Hyperextension Injury

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Information about Hyperextension Injury
Health & Medicine

Published on February 23, 2009

Author: Dr_Shammasi

Source: slideshare.net

Dr. Ahmed Mirza Al-Shammasi, MB ChB 2031040009 KFHU – Saudi Arabia

Outlines Introduction Definition of Traumatic Central Cord Syndrome Correlative Anatomy, Pathogenesis, Pathology Diagnosis Management Consevative vs. Operative Timing of Surgery

Introduction

Definition of Traumatic Central Cord Syndrome

Correlative Anatomy, Pathogenesis, Pathology

Diagnosis

Management

Consevative vs. Operative

Timing of Surgery

Introduction First reported by Thorburn in 1887, popularized by Schneider in 1954. TCCS is related to Hyperextension of the cervical spine without concomitant fracture of sublaxation. TCCS compromises 44% of clinical syndrome following traumatic SCI. 35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

First reported by Thorburn in 1887, popularized by Schneider in 1954.

TCCS is related to Hyperextension of the cervical spine without concomitant fracture of sublaxation.

TCCS compromises 44% of clinical syndrome following traumatic SCI.

35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

Introduction General trend since 1954 has been reluctance to undertake aggressive treatment: Lack of # or sublaxation on imaging studies. Spontaneous functional recovery. Comorbidities. Risk of Intraoperative worsening of neurological condition. Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.

General trend since 1954 has been reluctance to undertake aggressive treatment:

Lack of # or sublaxation on imaging studies.

Spontaneous functional recovery.

Comorbidities.

Risk of Intraoperative worsening of neurological condition.

Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.

TCCS Partial SCI with disproportionate: Motor loss in the distal upper extremities. Significant involvement of bladder function. Variable degrees of sensory impairment below the level of skeletal injury. Middle-aged men are mostly affected. In several recent series the proportion of men ranged from 56.2-88%. 35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

Partial SCI with disproportionate:

Motor loss in the distal upper extremities.

Significant involvement of bladder function.

Variable degrees of sensory impairment below the level of skeletal injury.

Middle-aged men are mostly affected.

In several recent series the proportion of men ranged from 56.2-88%.

35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

 

 

 

 

 

 

 

 

 

Pathogenesis Foerster and Schneider: Buckling of Ligamentum flavum + disc protrusion. Compression of the spinal cord. Formation of a hematoma at the center of the cord (Hematomyelic cavity). Fibers subserving the upper extremities, concentrated medially, are involved. Fibers subserving the lower extremities, concentrated laterally, are spared.

Foerster and Schneider:

Buckling of Ligamentum flavum + disc protrusion.

Compression of the spinal cord.

Formation of a hematoma at the center of the cord (Hematomyelic cavity).

Fibers subserving the upper extremities, concentrated medially, are involved.

Fibers subserving the lower extremities, concentrated laterally, are spared.

 

Pathogenesis Recent lines of evidence contradict that assumption. Pappas and Marchi, Coxe and Landau, Barnard and Woolsey studies in monkeys No somatotopic organization of the Corticospinal tract at the level of pyramids or cervical spinal cord. Studies of Nathan and colleagues in human patients tend to confirm this finding.

Recent lines of evidence contradict that assumption.

Pappas and Marchi, Coxe and Landau, Barnard and Woolsey studies in monkeys

No somatotopic organization of the Corticospinal tract at the level of pyramids or cervical spinal cord.

Studies of Nathan and colleagues in human patients tend to confirm this finding.

Pathogenesis Jimenez, Martin and Quencer: Correlating autopsy with MRI imaging of TCCS patients. Majority of patients with TCCS had no evidence of hematomyelia or significant injury to the centeral gray matter. Axonal disruption and swelling is widespread in the white matter of the lateral funiculi and to lesser extent the posterior columns.

Jimenez, Martin and Quencer:

Correlating autopsy with MRI imaging of TCCS patients.

