Spine Trauma Jember

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    Nugroho Setyowardoyo - NUG

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    Columna vertebralis

    Kolom tulang belakang terdiri dari tulang disebutvertebra

    Vertebra ini terhubung di bagian depan tulang belakang

    dengan diskus intervertebralis

    Kolom tulang belakang terdiri dari:

    vertebra cervikal tujuh (C1-C7) yakni leher

    dua belas vertebra toraks (T1-T12) yaitu punggung atas

    lima vertebra lumbal (L1-L5) yaitu punggung bawahtulang sakrum

    tulang ekor

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    Pada umumnya, vertebra terdiri dari:

    1. Vertebra body di depan2. 2 pedicle yang menghubungkan body

    dengan prossesus spinosus

    3. 2 prosesus tranversusBODY

    PEDICLE

    transverse

    process

    spinous process

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    SYaraf:

    Susunan saraf pada spine terdiri dariakar saraf ( roots) dan saraf tulang

    belakang (spinal cord).

    Spinal cord membentang dari dasar

    otak ke bawah hingga level L1-2.

    Dibawah tingkat L1-L2 ujung sumsumtulang belakang, anyaman dari akar

    saraf berlanjut, yang disebut cauda

    equina.

    Pada setiap tingkat vertebra tulang

    belakang terdapat sepasang akar saraf

    yang disebut roots . Saraf ini

    menginervasi bagian tubuh tertentu

    sesuai levelnya.

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    Denis membagi spine menjadi 3bagian:

    Columna Anterior

    Anterior longitudinal ligamen

    Anterior part of vertebral body

    Anterior portion of annulus fibrosis

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    Denis membagi spine menjadi 3bagian:

    Middle column

    Posterior logitudinal ligament

    Posterior part of vertebral body

    Posterior portion of annulus

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    Denis membagi spine menjadi 3bagian:

    Posterior column

    Bony and ligamentous posterior

    element

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    Berguna untuk:

    Menentukan MOI

    Menilai stabilitas dari spine

    Stabilitas tulang belakang tergantung padasetidaknya dua kolom yang utuh

    Fraktur yang melibatkan hanya kolom anteriordianggap stabil

    Fraktur melibatkan kolom media atau semua tigakolom dianggap tidak stabil

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    Fraktur kompresiHasil dari fleksi anterior atau lateral sehinggaadanya kerusakan kolom anterior

    Radiologi: Tinggi vertebral body bagiananterior berkurangBiasanya stabil dan jarang ada defisitneurologis

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    Fraktur Kompresi

    Thomson, 2002

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    Burst Fraktur

    Kegagalan kedua kolum anterior dan medial

    Aksial loading secara vertikal akan diteruskan ke

    segala arah pada kolum vertebra sehingga timbulletupan dan hancur

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    Burst Fraktur

    MOI yang sering terjadi

    Jatuh Dari Ketinggian

    Galli, 2007

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    Wong DA, 2007

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    Wong DA, 2007

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    Burst Fractures Lateral x-ray : vertebral body height

    AP x-ray : interpedicular distance

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    Flexion-Distraction Injury

    Radiologis

    interspinous process distance on AP view

    posterior height of vertebral body in lateral view

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    Fraktur-Dislocation Deniss subtipe fraktur dislokasi

    Posteroanterior shear-type

    Anteroposterior shear-type

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    Insult to spinal cord resulting in a change,

    in the normal motor, sensory or autonomic

    function. This change is either temporary orpermanent.

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    Runs through the vertebral canal

    Extends from foramen magnum tosecond lumbar vertebra

    Regions Cervical

    Thoracic

    Lumbar

    Sacral

    Coccygeal

    Gives rise to 31 pairs of spinal nerves

    All are mixednerves Not uniform in diameter

    Cervical enlargement: supplies upperlimbs

    Lumbar enlargement: supplies lowerlimbs

    Conus medullaris- tapered inferior end Ends between L1 and L2

    Cauda equina - origin of spinal nervesextending inferiorly from conusmedullaris.

