Vertebral Fracture

Clinical Related Module September 21, 2010

Vertebral Fracture1. Please draw transverse view of spinal cord systematically

1 by: Airin Aldiani PDA-09


Fasiculus cuneatus discriminative touch & sensation untuk upper limbFasiculus gracilis discriminative touch & sensation untuk lower limb

2. Please draw one motion segment of spinal column systematically

Each pair of vertebrae with its interposed disc and ligaments is termed a motion segment or functional spinal unit.

3. Describe the direction of thoracolumbar segment movement Flexi dan ekstensi pada daerah lumbal Lateroflexi pada daerah lumbal Rotasio pada daerah lumbal, thoracal



Fleksi kedepan 80-900 Ekstensi 200 fleksi lateral 200

4. Describe the primary spinal cord injuryYaitu spinal cord injury yang diakibatkan oleh adanya gangguan mekanik, transeksi, dan gangguan elemen neural. Biasanya terjadi dengan fraktur dan/atau dislokasi tulang belakang. Contoh: tertembak senjata dengan peluru akan menyebabkan primary spinal cord injuryThe primary injury results from tissue disruption by mechanical forces. The pathologic tissue changes resulting from the primary injury describe the extent of structural damage to neural tissue:

Contusion: kompresi singkat dan mendadak akibat pemidahan struktur yang memengaruuhi central tissue primer& bertanggung jawab atas neurologic deficits (memar).

Compression: injury akibat penurunan ukuran dari spinal canal akibat perubahan bentuk vertebrae yang menganggu aliran akson maupun darah maupun pada spinal vascularity yang menghasilkan ischemia dari neurologic structures (cth: epidural hematoma)

Stretch: injury akibat longitudinal traction pada kasus, sehingga terjadi tarikan pada spinal cord secara mendadak. Biasanya terjadi pada kasus flexion-distraction injury.

Laceration: Lecet karena fragmen-fragmen fraktur yang masuk ke spinal canal diakibatkan penetrasi dari foreign body, missile fragments, atau displaced bone.

5. Describe the secondary spinal cord injuryBiasanya disebabkan oleh vascular injury gangguan arterial, thrombosis arteri, hipoperfusion.The secondary injury results from the biologic response initiated by the mechanical tissue disruption. This injury will worsened the primary spinal cord injury if we could not treated promptly and immediately.

Terjadi perubahan structural maupun kimiawi pada jaringan lokal. Perubahannya antara lain pada local blood flow, tissue edema, metabolite concentrations & concentrations of chemical mediators yang mana dapat menyebabkan tissue destruction & functional loss.

Perfusi berkurang butuh diberi oksigen

Oxydative damage system imun; dilepaskannya neutrofil untuk menginfiltrasiExytocytotoxicity

6. What is the meaning of level of spinal cord injury according to ASIA



The ASIA defines it as the most caudal segment that tests intact for motor and sensory functions on both sides of the body. Fungsi motorik & sensori dari segment paling caudal yang masih bisa berfungsi normal di kedua bagian tubuh.

Grade A: Complete; No motor or sensory function is preserved in sacral segments S4-5 seluruh pergerakan harus dibantu.Fungsi S4-S5 sacral sparing yaitu fungsi bowel & bladder.

Grade B: Incomplete; Sensory but not motor function are preserved below the neurologic level and extend through the sacral segment S4-5. bisa bergerak sendiri tapi hanya bergeser saja, tidak bisa bergerak melawan gravitasi

Grade C: Incomplete; Motor function is preserved below the neurologic level; most key muscles below the neurologic level have a muscle grade <3. bisa bergerak melawan gravitasi 135o

Grade D: Incomplete; Motor function is preserved below the neurologic level; most key muscles below the neurologic level have a muscle grade >3.

Grade E: Normal; Motor and sensory function is normal.

Dermatome: untuk mengukur kekuatan sensorikBatch area di area deltoid; pin prick & light touchHematome: untuk mengukur kekuatan otot

ASIA penting untuk menetukan level spinal injury.