Majority of patients with TCCS had no evidence of hematomyelia or significant injury to the centeral gray matter.

Axonal disruption and swelling is widespread in the white matter of the lateral funiculi and to lesser extent the posterior columns.

 

Alternative hypothesis Proposed by Levi and Collignon: TCCS may result from pathological entities affecting the CST anywhere from the pyramids to the cervical spine. CST primarily subserve fine motor movements to the distal musculature, especially upper limbs. Preservation of leg movement is mediated by other descending motor pathways important to locomotion.

Proposed by Levi and Collignon:

TCCS may result from pathological entities affecting the CST anywhere from the pyramids to the cervical spine.

CST primarily subserve fine motor movements to the distal musculature, especially upper limbs.

Preservation of leg movement is mediated by other descending motor pathways important to locomotion.

Pathology Lesion of TCCS seem to comprise 3 main categories: Cervical Spondylosis associated with spinal canal stenosis Fracture sublaxation Sequestrated disc without evidence of spinal stenosis. The proportion of each is different in every case.

Lesion of TCCS seem to comprise 3 main categories:

Cervical Spondylosis associated with spinal canal stenosis

Fracture sublaxation

Sequestrated disc without evidence of spinal stenosis.

The proportion of each is different in every case.

Diagnosis CT, MRI, and when indicated, dynamic studies will essentially rule out skeletal damage, DLC injuries and hidden fractures. New technology even enables the measurement of the degree of canal compromise and cord compression. (MCC, LL)

CT, MRI, and when indicated, dynamic studies will essentially rule out skeletal damage, DLC injuries and hidden fractures.

New technology even enables the measurement of the degree of canal compromise and cord compression. (MCC, LL)

i b a MSCC (%) = [1-i/(a+b)/2] x 100 Maximum spinal canal compression

 

Management Surgical vs. Conservative Factors that discourage urgent surgery, experience of Schneider and colleagues: Lack of # or sublaxation on imaging studies. Spontaneous functional recovery. Comorbidities. Risk of Intraoperative worsening of neurological condition.

Factors that discourage urgent surgery, experience of Schneider and colleagues:

Lack of # or sublaxation on imaging studies.

Spontaneous functional recovery.

Comorbidities.

Risk of Intraoperative worsening of neurological condition.

Management In 1984, Bose review of patients with TCCS showed better motor scores in patients treated surgically. In 2005, Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.

In 1984, Bose review of patients with TCCS showed better motor scores in patients treated surgically.

In 2005, Yamazaki demonstrated “ Direct ” relationship between outcome and Midsagittal diameter of the spinal canal.

Timing of Surgery In 2002, Guest review of patients with TCCS and disc herniation or skeletal injury: Patient underwent Early surgery (<24 hours) had better motor recovery than Late surgery. The timing of surgery did not affect motor recovery in cases with spinal canal stenosis. Preliminary result of prospective multicenter trial, reported by Fehlings, indicate better functional recovery with early decompression.

In 2002, Guest review of patients with TCCS and disc herniation or skeletal injury:

Patient underwent Early surgery (<24 hours) had better motor recovery than Late surgery.

The timing of surgery did not affect motor recovery in cases with spinal canal stenosis.

Preliminary result of prospective multicenter trial, reported by Fehlings, indicate better functional recovery with early decompression.

Surgical Objectives Spinal Cord decompression Restoration of normal spinal alignment and internal fixation Prevent and/or interrupt of further secondary injury.

Spinal Cord decompression

Restoration of normal spinal alignment and internal fixation

Prevent and/or interrupt of further secondary injury.

Conclusion TCCS is most frequent syndrome after incomplete SCI. 50% is due to hyperextension injury. Until now, no standard algorithm of treatment. Further research should be multicenter, prospective and analytical rather than descriptive.

TCCS is most frequent syndrome after incomplete SCI.

50% is due to hyperextension injury.

Until now, no standard algorithm of treatment.

Further research should be multicenter, prospective and analytical rather than descriptive.

Thank you for listening

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