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التقييم السريري و الشعاعي لأذيات العمود الفقري الرضية
التقييم السريري و الشعاعي لأذيات العمود الفقري الرضية د.مؤيد كاظم 5/6/2007 12/6/2007
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Trauma patient with spine lesion
Spine anatomy * X-ray Cervical spine Thoracic spine Lumbar spine Spine trauma Thoracic & lumbar spine Trauma patient with spine lesion
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Cervical spine
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Spine Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy 3 2 4 1
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Cervical spine X-ray
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C spine X-ray Lateral view 5 4 6 1
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C spine X-ray Lateral view
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C spine X-ray Lateral view
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C spine X-ray Lateral view
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C spine X-ray Lateral view
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C spine X-ray AP view 2 1
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C spine X-ray AP view
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C spine X-ray AP view
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C spine X-ray Oblique view
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C spine X-ray Oblique view
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C spine X-ray Oblique view
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C spine X-ray OMO view 1 2 2 3
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C spine X-ray OMO view
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Thoracic spine
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Spine Anatomy
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Anatomy
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Normal kyphosis 15° - 50°
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Anatomy
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Anatomy
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T spine X-ray
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T spine X-ray AP view 1 2 3
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T spine X-ray AP view
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T spine X-ray lateral view
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T spine X-ray lateral view
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Lumbar spine
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Spine Anatomy
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Anatomy
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Normal lordosis < 60° slop of sacral base = 45° from horizon
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L spine X-ray
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L spine X-ray AP view
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L spine X-ray AP view
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L spine X-ray AP view
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L spine X-ray AP view 1 4 2 3
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L spine X-ray Lateral view
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L spine X-ray Lateral view
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L spine X-ray Oblique view Scotty dog sign 3 1 2 6 4 5
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L spine X-ray Oblique view Scotty dog
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L spine X-ray Oblique view
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L spine X-ray Oblique view
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عند دراسة صورة بسيطة للعمود الفقري
التناظر التمادي بين العناصر التشريحية للفقرات المتراكبة فوق بعضها ( الأجسام – النواتئ الشوكية – الوجيهات المفصلية .. ) وجود أي انحناء أو انكسار بهذا التمادي يجب أن يلفت الانتباه لوجود أذية. الفواصل بين الفقرات متساوية وجود خط كسر
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C spine trauma
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Denis’ three column model of the spine
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The stability Anterior column injury → stable
Anterior & middle column injury→more unstable 3 column injury → unstable
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C2 tear drop fracture stable
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Hangman fracture Unstable
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Wedge fracture Unstable
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Tear drop fracture
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C5-C6 Bilateral facet dislocation
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C4-C5 Bilateral facet dislocation
Unstable
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Unlateral facet dislocation
Unstable
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C5 C6 bilateral facet subluxation
Unstable
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Atlanto-axial instability
Atlantodental interval Atlanto-axial instability Unstable
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Occipitoatlantal articulation
Power ratio
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T+ L spine trauma
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90 % of spine fractures
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Effects on spine‘s functions
Stability Posture Neural protection Neurological function
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Denis’ three column model of the spine
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More columns damage → more instability
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2- Posture and deformity
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2- Posture and deformity
Pain Imbalance at the fracture site Compensatory curves
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Varying degree of compression
3- Neural protection Spinal deformity ↓ spinal canal stenosis Varying degree of compression
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Neural structures occupies 50% spinal canal volume
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4- neural function Nerve lesion Cord lesion
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Nerve lesion ↓ Irreversible Chance for recovery :
(Overstretched–crushed–severed) nerve structures ↓ Irreversible Chance for recovery : Partial lesion Release within 8 hours
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Cord lesion Drug may give a chance MPS ( corticosteroid ) Regimen :
Reduce necrosis / oedema In the first 8 hours Regimen : 30 mg/kg/15 minutes After 45 minute 5.4 mg/kg/hour for 23 hour
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Lesion classification
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T vertebra Burst fracture
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L2 burst fracture
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L3 burst fracture with rotation
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T8 burst fracture + T9 wedge fracture
2 T8 burst fracture + T9 wedge fracture 8
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Trauma patient with spine lesion
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Causes of spinal column and spinal cord injury
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Trauma patient The A – B – C – D RESUSCITATION ( BP )
Conscious level ( Glasgow coma scale ) Assessment of injuries ( Determine the PRIORITY )
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Trauma patient - accident scene
A : airways B : breathing C : circulation & cervical spine D : disability – drugs E : exposure ( undress the patient ) Spinal column injury must be suspected in in all poly-trauma patients, especially < intoxicated – unconscious > individuals .
