c5 c6 dislocation

ORTHO CONFERENCEExt pattraporn

HISTORY

Male 43 yr

cc: รถชน 3 hr PTA

PI : 3 hr PTA รถกระบะชนเสาไฟฟา้ มอีาการปวดต้นคอ มอีาการอ่อนแรงและชาท่ีแขนและ ขา ไมม่แีผลตามตัว สลบจำาเหตกุารณ์ไมไ่ด้ ไมม่อีาเจยีน ไมห่ายใจหอบเหนื่อย ไมป่วดท้อง

Past history : no underlying disease

PHYSICAL EXAMINATION Primary survey

A : Can talk, tender at neck with limited ROM

B : Equal breath sound, CCT -ve, no subcutaneous emphysema

C : BP 96/60 mmHg, PR 66 bpm, no active bleeding

D : E4V5M6, pupil 3 mm RTLBE

E : no external wound

PHYSICAL EXAMINATION

Vital sign : BP 96/60 mm Hg PR 90 bpm RR 20 /min Temp 37.2

GA : A Thai man , good consciousnessCVS : normal S1 , S2 , no murmur , cap refill < 2

secsLung : clear , equal both lung , no adventitious

soundAbd : soft , not tender , no guarding , no rebound

tenderness

PHYSICAL EXAMINATION Can't flexion and extension neck tender posterior

Decrease sensation below C6

Bulbocarvernosus reflex -ve

Loose sphincter tone

RT LT

C5 II II

C6 II I

C7 II II

C8 0 0

T1 0 0

RT LT

L2 0 0

L3 0 0

L4 0 0

L5 0 0

S1 0 0

INVESTIGATION

Film C-spine AP, Lateral

Swimming view

SPINOUS PROCESS LINE

Spinolaminar line

posterior vertebral body lineanterior vertebral body line

facet joints appear as stacked parallelograms

Prevertebral soft-tissue shadow Disc C2-C3 < 7mmDisc C6-C7 < 21 mm

AP TRANSLATION

3.5 mm of translational deformity is suggestive of mechanical instability

COBB ANGLE

>11 degrees suggestive of posterior ligamentous injury and potential instability

CT SCAN• More sensitive for detecting fractures

• More consistently enables assessment of the occipitocervical and cervicothoracic junctions

ALLEN & FERGUSON CLASSIFICATION

Distraction flexion II

DISTRACTIVE FLEXION

DIAGNOSIS

C5-C6 unilateral facet dislocation with complete cord injury

INITIAL MANAGEMENT High dose Methyl-prednisolone Methyl prednisolone 30mg/kg then 5.4 mg/kg over the next 24 hours

On skull traction

MRI c-spine

HIGH-DOSE METHYL PREDNISOLONE

MRI• Superiority in visualizing the spinal cord, intervertebral

disc, and spinal ligaments

• Detecting

• traumatic disc herniations

• epidural hematoma

• spinal cord edema or compression

• posterior ligamentous disruption

MRIIndication

• patients with neurological deficits

• patients with injuries in which the integrity of the posterior ligamentous complex is unclear and would directly influence the treatment plan

TREATMENT

SUBAXIAL CERVICAL SPINE INJURY CLASSIFICATION (SLIC)

<= 3 : nonoperative

>= 5 : operative

TREATMENT

8 point

Operative treatment

FACET DISLOCATIONNon-operative treatment

• Indication : unilateral facet dislocations without any signs of neurological injury

• Halo vest immobilization 3 month

• Flexion-extension views to confirm stability

FACET DISLOCATIONOperative treatment

• Closed reduction using cranial tong or halo traction as early as possible in awake, conscious, and able to be serially examined patient

• Pre-reduction and post-reduction MRI

FACET DISLOCATIONOperative treatment

• If there the spinal cord is being indented by a disc herniation, anterior surgery is preferred

• Anterior surgery followed by posterior stabilization for patients with highly unstable bilateral facet dislocations

TREATMENT

SPINAL CORD INJURY

ANATOMY

SPINAL CORD

SPINAL CORD INJURY

Complete cord injury syndrome

Incomplete cord injury syndrome

Conus medullaris syndrome

Clauda equine syndrome

COMPLETE CORD INJURY SYNDROME

After presence of bulbocavernosus reflex : no sensation or voluntary motor function is noted

INCOMPLETE CORD INJURY SYNDROME

Some neurological function persist after return of bulbocavernosus reflex

Sacral sparing : imply continuity between cerebral cortex and lower sacral motor neuron.

Such as 1. Perianal sensation 2. Voluntary rectal motor function 3. Big toe flexor activity

INCOMPLETE CORD INJURY SYNDROME

INCOMPLETE CORD INJURY SYNDROME

ANTERIOR CORD SYNDROMEBlood flow is reduced or interrupted in the artery that runs along the anterior portion of the spinal cord.

May be the result of bone fragments from traumatic injury to the vertebra, spinal disc herniations or flexion/compression injury.

Most poor prognosis : recovery rate 10%

CENTRAL CORD SYNDROMEMost common type

Characterized by impairment in the arms and hands and, to a lesser extent, in the legs.

Spare sacral spine thalamus and corticospinal tracts

Recovery from distal to proximal [toe flexion > toe extension > ankle > knee > hip]

recovery rate 75%

BROWN SEQUARD SYNDROMEHemisection of the spinal cord

Motor paralysis , loss of vibration and proprioception on the ipsilateral side as the lesion and deficits in pain and temperature sensation on the contralateral side of the lesion.

The most common cause of Brown-Séquard syndrome is penetrating trauma such as a gunshot wound or stab wound to the spinal cord.

Best prognosis : More than 90% of people regain bladder & bowel control and the ability to walk.

POSTERIOR CORD SYNDROME

SPINAL SHOCK

Immediate temporary loss of total power , sensation and reflexs below the level of injury

Loss of bulbocavernosus reflex

Usually recovery in 24-48 hrs