Long Case 5 Spinal Trauma

Long Case 5

Spinal Trauma

Name                                                   Age                                         Sex

Address                                               Profession                               Date of Admission

C/C      Lower Back ache for  2 months

HOPI –

 In the same format

Pain , Swelling  ,Deformity ,Wounds ,Discharge ,Limping ,Movements,Functions,Fever ,Trauma,Infection,other Constitutional symptoms – loss of appetite , weight loss, loss of sleep and excessive night sweat

Functions – Bowel bladder functions , sensation on lower extremities , ulcers on any part

Abilities – Able to changes posture , dressing , toiltet ,dressing ,

Treatment History

            Xray , Belt , CT , Lab investigations , Analgesics, Foely’s catheterization

            How to manage a patient ?

            Referral to a higher centre

           

Review of system

TB may be associated with Pulmonary / Genitourinary TB . So quick review of these systems during history taking.

MSK review – Other joints pain – neck , knee, ankle , shoulder , elbows , hands and feet during history taking.

Other systems during physical examination .

Past History – Drug allergy , Past history of Blood transfusion , Medical and Surgical Ilnesses

Family History – Socioeconomic status –

Poor or high

                                                             Congested living environment ?

                                                            Any history of contact with PTB

Personal ,Birth and Developmental ,Vaccination History – Unremarkable

Mesntrual History

Expectation

Clinical Examination

Introduction ownself

Exposure – Upto Umbilicus 

Hand scrubbing

General Examination

Healthi looking

Conscious

Well oriented to time place and person

Coperative

Not in distress

Attitude –Sitting comfortably on bed with hips and knees bent

Jaudince Pallor Cyanosis Clubbing Oedema Dehydration

Vitals

Skin / Hir

Systemic

HEENT – No redness of eyes , no ear discharge , good oral hygiene

Chest – Bilateral vescicular breathing sounds, with equal air entry with no added sounds

Cardiovascular System – S1S2  , BOTH S1 and S 2 are auscultated with no murmurs .

Per Abdomen – Soft , non tender , with no organomegaly

                        Pelvic compression

                        Per Rectal

Musculoskeletal Syestem

Look- Standing Patient

Comment on Cervical Collar

Attitude of the limb

Alignment       -           Front    Head at Centre

 Both shoulders are leveled,

                                                Chest is symmetric on both the sides

                                    No wasting of muscles on chest , shoulder ,arm , forearm                                                     , thenar and hypothenar muscles with normal overlying skin

                                    Side       Normal cervical lordosis

                                                  Maintained deltoid contour , elbows extended ,

                                                   Hands anterior to Greater trochanter

                                    Back               

  Spinal curvature is maintained with no kyphoscoliosis

  Normal overlying skin on back with no dimpling , tuft of hair

      and swelling

 No wasting of muscles on supr and intraspinatus fossa ,shoulder               and dorsal surface of arm , forearm and hands

Gait                                         Normal / Stooped wide based gait /frequent fall or early shuffling

Ask Patient to Sit

Palpation                                 Superficial Palpation

                                                            Normal temperature ,no soft tissue tenderness

                                                Deep Paplation

                                                Thumb – palpate spinous process

                                                Percussion tenderness

                                                Twisting tenderness

                                                Deep with fist on ulnar border over spinous process

                                                Feel curve

                                                            Kyphosis - D 12 – L 4

Neck ROM –                          Decreased ROM particularly Lateral Flexion

Lumbar ROM                         Flexion / Extension

                                                Rt and Lt Bending

For C –spine

Spurling sign + -                      Hyperextension + Lateral rotation towards affected side + gentle           compression – if illicits Pain – s/o Radiculopathy

Shoulder Abduction sign        + , Relief of pain with hands putting on head with shoulder abducted.

Hoffman’s Reflex                   Reflex – thumb and other fingers extend with sudden long finger DIP joint extension

Scapulohumeral Reflex           Taping spine of scapula illicits a brisk scapular elevation and abduction of humerus .

Reverse Asymmetric Jerk       Biceps / Supinator

Inverted Radial Reflex           During testing Brachioradialis reflex , the response is reciprocal spastic contracture of fingers.

Lhermitte’s Sign                     Neck – Flexion leads to burning sensation involving upper and lower extremities and trunk.

Finger Escape Sign                 In making a grip , 2 ulnar digits drift out.

                                                In grip and release test , patient unable to form a fist and release all digits within 10 seconds period

Examine upper and lower limbs for C-spine in a more detailed way.

UE – C 5 – T 1 , LE – l2 – S 5

For Lumbar spine – Lower Extremity Neurology in a more detailed manner .

Gait

Sqautting

Trendelburg test

Inspection

Alignment

Muscles wasting

Attitude of the limb

Inspection – Sinuses – Active / Healed – Site , Size , discharge ,

Palpation – Temperature ,tenderness ,Scar tenderness ,mobility

Movement

Hip /Knee /Ankle  / Toes 

Neurovascular Examination

LE – l2 – S 5

Spasticity / Clonus

Sensation – including joint position which is maintained

Motor – Bulk , tone, Power – L2 – S 1

Reflexes – Knee and Ankle – Brisk bilaterally

                  Plantar reflex upgoing

In case of Myelopathy spasticity , clonus , brisk reflexes , plantar upgoing.

Radiculopathy has LMN type presentation .

DPA and PTA

Per rectal examination and Bulbocavernous reflex is important when patient has areflexia.

           

           

How do you investigate ?

TL X-ray

Confirm diagnosis

To assess magnitude of injury

Lateral – Height of vertebrae , Anterior , Posterior Vertebral lines

AP – Scoliosis , Interpedicular distance increase s/o Burst fracture

What else

CT – TO study fracture more detailed ,fragment in spinal canal .

MRI

To see cord status above L1 – Primary investigation , below this – CT is the choice )

To assess if PLL is intact

Intact – We can do indirect reduction with a ligamentotaxis.

Rupture –direct reduction of fragement via anterior approach .

            Posterolateral approach can also be used for decompression .

Plan – Burst Fracture – Unstable – Fixation

Neurologic Involvement – E.g. Cauda Equina – Emergency decompression .

 Post Traumatic Deformity and TB Spine may be argued.

 Some Discussion on TB Spiine 

Zehl –Neelson Staining

Sample fixed in a glass slide

Flooded with Carbol-Fuschin and Phenol for 3 mintues , it turns sample into a red colored .

Decolorise with 3 % HCL in 70 % Alcohol , it turns sample into a white colored sample.

Side flooded with Methylene blue to counterstain for 30 seconds , rinsed with water and air dried

If result – Sample Blue – No AFB

                           Red -  AFB present

X ray Findings – Differences TB Hip and Septic Arthritis of Hip   

TB Hip	Septic Hip
Osteopaenia	Soft tissue shadows
Decreased joint space	Osteomyelitis
Localized Bone Destruction	Osteomyelitis Iliac Bone, Proximal Femur
Wandering Acetabulum	Dislocation
	Capital Epiphysis Destruction

TB Spine X- Ray Changes

Osteopaenia, Decreased joint space

End plate changes –loss of paradiscal margins

Vertebral body involvement – Anterior / Centre / Posterior – Bird nest appearance – T –spine crowding of ribs and destroyed vertebral bodies

Collapse of vertebral bodies

            Telescopic – Cervical and lumbar region

            Flexion Contracture

           

Atlantoaxial instability

Deformity

Adverse effects of Chemotherapy

Isoniazide

            Hepatotoxicity,Periphernal Neuritis,

            Precipitates Epilepsy , Lupus ,Psychotic Changes

Rifampicin

            Heaptotoxicity,Flu like symptoms,Thrombocytopaenia , Haemolytic Anaemia

Pyrazinamide

            Hepatotoxic , Hyperuricaemia,

Ethambutol

            Optic Neuritis , Color Blindness, Allergic Reactions

Streptomycin

            Nephrotoxicity,Vestibular Dysfunction

Surgery in C-Spine

Anterior Approach , Anterior Retrophalangeal – pioneered in John Hopkins

Anterior Approach

Postion – Supine , Shoulder blade supported

Head – supported

Interval – Strap muscles and Sternocleidomastoid

Strap Muscles – Sternothyroid ,Steronhyoid muscles supplied vy Ansa Cervicalis,underneath these lie Trachea and Oesophagus

            Deeper lies Longissimus Coli

Posterior Approach – Patient prone , Head Supported .

Thoracic Vertebrae Involvement – Approach ambigious ,

Anterior  Transpleural –Transthoracic –Pleura , underlying descending aorta

                                                   Trans-sternal

Extrapleural Anterolateral (Costovertebrectomy)

Posterolateral Costotransversectomy

Posterolateral (Martin 1970 )- Dura exposure

Hemilaminectomy

Removal of posterior ends of 2-4 ribs ,transeverse process and pedicles

Rib head and neck resected

            He adds that this is a risky exposure .

Approach to Atlanto-occipital and Atlantoaxial Vertebrae

            Supine , 5-10 degrees hyperextended , Tracheostomy

            Transoral Anterior Approach

            Uvula, Soft palate bisected , Hypopharynx packed, 5 cm long incision

Bone and flaps raised , Stay sutures applied.Anterior Arch of atlas , body of axis , atlantoaxial joints exposed.

Lumbar Vetebrae Exposure

Retroperitoneal (From Renal angle down to lateral border of Rectus Abdominis )

Superficial to Deep abdominal muscles

Away from Rectus Abdominis

External Oblique  / Interal Oblique / Transversalis fascia / Pertitoneum  

Near Rectus Abdominis

                        Anterior Rectus Sheath / Rectus Abdominalis / Posterior Rectus Sheath

Posterior

Transperitoneal

            Linea Alba, Perotineum , Bowel

Posterior

            Errector Spinae

                        Superior Layer – Lateral Dorsi

                        Deep – Superficially – Superior Sacrospinalis

Deep – Multifidus ,Rotators

Head and neck  ......