7. Please mentioned 10 keys muscle must be assessed in spinal trauma patient according to ASIA For upper extremities ( cervical myotome )

1. Elbow flexor m. biceps diinervasi oleh n. musculocutaneous dari C52. Wrist extensor3. Elbow extensor4. Finger flexor5. Finger abductor ( little finger )

For Lower extremities ( lumbosacral myotome )1. Hip flexor2. Knee extensor3. Ankle dorsoflexor4. Long toe extensor5. Ankle plantar flexor

8. Describe the types of incomplete spinal cord injurySyndrome Lesion Clinical PresentationBell cruciate paralysis Long tract injury at the level Variable cranial nerve



of decussation in brainstem involvement, greater upper extermity weekness than lower, greater proximal weakness than distal

Anterior cord Anterior gray matter, descending corticospinal motor tract, and spinothalamic tract injury with preservation of dorsal columns. 2/3 anterior spinal cordnya yang rusak. 1/3 bagian berguna untuk mempertahankan posisi (proprioception).

Variable motor and pain and temperature sensory loss with preservation of proprioception and deep pressure sensation

Central cord Incomplete cervical white matter injury

Sacral sparing and greater weakness in the upper limbs than the lower limbs

Brown-Sequard Injury to one lateral half of cord and preservation of contralateral half.

Ipsilateral motor and proprioception loss and contralateral pain and tempture sensory loss

Conus medullaris Injury to the sacral cord (conus) and lumbar nerve roots within the spinal canal

Areflexic bladder, bowel, and lower limbsMay have preserved bulbocavernosus and micturition reflexes

Cauda equine Injury to the lumbosacral nerve roots within the spinal canal

Areflexic bladder, bowel, and lower limbs

Root injury Avulsion or compression injury to single or multiple nerve roots (brachial plexus avulsion)

Dermatomal sensory loss, myotomal motor loss, and absent deep tendon reflexes

Posterior cord White matter bagian posterior

Hilangnya sensasi getaran & positional. Kadang disertai dengan hilangnya sensor rabaan kasar

9. Describe about spinal shock and neurogenic shockSpinal shock : is a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) after spinal cord injury. Note that the 'shock' in spinal shock does not refer to circulatory collapse.


http://en.wikipedia.org/wiki/Shock_(medicine)

http://en.wikipedia.org/wiki/Reflexes

http://en.wikipedia.org/wiki/Paralysis

http://en.wiktionary.org/wiki/sensation


Kehilangan fungsi akibat spinal cord injury. Disebabkan immediate depression pada semua aktivitas reflex caudal di daerah lesi. Semua fungsi dari spinal cord di shutdown sebagai respon terhadap SCI. Tapi tidak semua SCI menimbulkan spinal shock, seperti shock-shock yg incomplete.

Caranya dengan menilai respon bulbocavernosus dan anal wing. Apablia dia merespon berarti seseorang sudah tidak terkena spinal shock dan bisa dinilai level dari SCI-nya.

Symptoms: bowel & bladder reflexes stop, blood pressure menurun, semua otot di area injury menjadi kaku dan insensitive, hipotensi, bradycardi.

Fase-fase penyembuhan: Beberapa jam - 1 hari: Arefleksia hilangnya fase refleksi 1-3 hari: Refleksi awal kembali 1-4 minggu: hiperrefleksia awal 1-12 bulan: hiperrefleksia akhir

Jika dalam 48 jam fungsi tidak kembali normal, kemungkinan paralisis terjadi secara permanen. Jika terjadi diatas saraf simpatis (daerah cervical) Neurogenic Shock.

Overflow incontinence. Shock usaha tubuh untuk melindungi tubuh dari kelebihan…

Neurogenic shock : loss of symphatetic outflow.Disebabkan vasodilatasi neurogenic. Incontinence normal.Shock disini bukanlah circulatory shock melainkan vascular shock dimana blood volume normal, tapi sirkulasi buruk akibat ekpansi abnormal dari vascular bed akibat extreme vasodilatation.