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    Connective tissue membranes Dura mater: outermost layer; continuous

    with epineurium of the spinal nerves

    Arachnoid mater: thin and wispy

    Pia mater: bound tightly to surface Forms the filum terminale

    anchors spinal cord to coccyx

    Forms the denticulate ligaments that attachthe spinal cord to the dura

    Spaces

    Epidural: external to the dura Anesthestics injected here

    Fat-fill

    Subdural space: serous fluid

    Subarachnoid: between pia andarachnoid

    Filled with CSF

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    Anterior median fissure andposterior median sulcus deep clefts partially separating left

    and right halves

    Gray matter: neuron cell bodies,dendrites, axons

    Divided into horns

    Posterior (dorsal) horn

    Anterior (ventral) horn

    Lateral horn

    White matter Myelinated axons

    Divided into three columns(funiculi) Ventral

    Dorsal

    lateral

    Each of these divided intosensory or motor tracts

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    Commissures: connections betweenleft and right halves

    Gray with central canal in thecenter

    White

    Roots

    Spinal nerves arise as rootletsthen combine to form dorsal andventral roots

    Dorsal and ventral roots mergelaterally and form the spinal

    nerve

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    Recall, it is divided into horns Dorsal, lateral (only in thoracic region), and ventral

    Dorsal half sensory roots and ganglia

    Ventral half motor roots

    Based on the type of neurons/cell bodies located ineach horn, it is specialized further into 4 regions Somatic sensory (SS) - axons of somatic sensory neurons

    Visceral sensory (VS) - neurons of visceral sensory neur.

    Visceral motor (VM) - cell bodies of visceral motor neurons

    Somatic motor (SM) - cell bodies of somatic motor neurons

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    Figure 12.31

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    Divided into three funiculi (columns) posterior, lateral,and anterior Columns contain 3 different types of fibers (Ascend., Descend.,

    Trans.)

    Fibers run in three directions Ascending fibers - compose the sensory tracts

    Descending fibers - compose the motor tracts

    Commissural (transverse) fibers - connect opposite sides of cord

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    Pathways decussate (most)

    Most consist of a chain of two or three neurons

    Most exhibit somatotopy (precise spatial

    relationships) All pathways are paired

    one on each side of the spinal cord

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    Descending tracts deliver motorinstructionsfrom the brain to the spinal cord

    Divided into two groups Pyramidal, or corticospinal, tracts

    Indirect pathways, essentially all others Motor pathways involve two neurons

    Upper motor neuron (UMN)

    Lower motor neuron (LMN)

    aka anterior horn motor neuron (also,finalcommon pathway)

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    Includes all motor pathways not part of the pyramidal system

    Upper motor neuron (UMN) originates in nuclei deep in cerebrum(notin cerebral cortex)

    UMN does notpass through the pyramids!

    LMN is an anterior horn motor neuron

    This system includes

    Rubrospinal

    Vestibulospinal

    Reticulospinal

    Tectospinal tracts

    Regulate: Axial muscles that maintain balance and posture

    Muscles controlling coarse movements of the proximal portions of limbs

    Head, neck, and eye movement

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    Note:1. UMN cell body location

    2. UMN axon decussates in pons3. Synapse between UMN and LMN

    occurs in anterior horn of sc3. LMN exits via ventral root4. LMN axon stimulates skeletal

    muscle

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    Reticulospinal tracts originates at reticular formation ofbrain; maintain balance

    Rubrospinal tracts originate in red nucleus of

    midbrain; control flexor muscles

    Tectospinal tracts - originate in superior colliculi andmediate head and eye movements towards visual targets(flash of light)

    Nerve pathways

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    Descending Tracts

    Tract Signal functionCorticospinal (pyramidal) Fine voluntary motor control of the limbs. The

    pathway also controls voluntary body posture

    adjustments.

    Rubrospinal Involved in involuntary adjustment of arm position inresponse to balance information; support of the body.

    Reticulospinal (1)Pontine Regulates various involuntary motor activities andassists in balance (leg extensors). Some pattern

    movements e.g. stepping

    (2) Medullary Inhibits firing of spinal and cranial motor neurons,control of antigravity muscles.

    Vestibulospinal (1) MedialIt is responsible for adjusting posture to maintain

    balance (neck muscles).

    (2) Lateral It is responsible for adjusting posture to maintainbalance (body/lower limb).

    Tectospinal Controls head and eye movements, Involved ininvoluntary adjustment of head position in response to

    visual information.

    Nerve pathways

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    The nonspecific and specific ascendingpathways send impulses to the sensory cortex These pathways are responsible for discriminative

    touch (2 pt. discrimination) and consciousproprioception (body position sense).

    The spinocerebellar tracts send impulses to thecerebellum and do not contribute to sensory

    perception

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    Include the lateral andanterior spinothalamic tracts

    Lateral: transmits impulsesconcerned with pain andtemp. to opposite side ofbrain

    Anterior: transmits impulsesconcerned with crude touchand pressure to opposite

    side of brain 1st order neuron: sensory

    neuron 2nd order neuron:

    interneurons of dorsal horn;synapse with 3rd orderneuron in thalamus

    3rd order neuron: carryimpulse from thalamus topostcentral gyrus

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    Dorsal Column Tract1. AKA Medial lemniscal pathway2. Fibers run only in dorsal column

    3. Transmit impulses from receptors inskin and joints

    4. Detect discriminative touch andbody position sense =proprioception

    1st O.N.- a sensory neuronsynapses with 2nd O.N. in nucleus

    gracilis and nucleus cuneatus ofmedulla

    2nd O.N.- an interneurondecussate and ascend to thalamuswhere it synapses with 3rd O.N.

