demam berdarah dengue
TRANSCRIPT
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Physical and Radiographic Examination of the Spine
Christopher M. Bono, MDAssistant Professor, Department of Orthopaedic Surgery
Boston University School of Medicine, Boston Medical Center, Boston, MA
Original Authors: Ramil S. Chatnagar, MD andJoel Finkelstein, MD; March, 2004
New Author: Christopher M. Bono, MD; Revised 2005, 2009, 2011
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Key
to th
e sp
ine
Task at hand...
• How to examine a patient• How to interpret radiographic images
SYSTEMATIC APPROACH
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Systematic Approach
• Steps– Components
Correct Diagnosis
Best Treatment
Injury
Listen
Touch
Think
Obtain Imaging Studies
Interpretation and Synthesis
1
2
3
4
5
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Systematic Approach
• Miss a Step
?
Injury
Listen
Touch
Think
Obtain Imaging Studies
Interpretation
and
Synthesis
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Examination
Trauma BayE.R.
• Information• Mechanism
energy, energy• Direction of Impact• Associated Injuries
Starts in the….
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Is the patient awake or “unexaminable”?
• What’s the difference– Awake
• ask/answer question• push/pain/tenderness• motor/sensory exam
– Not awake• you can ask (but they won’t answer)• can’t assess tenderness• no motor/sensory exam
OW!
------
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Does “unexaminable” mean no exam?
NO!• Inspect for bruising or ecchymosis• Palpate for step-off or deformity• Rectal Tone• Reflex exam
– Bulbocavernosus– Clonus/Babinski– Posturing
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Ideal:Patient Awake
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Step1: Frontal Inspection• Inspection--patient flat/frontal view
– Head: Raccoon eyes
– Neck: cock-robin posture
– Thorax: chest contusions, flail chest, asymmetric chest expansion
Remove all
clothes
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Step1: Frontal Inspection• Inspection--patient flat/frontal view
– Abdomen: lap-belt ecchymosis
– Peritoneum/Pelvis: priapism, scrotal swelling, bruising
– Extremities: gross movement, tone, flaccid
Remove all
clothes
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Special CircumstancesMotorcyclists and Athletes
• Helmet--stays in place initially• Face mask off• Complete initial inspection• Multi-member team to remove• x-rays before/after
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Step 2: Neurological Examination
• Detailed and Systematic– Motor– Sensory– Reflexes
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MotorCervical
1 muscle to test each level/root
C5: DeltoidC6: BicepsC7: TricepsC8: Finger flexorsT1: Hand Intrinsics
Pick one
muscle
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MotorLumbar
1 motion to test each level/root
L1/2: Hip FlexionL2/3: Knee ExtensionL4: Tibialis Ant. - foot dorsi-flexionL5: EHL and toe dorsi-flexionS1: Ankle plantar flexion
Pick one
motion
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Motor
Thoracic
Testable?Functional?
(e.g. T5 intercostals vs. T7 intercostals)
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Motor Grade
0/5 none1/5 trace2/5 some movement3/5 anti-gravity4/5 anti-resistance5/5 normal
+/-
Test in contracted/shortened position
Biceps
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Sensory
Normal
Diminished
None
Light touch
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Dermatomes
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Beware: “Cervical
Cape”Sensation over the sternum is not “sensory sparing”
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S1
L3
L5
L4
T10 umbilicus
T12 inguinal crease
Pick one spot
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Rectal
• Anal sensation
• Rectal tone
• Anal sphincter contraction
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Reflexes Hyper (3+) or Hypo (1+)Present or absent
C5 Biceps
C6 Brachialis
C7 Triceps
L3 Patellar Tendon
S1 Achilles
Conus Bulbo-Cavernosus
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Pathologic Reflexes
• Hyperreflexia• Clonus 4 beats• Babinski• Inverted Radial Reflex• Hoffmans
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Don’t forget the Cranial Nerves
• Why?– Occipito-atlantal injuries incidence of CN injuries
• VI• IX• X• XI• XII
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Step 3: Posterior Inspection
• Log-roll side-to-side– palpate spinous processes– palpate ribs– again-----inspection
• ecchymosis• bullet wounds-markers• open wounds (probe)
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Step 4: Radiographic Examinationwhat to order
how to interpret
• Studies that are “automatic”–lateral C-spine (or equivalent)
CT scan w/ sagittal recon
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Step 4: Radiographic Examinationwhat to order
how to interpret
• Studies that are “automatic”
–complete C, T, L films if 1 injury is detected
10-15 % non-contiguous injuries
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Step 4: Radiographic Examinationwhat to order
how to interpret
• Studies that are “automatic”
–calcaneus fxlumbar films
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Getting organized…make a distinction between:
InjuryDetection
InjuryDescription
Vs.