Tidak ada gangguan bulbocavernous.

Hipotensi, bradycardi

Obatnya: vasopressor.



10. Describe the type of thoracolumbar fracture Compression fracture

Seringnya pada daerah anterior atau lateral Jarang membahayakan saraf Ligamen biasanya tetap utuh, walaupun bisa rusak

karena distraction Dari hasil CT scan bagian posterior dari vertebral

body (middle column) tidak patah Termasuk stable injury

Type A: fracture of both endplatesType B: fracture of superior endplateType C: fracture of inferior endplateType D: Both endplates intact

Burst fractureKompresi axial yang cukup parah dapat merusak vertebral body, menyebabkan kegagalan anterior & middle columns. Bagian posterior dari vertebral body terpecah-pecah & dapat displaced ke dalam spinal canal. Biasanya termasuk unstable injury.

Type A:Fracture of both endplates (24%)

Type B:Fracture of the superior endplate (49%)

Type C:Fracture of inferior endplate (7%)

Type D:Burst rotation (15%)

Type E: Burst lateral flexion (5%)

Flexion distraction injuryCompression failure pada anterior column & tension failure pada posterior & middle columns. Biasanya tidak hanya terjadi di tulang tapi juga pada osseus & ligamen. Pasien biasanya neurologically intacct tapi sering berhubungan dengan abdominal injuries.



Fracture dislocationSegmental displacement dapat terjadi akibat kombinasi dari fleksi, kompresi, rotasi, dan shear. Semua bagian/column & spine sangatlah unstable. Ini sangatlah berbahaya & berhubungan dengan neurological damage pada cauda equine. Luka biasanya pada thoracolumbar junction.



11. Explain the abnormality should be explored in plain x-ray examination of spinal trauma cases

ABCS

Alignment malalignment Bone fractures Cartilage ( Intervertebral disc ) narrowing ( HNP or

degenerative disc ) or widening ( flexion distraction injury ) Soft tissue ( pre tracheal or retropharyngeal soft tissue will be

widened because of haemorrhage )

12. What are the primary goals in treatment of patient with spinal trauma

preservation of life protection of neurologic function restoration and maintenance of alignment and stability of the spine. rehabilitate the patient

SCENARIOA 25 years old male motorcycle rider was found unconscious after traffic accident . He still use the helmet.Vital sign BP : 110 / 80 mmHgHR : 90 bpmRR : 20

1. How to treat this patient in prehospital scene ? evaluation of ABC resuscitation



immobilization extrication transport.The extrication and immobilization of the patient must proper to avoid further neurologic injury. The head and neck need to be aligned with the long axis of the trunk and immobilized in this position. Immobilization with cervical collar, sandbags, tape, and spine board is superior to immobilization with a collar alone. For field transportation of injured patients, a scoop stretcher is an adjunct to the spine board. Cervical extension narrows the spinal canal more than flexion. It is important to maintain neutral head-neck alignment; helmet should be left in position until personnel trained in safe removal techniques are available

2. After arrived at A & E department, his consciousness return, but he feel weakness at upper extremity but unable to move his both leg. What is the further examination should done and the most possible diagnosis for this patient? Re assessment of ABC and followed by prompt resuscitation Evaluation of neurological status once the patient’s condition stable Imaging examination : plain x-ray, with focusing in the pathologic area

Central cord syndrome The level of trauma is at cervical region, because involve of both leg which are innervated by cervical segment of spinal cord

3. Please describe initial treatment for this patient? Prompt resuscitation in presence of ABC problem Strict spinal nursing (proper position, turning patient in regularly with log roll

technique, soft padding) Pharmacologic therapy: methylprednisolon (approved by FDA, but still controversy )

as long as the patient arrived within 8 hours


Vertebral Fracture

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