediately after injury
• Intensity & duration vary with the level & degree of injury
Neurogenic Shock• The body’s response to the
sudden loss of sympathetic control
• Distributive shock • Occurs in people who have
SCI above T6 (> 50% loss of sympathetic innervation)
• Paralyzed, hypotensive patient with warm, dry, hyperemic extremities, and bradycardia
Rapid neurological assessment: prior to the administration of paralytic agents
Pupils for size and reactivity
GCSExtremities powerRectal tone
Head-to-toe Complete neurological examinationSpinal injury: tenderness, step-off
deformities, edema, and ecchymosesLong bone fracturesSevere soft tissue injuries
Head InjuryChest injury
Chest wallRib fracturesPulmonary
contusionsHemothoraxPneumothorax
Abdominal injuryPelvic injuryBony injury
Plain X raysC spineCXRDL / LS SpineLong bonesPelvis
CT scanMRI
Inadequate plain filmsSuspicious plain film findingsAny fracture / displacement on plain filmsHigh clinical suspicion of injury despite
normal plain films
Anterior cord syndromeCentral cord syndrome
Posterior cord syndromeBrown–Séquard syndrome
Conus medullaris syndromeCauda equina syndrome
• Flexion-rotation force to the spine producing an anterior dislocation or by a compression fracture of the vertebral body• There is often anterior spinal artery compression so that the corticospinal and spinothalamic tracts are damaged• Loss of power as well as reduced pain and temperature sensation below the lesion
Older patients with cervical spondylosis
Hyperextension injury Flaccid (lower motor neuron) weakness of the
arms and relatively strong but spastic (upper motor neuron) leg function
Sacral sensation and bladder and bowel
function are often partially spared
• Hyperextension injuries with fractures of the posterior elements of the vertebrae
• Good power and pain and temperature sensation but there is sometimes profound ataxia due to the loss of proprioception, which can make walking very difficult
Stab injuries, lateral mass fractures of the vertebrae
Power is reduced or absent Pain and temperature
sensation are relatively normal on the side of the injury
The uninjured side therefore has good power but reduced or absent sensation to pin prick and temperature
Loss of bladder, bowel and lower limb reflexes
Injury to the lumbosacral nerve roots results in areflexia of the bladder, bowel, and lower limbs
Primary Injury
Secondary Injury
Hypotension should be avoidedOptimal blood pressure in the first week after
SCI through aggressive volume expansion and the use of pressor agents may improve outcome
SBP in adults should be kept 90 mmHg
Skin careFoley catheterRespiration Low molecular Weight HeparinAdequate analgesiaSpinal bracesManagement of associated injuries
30 mg /kg bolus
5.4 mg/kg/h x 23 hours
MPSS
˂ 8 hours : Better neurologic recovery at 6w / 6 m / 1 yr˃ 8 hours : Worse neurologic function than the placebo group.
3- 8 hoursMPSS> 8 hours
30 mg /kg bolus
5.4 mg/kg/h x 48 hours
Maximize neurologic recoveryRestore normal alignment and correct deformityPromote spinal stability, fusion, or bothMinimize painFacilitate early mobilization and rehabilitationMinimize hospitalization and costPrevent secondary complications
Irreducible anatomic compressive lesion with neurological deficits (spl incomplete or progressive)
Complete injury except MR showing transection of cord
InstabilityNeed for multiple surgical procedures or
associated multiple trauma
Neurologically complete injury of thoracic cord with compression but stable fracture
Incomplete neurological injury with modest compression ( for example 25%)
Central cord syndrome with associated spondylotic compression of cord
Hemodynamic instabilityInadequate resuscitationSevere TBIInsufficient radiological imagingMRI showing complete transaction
Decompressive StabilizationBoth the above
Quick decision of screw dimensions
Decreased deviation between plan and results