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Injury Detection
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WORKHORSEWORKHORSE OF CERVICAL TRAUMA
Injury Detection: Cervical Spine
• Systematic• Start at the top• Start with PLAIN LATERAL FILM
85% of injuries
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Occipitocervical Junction
• Dislocations• Dissociations• Challenges of
Detection/Missed Diagnosis
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Detecting O-A Injuries
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C1-C2: sagittal instability
• Widened ADI• 3mm in adults• 4-5 mm in children
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Lower Cervical (C3-T1)
CHECK YOUR LINES• Spinolaminar line• Posterior VB line• Anterior VB line
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Lower Cervical Detection
• Spinous process gapping
• Facet joint Apposition
• Inter-vertebral Gapping
• Angulation• Translation
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Subtle Signs of Injury
• No obvious fracture/dislocation• look for
RETROPHARYNGEALOR PRE-VERTEBRAL SOFT
TISSUE SWELLING
PRESENT +injuryNOT PRESENT +/- injury
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Soft Tissue EdemaUsing:• 6 mm at C3
• 22 mm at C659% sensitivity
5% sensitivity
Doesn’t mean much if not thereDeBehne and Havel, 1994
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Anteroposterior (A-P) View
• Spinous process deviation• Lateral Translation• Coronal deformity
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Open Mouth View
• Mostly C1-C2 lateral massOccipital Condyles/CO-C1• Odontoid Process
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Swimmer’s View
• Cervico-thoracic junction– obliques sometimes helpful
CASETTE
X-ray BEAM
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CT: as initial screening modality
• Sagittal recon--like lateral x-ray
• Most sensitive for fracture detection– esp. Upper/Lower
(difficult w/ x-ray)
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MRI for injury detection
negative plain filmsnegative CT scan
but still suspicious
MRI•Continuity of ligaments
•edema in soft-tissues
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MRI for injury detection
MRI
•Herniated Discs
Clinical suspicion/neural
deficit
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“Clearing” the C-spine• Standardized Protocol• no consensus
Flex-Ex CT
MRI
Trac
tion
Film
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Neck PainNeurological DeficitDistracting InjuryIntoxicated
3-viewsCT through suspicious areas or if not visualizedCT entire w/ Hd CT
Flexion/Extension Lateral X-rays
MRI
Yes
no D/C collar
Abnormal
Normal
Neck Pain (Alert/Awake)
Normal:D/c collar
Neuro Def (Alert/Awake)Or, AlteredConscious-ness
Normal: d/c collar
Abnormal
Consult Spine
Abnormal
Boston Medical Center Protocol
Agreement between:
Ortho, Neuro, Trauma, Radiology
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Neck PainNeurologic DeficitDistracting Injury)Intoxicated
3-viewsCT through suspicious areas or if not visualizedCT entire w/ Hd CT
Flexion/Extension Lateral X-rays
MRI
yes
no D/C collar
Abnormal
Normal
Neck Pain (Alert/Awake)
Normal:D/c collar
Obtunded Patient
Normal: d/c collar
Abnormal
Consult Spine
Abnormal
Goal: clear w/in 48 hrs
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Injury DetectionThoracic and Lumbar Spines
• Same principles• Landmarks and Lines:
Lateral View– Posterior VB line– Anterior VB line– Inter-spinous Distance– Translation
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Injury DetectionThoracic and Lumbar Spines
• Same principles• Landmarks and Lines: A-P
View– Spinous process to Pedicles– Inter-pedicular Distance– Translation
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CT
• More common as initial study
• indicated if suspicious plain film
• best for bony detail• axial--can miss translation
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Thoracic and Lumbar Injuries
What is “normal” angulation
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Height Loss
Adjacent fracture
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Frequently Missed Injuries
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Flexion-Distraction Injuries
Look at Facets
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Using MRI to assess the PLC
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Using MRI to assess the PLC
Continuity of the
Ligamentum Flavum
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Using MRI to assess the PLC
Anterior Alone vs.
Combined A/P
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Thankyou
Spine rules
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