Transcript
8/11/2019 Spine Trauma Jember
1/70
Nugroho Setyowardoyo - NUG
8/11/2019 Spine Trauma Jember
2/70
8/11/2019 Spine Trauma Jember
3/70
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
8/11/2019 Spine Trauma Jember
4/70
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
8/11/2019 Spine Trauma Jember
5/70
8/11/2019 Spine Trauma Jember
6/70
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.
8/11/2019 Spine Trauma Jember
7/70
Denis membagi spine menjadi 3bagian:
Columna Anterior
Anterior longitudinal ligamen
Anterior part of vertebral body
Anterior portion of annulus fibrosis
8/11/2019 Spine Trauma Jember
8/70
Denis membagi spine menjadi 3bagian:
Middle column
Posterior logitudinal ligament
Posterior part of vertebral body
Posterior portion of annulus
8/11/2019 Spine Trauma Jember
9/70
Denis membagi spine menjadi 3bagian:
Posterior column
Bony and ligamentous posterior
element
8/11/2019 Spine Trauma Jember
10/70
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
8/11/2019 Spine Trauma Jember
11/70
Fraktur kompresiHasil dari fleksi anterior atau lateral sehinggaadanya kerusakan kolom anterior
Radiologi: Tinggi vertebral body bagiananterior berkurangBiasanya stabil dan jarang ada defisitneurologis
8/11/2019 Spine Trauma Jember
12/70
Fraktur Kompresi
Thomson, 2002
8/11/2019 Spine Trauma Jember
13/70
Burst Fraktur
Kegagalan kedua kolum anterior dan medial
Aksial loading secara vertikal akan diteruskan ke
segala arah pada kolum vertebra sehingga timbulletupan dan hancur
8/11/2019 Spine Trauma Jember
14/70
Burst Fraktur
MOI yang sering terjadi
Jatuh Dari Ketinggian
Galli, 2007
8/11/2019 Spine Trauma Jember
15/70
Wong DA, 2007
8/11/2019 Spine Trauma Jember
16/70
Wong DA, 2007
8/11/2019 Spine Trauma Jember
17/70
Burst Fractures Lateral x-ray : vertebral body height
AP x-ray : interpedicular distance
8/11/2019 Spine Trauma Jember
18/70
8/11/2019 Spine Trauma Jember
19/70
8/11/2019 Spine Trauma Jember
20/70
Flexion-Distraction Injury
Radiologis
interspinous process distance on AP view
posterior height of vertebral body in lateral view
8/11/2019 Spine Trauma Jember
21/70
Fraktur-Dislocation Deniss subtipe fraktur dislokasi
Posteroanterior shear-type
Anteroposterior shear-type
8/11/2019 Spine Trauma Jember
22/70
8/11/2019 Spine Trauma Jember
23/70
Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic
function. This change is either temporary orpermanent.
8/11/2019 Spine Trauma Jember
24/70
8/11/2019 Spine Trauma Jember
25/70
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.
8/11/2019 Spine Trauma Jember
26/70
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
8/11/2019 Spine Trauma Jember
27/70
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
8/11/2019 Spine Trauma Jember
28/70
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
8/11/2019 Spine Trauma Jember
29/70
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
8/11/2019 Spine Trauma Jember
30/70
Figure 12.31
8/11/2019 Spine Trauma Jember
31/70
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
8/11/2019 Spine Trauma Jember
32/70
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
8/11/2019 Spine Trauma Jember
33/70
8/11/2019 Spine Trauma Jember
34/70
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)
8/11/2019 Spine Trauma Jember
35/70
8/11/2019 Spine Trauma Jember
36/70
8/11/2019 Spine Trauma Jember
37/70
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
8/11/2019 Spine Trauma Jember
38/70
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
8/11/2019 Spine Trauma Jember
39/70
8/11/2019 Spine Trauma Jember
40/70
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
8/11/2019 Spine Trauma Jember
41/70
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
8/11/2019 Spine Trauma Jember
42/70
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
8/11/2019 Spine Trauma Jember
43/70
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
8/11/2019 Spine Trauma Jember
44/70
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
8/11/2019 Spine Trauma Jember
45/70
8/11/2019 Spine Trauma Jember
46/70
8/11/2019 Spine Trauma Jember
47/70
8/11/2019 Spine Trauma Jember
48/70
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
8/11/2019 Spine Trauma Jember
49/70
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
8/11/2019 Spine Trauma Jember
50/70
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
8/11/2019 Spine Trauma Jember
51/70
8/11/2019 Spine Trauma Jember
52/70
8/11/2019 Spine Trauma Jember
53/70
8/11/2019 Spine Trauma Jember
54/70
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
8/11/2019 Spine Trauma Jember
55/70
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 -
8/11/2019 Spine Trauma Jember
56/70
Neurogenic shock:
Triad of i) hypotension
ii) bradycardia
iii) hypothermia More commonly in injuries above T6 Secondaryto disruption of sympathetic
outflow from T1 L2
8/11/2019 Spine Trauma Jember
57/70
Incomplete
Any sensation
Position sense
Voluntary movementin lower extremity
Sacral sparing(Perianal Sensation)
Complete
No motor/sensoryfunction
No sacral sparingwith BCR +
May have reflexes
8/11/2019 Spine Trauma Jember
58/70
8/11/2019 Spine Trauma Jember
59/70
Cord transection
Complete
all tracts disrupted
cord mediated functions below transection arepermanently lost
determined ~ 24 hours post injury
possible results
quadriplegia
paraplegia
8/11/2019 Spine Trauma Jember
60/70
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)
8/11/2019 Spine Trauma Jember
61/70
8/11/2019 Spine Trauma Jember
62/70
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
8/11/2019 Spine Trauma Jember
63/70
Exam Findings Ipsilateral loss of motor
function motion, position,vibration, and light touch
Contralateral loss ofsensation to pain andtemperature
Bladder and boweldysfunction (usually shortterm)
8/11/2019 Spine Trauma Jember
64/70
8/11/2019 Spine Trauma Jember
65/70
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
8/11/2019 Spine Trauma Jember
66/70
Usually occurs with ahyperextension of the
cervical region Exam Findings
weakness or paresthesiasin upper extremities butnormal strength in lowerextremities
varying degree of bladderdysfunction
8/11/2019 Spine Trauma Jember
67/70
Classification incomplete SCI syndromes
Central Cord Syndrome
Motor loss UE>LE
Hands usu affected
Common in elderly w/
pre-exist
spondylosis/stenosis
Substantial recovery
8/11/2019 Spine Trauma Jember
68/70
8/11/2019 Spine Trauma Jember
69/70
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
8/11/2019 Spine Trauma Jember
70/70
top related