    3rd-order (thalamic neurons)transmits impulse to somato-sensory cortex (postcentral gyrus)

    Spinocerebellar TractTransmit info. about trunk and lowerlimb muscles and tendons to cerebellumNo conscious sensation

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    Dermatome Specific area in which the spinal

    nerve travels or controls

    Useful in assessment of specific

    level SCI Plexus

    peripheral nerves rejoin andfunction as group

    Cervical Plexus

    diaphragm and neck

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    C3,4 motor:shoulder shrug

    sensory: top of shoulder

    C3, 4, 5

    motor: diaphragm sensory: top of shoulder

    C5, 6 motor:elbow flexion

    sensory: thumb

    C7 motor: elbow, wrist,

    finger extension

    sensory: middle finger

    C8, T1 motor: finger abduction &

    adduction

    sensory: little finger

    T4

    motor: level of nipple T10

    motor: level of umbilicus

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    L1, 2 motor: hip flexion

    sensory: inguinal crease

    L3,4

    motor: quadriceps sensory: medial thigh, calf

    L5 motor: great toe, foot

    dorsiflexion sensory: lateral calf

    S1 motor: knee flexion

    sensory: lateral foot

    S1, 2

    motor: foot plantarflexion

    S2,3,4 motor: anal sphincter tone

    sensory: perianal

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    A Complete: no sensory or motor function

    B Incomplete: sensory, but no motor function in

    sacral segmentsC Incomplete: motor function preserved below level

    and power graded < 3

    D Incomplete: motor function preserved below level

    and power graded 3 or more

    E Normal: sensory and motor function normal

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    Spinal Shock :

    Transient reflex depression of cord function belowlevel of injury

    Initially hypertension due to release of catecholamines Followed by hypotension

    Flaccid paralysis

    Bowel and bladder involved

    Sometimes priaprism develops Symptoms last several hours to days

    BCR -

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    Neurogenic shock:

    Triad of i) hypotension

    ii) bradycardia

    iii) hypothermia More commonly in injuries above T6 Secondaryto disruption of sympathetic

    outflow from T1 L2

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    Incomplete

    Any sensation

    Position sense

    Voluntary movementin lower extremity

    Sacral sparing(Perianal Sensation)

    Complete

    No motor/sensoryfunction

    No sacral sparingwith BCR +

    May have reflexes

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    Cord transection

    Complete

    all tracts disrupted

    cord mediated functions below transection arepermanently lost

    determined ~ 24 hours post injury

    possible results

    quadriplegia

    paraplegia

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    Plegia = complete lesion Paresis = some muscle strength is preserved Tetraplegia (or quadriplegia)

    Injury of the cervical spinal cord Patient can usually still move his arms using the

    segments above the injury (e.g., in a C7 injury, thepatient can still flex his forearms, using the C5segment)

    Paraplegia Injury of the thoracic or lumbo-sacral cord, or cauda

    equina Hemiplegia

    Paralysis of one half of the body Usually in brain injuries (e.g., stroke)

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    Incomplete Cord Injury

    Injury to one side of the cord (Hemisection)

    Often due to penetrating injury or vertebral

    dislocation Complete damage to all spinal tracts on affected side

    Good prognosis for recovery

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    Exam Findings Ipsilateral loss of motor

    function motion, position,vibration, and light touch

    Contralateral loss ofsensation to pain andtemperature

    Bladder and boweldysfunction (usually shortterm)

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    Exam Findings

    Variable loss of motorfunction and sensitivityto pinprick and

    temperature loss of motor function

    and sensation to pain,temperature and lighttouch

    Proprioception(position sense) andvibration are preserved

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    Usually occurs with ahyperextension of the

    cervical region Exam Findings

    weakness or paresthesiasin upper extremities butnormal strength in lowerextremities

    varying degree of bladderdysfunction

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    Classification incomplete SCI syndromes

    Central Cord Syndrome

    Motor loss UE>LE

    Hands usu affected

    Common in elderly w/

    pre-exist

    spondylosis/stenosis

    Substantial recovery

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    Injury to nerves within the spinal cord as theyexit the lumbar and sacral regions

    Usually fractures below L2

    Specific dysfunction depends on level of injury Exam Findings

    Flaccid-type paralysis of lower body

    Bladder and bowel impairment

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