SPINAL INJURY

Alfan Syah Putra Nasution

RSUD. Taman Husada Bontang

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 SPINAL ANATOMY
Tulang belakang, 33
ruas
7 servikal

12 torakal

5 lumbal

5 sakral (Fusi)

4 koksik (Fusi)

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 Spinal Cord

Dari batang otak

sampai vert. L1
Diameter : 10-13 mm
Di dlm kanalis spinalis
Radiks (31 pasang)
Sensoris , motoris,
Autonom
Refleks
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 Cord Level

C2 C7 = add +1 for cord level

T1 T6 = add +2
T7 T9 = add +3
T10 = L1, L2 level
T11 = L3, L4 level
L1 = sacro coccygeal segments

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 SPINAL TRAUMA

Definition: Any injury that has occurred

to any of the following structures:
Bony elements
Soft tissues
Neurological structures

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ETIOLOGY OF SPINAL CORD INJURY
TRAUMATIC :
50% motor vechicle accidents
20-30% Falls
12-21% gun shots
6-7% sport related activities

NONTRAUMATIC ;
Intraspinal tumors

Infections & inflammatory diseases

Intraspinal abscesses

Iatrogenic complications of surgical or diagnostic procedures

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 DISTRIBUTION OF SPINAL
TRAUMA

1. 55% involve the cervical spine

2. 15% involve the thoracic spine

3. 15% involve the thoracolumbar region

4. 15% involve the lumbosacral region

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 TWO IMPORTANT FACTORS IN
SPINAL TRAUMA

1. Instability of the vertebral column

2. Actual or potential neurological injury

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 SPINAL INSTABILITY
Definition: Loss of normal relationship between
anatomic structures with a resulting alteration of
natural function:
Spine can no longer carry normal loads
Permanent deformity may occur resulting in
severe pain
Potential for catastrophic neurological injury
Instability results from:
Fracture of vertebral body, lamina, and/or pedicles
Dislocation of anatomic components caused by
disruption of soft tissues
Fracture and dislocation may occur together

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 Classification of Fractures
Major and Minor
Major = fracture of vertebral body, pedicles, lamina
Minor = fracture of transverse, spinous, articular processes

Major fracture Minor fracture 11

Classification of Fractures
Stable and Unstable
Stable

Spine can withstand physical

loads
No significant displacement or
deformity to bone or soft tissue
Unstable
Spine may not be able to carry
normal loads
Most likely have significant
deformity and pain
Potential for catastrophic
neurologic injury 12
 Denis Classification Method
Used to grade thoracolumbar and cervical
fractures
Based on 3-column theory of the spine:
Anterior

ALL and anterior 2/3 of vertebral body/disc

Middle

posterior 1/3 of vertebral body/disc and

PLL
Posterior

pedicles, lamina, facets, post. ligaments

Middle column is the key to stability

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 Type of Spinal cord injury
Direct : tembus bacok/tusuk/peluru

Indirect:
fleksi-ekstensi
Kompresi
Burst
instabilitas
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 Type of Spinal cord injury
Incomplete:
Masih ada fungsi(motorik/sensorik)

Complete:
Tidak ada motorik/sensorik > 24 jam

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 Initial management
Penyebab kematian:
Aspirasi
Distres nafas
Hipotensi/shock
Masking cidera lain:
torak , abdomen , kepala
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 Harus curiga spinal cord injury

Trauma berat
Trauma Multipel
Trauma Jatuh dari Ketinggian
Trauma dgn gangguan kesadaran
Trauma dgn Nyeri leher
Trauma dgn Defisit Neurologis
Trauma dgn Nafas abdominal
Trauma dgn Hipotensi & Bradikardi
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 Neurologis
Frankel
Mekanisme injury
Palpasi step-off
Level : (motorik /sensorik / reflek /otonom)

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 Scoring of Neurologic Injury

Frankel Score
A = Complete loss of motor and sensory function
B = Only sensory function remains
C = Motor function is present but of no practical use (i.e.,

can move legs but not walk)

D = Motor function impaired (i.e.can walk but not with

normal gait)
E = No neuro impairment noted 19
 Neurologis
Motorik :
C 5 : Shoulder abduction
C 6 : Elbow Flexion
C 7 : Elbow Extension
C 8 : Fingers Flexion
T 1 : Adduksi dan abduksi jari

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 Neurologis
Lumbal:
L 2 : Hip Flexion
L 3 : Knee Extension
L 4 : Foot Dorso flexion
L 5 : Big Toe Extension
S 1 : Foot Plantar flexion

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 Muscle Grading Scale
grade 0 : tidak ada aktivitas motorik sama sekali
grade 1 : teraba kontraksi otot,tapi tdk ada pergerakan sendi
grade 2 : bisa bergerak kesegala arah tapi tidak bisa melawan
gravitasi
grade 3 : bisa bergerak kesegala arah ,juga melawan
gravitasi
grade 4 : sama dengan grade 3 tapi tidak kuat menahan
beban/tahanan
grade 5 : normal

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 Neurologis
Sensoris:
C5 : bahu
C6 : ibu jari tangan
C7 : jari tengah
C8 : jari kelingking
T4 : papilla mamae
T6 : xiphoid
T 10 : umbilikus
L1 : inguinal
L3 : atas lutut
L4 : maleolus medialis
L5 : ibu jari kaki
S1 : maleolus lateralis 23
 GAMBARAN KLINIS
SINDROM-SINDROM:
Anterior Cord
Brown-Sequard
Central Cord
Posterior Cord
Cauda equina

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Sindrom Anterior Cord
Lesi di 2/3 anterior spinal
cord akibat gangguan
perfusi berat pada arteri
spinal anterior (vascular)
KELUMPUHAN BILATERAL
KOMPLIT dan sensasi nyeri
hilang ( level lesi kebawah )
Rasa posisi normal

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Brown-Sequard Syndrome

Penyebab: fraktur / dislokasi

/trauma tembus
Tanda: Hemitranseksi ( inkomplit )
- ipsilateral:
- Motorik (Paralise)
- Rasa posisi
- kontralateral:
- ggn rasa nyeri dan suhu

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Sindrom Sentral Cord
Cidera Ekstensi pd umur
tua
Paralise tipe UMN pada
tungkai dan LMN pada lengan
Gangguan motoris lebih
tampak dari sensoris,
gangguan lengan lebih dari
tungkai dan gangguan distal
lebih dari proksimal
Gangguan bladder and
bowel

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Sindrom Posterior Cord

1. Rasa panas/terbakar

2. Parestesia

3. Motorik normal

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 Sindrom Cauda Equina
- Penyebab : Trauma , HNP Akut
- Prognosis cukup baik
- Cauda equina : L 1 sacro coccygeus
- Tanda: - saddle back anaesthesia
- retensi urin
- tonus rektal lemah
- kelumpuhan tungkai

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 imaging
X-Ray:

X Cervikal:
Lateral C1 s/d T1
Bila perlu :
Open Mouth, oblique, fleksi-ekstensi

X Torakal / X Lumbal
Lateral
Oblique

Fleksi-ekstensi

CT Scan

MRI

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GENERAL PRINCIPLES OF
MANAGEMENT
Imobilisation
Stabilized medically
Maintain spinal alignment
Decompression
Spinal stabilisation
Rehabilitation

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Mengangkat ,memiringkan
,mengatur posisi atau merawat

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 Spinal Cord Injury
Efek terhadap organ lain :

Paralisis interkostalis Hipoventilasi

Paralisis diafragma C3-C5

Trauma abdomen masking

effect
MEDICAL STABILISATION
Especially in a tetraparetic or tetraplegic
Normalised vital signs
Maintain adequate circulation and tissue
perfusion
Monitor urine production
Monitor blood gas analysis
Neurogenic shock ?

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 Neurogenic Shock
Loss of symphatetic tone on the
periphery
Vasodilatasi
Increase blood vessel capacity
Venous swelling on lower extremities
Hypotension and bradycardia
Hypothermia
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 Clinical Features

Symptoms of Spinal Shock:

Flaccid paralysis
Loss of autonomic reflexes (injury above T6 )
Bowel & bladder dysfunction
Clinical Findings :
Loss of Bulbocavernosus reflex or anal wink reflex

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Reflek Bulbokavernosus

Reflek Anal (Anal Wink)

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 Neurogenic Shock
Treatment

Adequate fluid ( do not overload )

Trendelenburg position
Atropine 0.4 mg
Cardiopressors to increase peripheral
vascular tone and cardiac output

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MEDICAL STABILISATION
Insert NGT gastric decompression and
prevention of stress ulcer
Insert urinary catheter to monitor fluid
output and to decrease the hypotonic
bladder
Mega dose of methylprednisolone (???)

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 Metil Prednisolon
Syarat :8 jam pertama & tdk ada kontra indikasi
Dosis : diencerkan dulu : 62,5 mg/ ml

Bolus: Vol (ml) = BB x 1,92 (dalam 15 menit)

Istirahat 45 menit
Infus: Vol (ml) /jam= BB x 0,0864 (dlm 23 jam)

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 Metilprednisolone:

Hanya diberikan selama 24 jam dengan dosis awal: jam

pertama 30mg/kg BB bolus dalam 15 menit dilanjutkan
pada jam kedua perdrip 5,4 mg/kg BB / jam selama 23
jam berikutnya.

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spinal alignment Gardner tongs traction

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