REFERATPhysical examination & early management of spine injury
Pembimbing : dr. Dhevariza PD. Sp.OTOleh :Alita palpialy 406138136
Fakultas Kedokteran Universitas TarumanagaraKepaniteraan Klinik Ilmu Bedah UmumRumah Sakit Umum Daerah Ciawi
KATA PENGANTARPertama-tama penulis memanjatkan puji dan syukur kepada Tuhan Yang Maha Esa atas berkah dan rahmat yang telah diberikan, sehingga penulis dapat menyelesaikan referat yang berjudul Tumor jinak colli ini tepat pada waktunya. Adapun tujuan pembuatan referat ini adalah untuk memenuhi tugas di kepaniteraan klinik Ilmu Bedah Rumah Sakit Umum Daerah Ciawi,, serta agar dapat menambah kemampuan dan ilmu pengetahuan bagi para pembacanya. Pada kesempatan ini, penulis juga ingin mengucapkan terima kasih kepada:1. dr. Dhevariza PD, SpOT1. dr. Sjaiful Bachri, SpB1. dr. Ooki Nico Junior, SpB(K)Onk1. dr. Johan Lucas, SpB1. dr.Relly, SpB1. Teman-teman dan semua pihak yang telah banyak membantu penulis dalam penyusunan referat ini.Penulis menyadari bahwa banyak kekurangan dalam penyusunan referat ini, oleh karena itu penulis mohon maaf yang sebesar-besarnya atas kekurangan-kekurangan tersebut.Besar keinginan penulis untuk dapat menerima saran dan kritik yang membangun demi kesempurnaan referat ini. Demikian harapan penulis agar referat ini dapat bermanfaat bagi kita semua. Akhir kata penulis mengucapkan terima kasih atas perhatiannya.
Bogor,30 mei 2014 Penulis
Physical examination & early management of spine injury
Dipersiapkan dan disusun oleh :Alita Palpialy 406138136
Kepala KSMF Pembimbing
(dr.Sjaiful Bachri, SpB) (dr.Dhevariza PD. SP.OT)
Bagian Ilmu BedahRumah Sakit Umum Daerah CiawiDAFTAR ISI
KATA PENGANTAR...........iLEMBAR PENGESAHAN..............................iiDAFTAR ISI........................................iiiBAB I PENDAHULUAN...................................................................ivBAB II PEMBAHASAN......................................................................vANATOMY AND PHYSIOLOGYCLASSIFICATIONS OF SPINAL CORD INJURIES SPECIFIC TYPES OF SPINAL INJURIES X-RAY EVALUATIONMANAGEMENTTREATMENT PRINCIPLES FOR PATIENTS WITH SPINAL CORD INJURIES
BAB 1 INTRODUCTIONVertebral column injury, with or without neurologic deficits, must always be considered in a patient with multiple injuries. Approximately 5% of brain-injured patients have an associated spinal injury, while 25% of spinal injury patients have at least a mild brain injury. Approximately 55% of spinal injuries occur in the cervical region, 15% in the thoracic region, 15% at the thoracolumbar junction, and 15% in the lumbosacral area. Approximately 10% of patients with a c-spine fracture have a second, noncontigu- ous vertebral column fracture. The doctor and medical personnel taking care of such patients must be constantly aware that exces- sive manipulation and inadequate immobilization of a patient with a spinal injury can cause additional neurologic damage and worsen the patients out- come. At least 5% of patients experience the onset of neurologic symptoms, or worsening of preexisting ones, after reaching the emergency department. This is usually due to ischemia or progression of spinal cord edema, but may also be the result of failure to provide adequate immobilization.As long as the patients spine is protected, evaluation of the spine and exclusion of spine injury may be safely deferred, especially in the presence of systemic instability, eg, hypotension and respiratory inad- equacy. Excluding the presence of a spinal injury is far simpler in a patient who is awake and alert. In a neurologically normal patient, the absence of pain or tenderness along the spine virtually excludes the presence of a significant spinal injury. However, in a patient who is comatose or has a depressed level of consciousness, the process is not as simple, and it is incumbent on the treating doctor to obtain the appropriate x-rays to exclude a spinal injury. If the x-rays are inconclusive, the patients spine should remain protected until further testing can be per- formed. While the dangers of inadequate immobili- zation have been fairly well documented, there also is some danger in prolonged immobilization of a patient on a hard surface such as a backboard. Apart from causing severe discomfort in an awake patient, prolonged immobilization can lead to the formation of serious decubitus ulcers in patients with spinal cord injuries. Therefore, the long backboard should be used only as a patient transportation device, and every effort should be made to have the patient eval- uated by the appropriate specialists and removed from the spine board as quickly as possible. If this is not feasible within 2 hours, the patient should be re- moved from the spine board and be logrolled every 2 hours, while maintaining the integrity of the spine, to reduce the risk of decubitus ulcer