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Trauma patient - Transfer
Scoop-style stretcher
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Trauma patient Transfer
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Trauma patient - Resuscitation
Blood pressure BP > 85 mm Hg → better neurogenic outcome
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Disruption of sympathetic outflowT1-L2
Neurogenic shock 3 vital signs indicates above T6 injury : Hypotension Hypothermia Bradycardia Disruption of sympathetic outflowT1-L2 ↓ unopposed vagal tone
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Low blood pressure ..!? ↓ BP + bradycardia =Neurogenic shock
↓ BP + tachycardia = blood loss occult intra-abdominal injuries
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Trauma patient - Resuscitation
How to deal with Neurogenic shock : volume replacement vasopressors And of course<Treat other injuries>
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Trauma patient - Assessment
Physical examination : Head lacerations Contusions Facial fractures ear canal - nasal leakage ( CSF – blood ) Spinous processes palpation Bowel / bladder incontinence Penile erection Occult injury ( abdomen – chest – extremities )
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Neurologic evaluation
Level of conscious : Glasgow coma scale Eyes open Best verbal response Best movement response
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Sensory examination
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Dermatomes the nipple line (T4) xiphoid process (T7) umbilicus (T10)
inguinal region (T12, L1) The perineum and perianal region (S2, S3, S4)
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Motor examination
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Motor examination
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Reflexes Stretch reflexes: Spinal shock = absent
Upper motor neuron lesion = hyperreflexia + spasticity + clonus Lower motor neuron lesion = absent
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Reflexes Planter reflex : Cremasteric reflex T12-L1 Babinski’s sign
Oppenheim’s sign Cremasteric reflex T12-L1
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Lesion level The most caudal segment with both sensory and motor function bilaterally
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Complete / incomplete cord lesion?
Complete : no motor/sensory function exist more than 3 segments below the site of injury. Incomplete : some neurologic function below it .
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Just to remember !
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Classification Central cord syn. Posterior cord syn.
Anterior cord syn. Brown-Sequal syn.
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incomplete cord injury
Sacral sparing Continued function in the conus medularis = incomplete cord injury Assessment : Perianal sensation Toe flexion Rectal sphincter
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Spinal shock After severe spinal cord injury
A state of complete spinal Areflexia . Last for varying length of time . 99% within 24 hour. Evaluation by : Testing the bulbocavernosus reflex ( S3 – S4 ) Anal wink reflex
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Bulbocavernosus reflex
Anal wink
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Spinal shock After injury :
No evidence of spinal function below the level of injury ( even bulbocavernosus reflex ) → no determination of completeness of injury Return of bulbocavernosus reflex with no sacral sparing signs → complete lesion
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Roentgenogram Plain Xray : CT MRI Routinely Chest Pelvis
Cervical spine <AP/Lateral> Poly trauma <AP/Lateral> thoraco-lumbar spine film CT MRI
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ER intervention High dose intravenous methylprednisolone
Within 8 hours = more significant improvement 30mg/kg in 15 minutes → after 45 minutes → 5.4mg/kg/hr in the remained 23 hour Complications : Wound infection GI Haemorrhage
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No clinical effectiveness in spinal cord injury
ER intervention Osmotic diuretics Manitol Low molecular weight dextran Used in head trauma No clinical effectiveness in spinal cord injury
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ER intervention Cervical stabilization : Bilateral sand bag + taping
Philadelphia collar Traction : Gardner wells Halo vest
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Taping
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Philadelphia collar
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Gardner-wells tongs
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Halo vest orthosis
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Thoraco-lumbar braces
Jewett brace Custom-molded TLSO
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Jewett brace
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Full contact braces
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MoKazem.com هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي. الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة. This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali. This site is not responsible of any mistake may exist in this lecture. Dr. Muayad Kadhim د. مؤيد كاظم
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