           

Ribs Part

 

            Surgical Indications –Pott’s Spine

1)      Not Involving Neurology

-failure of improvement after 6-10/12 ATT (middle path regimen waits for 3-6/12)

-Recurrence of disease

-primary drug resistance , history of irregular chemotherapy

-to prevent deformity

      Adults – Vertebral body loss > 1 Thoracic vertebra

      Children Kyphosis > 30 degrees before starting treatment

2)      Rare Indications

To establish indications

Persisting sinuses and discharges

TB C-spine – difficulty deglutition and breathing

 3)Involving Neurology

            -No neurological recovery even after 4 weeks chemotherapy

            -Development of neurological complications during chemotherapy

            -Worsening neurological complications during chemotherapy

            -Advanced cases of neurological involvement

            -Rapidly advancing paresis advancing daily

            -Paravertebral abscess with difficult deglutition and breathing

            -Older patients to avoid recumbency

How Spine is involved ?

Via – Arterial vascular channels

Venous perivertebral Plexus (Batson’s)

Direct mesentry , Cysterna Chyli , direct implantation

Cutaneous or lypmhadenopathy – uncommon

Invovlement

Paradiscal – Complete , child < 1 years

Central ,Anterior , Posterior , Skip lesions

Spinal tumor syndrome start at posterior margins with cord  compression with granulation tissue

True Tuberculos Arthritis at occipital Atlanto-Axial arthritis

Abscesss Natural Path

May track into

From C-spine – Retropharyngeal Space –Behind Prevertebral fascia

Posterior and Lateral to it

Mediastinum

Axilla /Cubital Fossa

Thoracic Spine

Paravertebral Abscess

            Upper –Squaring of Mediastinum

            Mid – Fusiform swelling

Extrapleural space

Intrapleural Space

Alongside Intercostal Nerves and Vessels

           

Lumbar Spine

Psoas Abscess

Petit’s Triangle /Lumbar Triangle

Scarpa’s triangle

Posterior aspect of thigh / Popliteal fossa

Classification – TB Vertebrae

I –Predestructive

< 3 months

Straightening of Curves ,paraspinal spasm

Marrow edema in MRI

II- Early Destructive

2-4 months

Decrease disc space

Paradiscal involvement

Kyphosis < 10 degrees

Marrow edema and Osseous break

Marginal erosions or cavitations

III. Mild Angular Kyphosis

3 – 9 months

2-3 Vertebra involved

Kyphosis angle upto 30 degrees

IV. Severe Angular Kyphosis

            Kyphosis angle > 60 degrees

3 Vertebrae involved

2 years

Pott’s Paraplegia Classification

Common in dorsal and Cervical dorsal region – Canal narrow and propensity towards kyphosis and retropulsion

Lumbar Vertebrae – less common – canal wider , cord ends at lower border of L 1.

Girdlestone’s and Grififth’s Classificaiton

Early < 2 years of onset

Late > 2 years of onset

Hodgson’s Classificaiton

1 Paraplegic due to Extrinsic causes

            Abscess

            Sequestrate

            Discal fibrosis

            Pathological subluxation /dislocation of vertebrae

            Transverse ridge of bone anteriorly

2 Paraplegia due to Intrinsic Causes

            Meningitis

            Meningomyelitis

            Inflammatory thrombosis

Seddon’s Classification

            Paraplegia of active disease

            Paraplegia of healed disease

Causes of Paraplegia

Active disease

Compression – Inflammatory edema             

                                    Grnaulation

Infective vasculitis

Spinal tumor syndrome

Direct bacilli into cord

Healed disease

            Gibbus – stretching of scord

            Epidural fibrosis

Thoriacic Spine TB Management

Mehta and Bhoraj Classificaiton

          A-    Paradiscal and Central Involvement  

Management – Transpleural debridement+ fusion

                        No instruments

B    -      A (Paradiscal and Central Involvement + Deformity

Management – A (Transpleural debridement+ fusion) + Instrumentation

C – To ill to undergo transpleural approach

Management – transpeduclar decompression and posterior instrumentation

Note : if arthrodesis also required , use transpleural approach instead of costovertebrectomy

Complications of Pott’s Spine

1 Abscess and Sinus formation

2 Neurological Involvement

      Pott’s Paraplegia

      Bed Sores

      Pneumonia

      UTI

      Sepsis

      Death

3 Deformity with Kyphosis

4 Fracture – C- spine

5 Atlantoaxial Instability

Mantoux Test

	Possible causes	People at risk	Actions to be done
False +ve	Non TB Mycobacteria BCG Vaccination	People infected with non-TB Mycobacteria BCG vaccination	Evaluate TB if symptoms persist Assess likelihood of TB
False –ve	Anergy Recent TB Very young age	HIV Infected Other people with weakened immunity MTB infection within past 10 days Children < 6 months	Anergy testing Retest …….. after exposure to TB ended Retest when child 6 months old and 10 week after exposure to TB ended

May have associated active infection in

Pulmonary and Urogenital TB