formation.BAB II. PEMBAHASANANATOMY AND PHYSIOLOGYA.Spinal ColumnThe spinal column consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae as well as the sacrum and the coccyx. The typical vertebra consists of the ante- riorly placed vertebral body, which forms the main weight-bearing column. The vertebral bodies are separated by intervertebral discs and are held to- gether anteriorly and posteriorly by the anterior and posterior longitudinal ligaments, respectively. Pos- terolaterally, 2 pedicles form the pillars on which the roof of the vertebral canal (ie, the lamina) rests. The facet joints, interspinous ligaments, and paraspinal muscles all contribute to the stability of the spine. For many reasons, the cervical spine is most vulner- able to injury. The cervical canal is wide in the up- per cervical region, ie, from the foramen magnum to the lower part of C2. The majority of patients with injuries at this level who survive are neurologically intact on arrival at the hospital. However, approxi- mately one-third of patients with upper c-spine in- juries die at the injury scene from apnea caused by loss of central innervation of the phrenic nerves due to spinal cord injury at C1. Below the level of C3 the diameter of the spinal canal is much smaller relative to the diameter of the spinal cord, and vertebral col- umn injuries are much more likely to cause spinal cord injuries. The mobility of the thoracic spine is much more restricted.This part of the spine also has additional support from the rib cage. Hence, the incidence of thoracic fractures is much lower, with most thoracic spine fractures being wedge compression fractures not associated with spinal cord injury. However, when a fracture-dislocation in the thoracic spine does occur, it almost always results in a complete neurologic deficit because of the relatively narrow dimension of the thoracic canal. The thoracolumbar junction is a fulcrum between the inflexible thoracic region and the stronger lumbar levels. This makes it more vulnerable to injury, and 15% of all spinal injuries occur in this region.
A.Spinal Cord AnatomyThe spinal cord originates at the caudal end of the medulla oblongata at the foramen magnum. In the adult, it usually ends around the L1 bony level as the conus medullaris. Below this level is the cauda equina, which is somewhat more resilient to injury. Of the many tracts in the spinal cord, only 3 can be readily assessed clinically: (1) the corticospinal tract, (2) the spinothalamic tract, and (3) the posterior col- umns. Each is a paired tract that may be injured on 1 or both sides of the cord. The corticospinal tract, which lies in the posterolateral segment of the cord, controls motor power on the same side of the body and is tested by voluntary muscle contractions or involuntary response to painful stimuli. The spino- thalamic tract, in the anterolateral aspect of the cord, transmits pain and temperature sensation from the opposite side of the body. Generally, it is tested by pinprick and light touch. The posterior columns carry position sense (proprioception), vibration sense, and some light-touch sensation from the same side of the body, and these columns are tested by position sense in the toes and fingers or by vibration sense using a tuning fork. If there is no demonstrable sensory or motor func- tion below a certain level, this is referred to as a complete spinal cord injury. During the first few days after injury, this diagnosis cannot be made with certainty, because of the possibility of spinal shock. If any motor or sensory function remains, this is an incomplete injury and the prognosis for recovery is significantly better. Sparing of sensation in the perianal region (sacral sparing) may be the only sign of residual function. Sacral sparing may be demon- strated by preservation of some sensory perception in the perianal region and/or voluntary contraction of the rectal sphincter.
A.Sensory ExaminationA dermatome is the area of skin innervated by the sensory axons within a particular segmental nerve root. Knowledge of some of the major dermatome levels is invaluable in determining the level of injury and in assessing neurologic improvement or dete- rioration. The sensory level is the lowest dermatome with normal sensory function and can often differ on the 2 sides of the body. For practical purposes, the upper cervical dermatomes (C1 to C4) are somewhat variable in their cutaneous distribution and are not commonly used for localization. However, it should be remembered that the supraclavicular nerves (C2 through C4) provide sensory innervation to the re- gion overlying the pectoralis muscle (cervical cape). The presence of sensation in this region may confuse the examiner when trying to determine the sensory level in patients with lower cervical injuries. The key sensory points are: