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Spine to Move Mobile Lumbar Spine 7) Cauda Equina Syndrome

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Spine to Move Mobile Lumbar Spine 7) Cauda Equina Syndrome 13rd EDITION by Anika A Alhambra PERIPHERAL NERVE INJURY SEDDON classification: I. NEUROPRAXIA. − Transient disorder (spontan recovery), several weeks. − EMG of the distal lession usually normal. − Caused by mechanical pressure, exp: − Crutch paralysis − Good prognosis. II. AXONOTMESIS − A discontinuity of the axon, with intact endoneurium. − Wallerian degenration on the distal side. − There is an axon regeneration : 1 – 3 mm/day − Good prognosis III. NEUROTMESIS − Nerve trunk has distrupted, include endoneural tube − Regeneration process Æ neuroma − Prognosis: depend on the surgery technique. SUNDERLAND Classifications: I. Loss of axonal conduction. II. Loss of continuity of the axon, with intact endoneurium. III. Transection of nerve fiber (axon & sheath), with intact perineurium. IV. Loss of perineurium and fascicular continuity. V. Loss of continuity of entire nerve trunk. DEGREE DISCONTINUITY DAMAGE TREATMENT PROGNOSIS 1st None, conduction block Distal nerve fibers Observation Excellent (neuroprxia) remain intact 2nd Axon (axonotmesis) Based on fibrosis Observation Good 3rd Axon & endoneurium Based on fibrosis Lysis Ok 4th Axon, Fibrotic Nerve graft Marginal endoneurium,perineurium connective tissue connects 5th Complete (neurotmesis) Complete Graft/transfer Poor PATOPHYSIOLOGY on the nerve compression injury: 23rd EDITION by Anika A Alhambra 1. Disturb to microcirculation Æ ischemia 2. Disturb to axoplasmic transport Æ neruroaxonal transport Intravascular edema (Increase of vascular permeability) (Degeneration process) Proliferating fibroblast Separation nerve fiber One week (Demyelination) Note: compression 20-30 mmHg Æ pathology on epineurium >80 mmHg Æ completely stop 30 mmHg (8j); 50 mmHg (2j) Æ reverse after 24 hours 400 mmHg (2j) Æ reverse after 1 week ‘Tinnel sign’, is happened on injury and compression, it is sign of regeneration process (continuity sign) Pathological changes on ‘PRIMARY NERVE REPAIR’ 1. Fragmentation of axon and myelin in distal part 2. Schwan cell proliferation in distal segment, with macrophage phagocytes debris material. 3. Axonal sprouting from proximal segment 4. Axonal connection with periphery and maturation of the nerve fiber. CNS PERIFER SCHWANNCELL RESPONSIBLE FOR MYELINATING PERIPHERAL NERVES AXON - + OLIGODENDROCYTES RESPONSIBLE FOR FORMATION OF MYELIN + - ASTROCYTES SUPPORTING STRUCTURE OF THE BRAIN + - VASKULARISASI tendon PARATENON VINCULA SYNOVIAL FEATURES - Fibrosis capsule - Synovial membrane - Fat pad - Synovial fluid - Articular cartilage ANTIBIOTIK GAS GANGGREN: PENICILLIN & CLINDAMYSIN PATOLOGY of peripheral neuropathy: 33rd EDITION by Anika A Alhambra - Acute interruption of axonal continuity - Axonal degeneration - Demyelination Classification *mononeuropathy & *polyneuropathy Cause of polyneuropathy: A] Hereditary: - hereditary motor neuropathy C - Hereditary sensory neuropathy - Friedreich ataxia B] Infection: - Herpes zoster - Leprosy C] Inflammation: - GBS - SLE I - Sarcoidiosis - Neurologic Amyyotrophy D] Nutritional & Metabolic: -DM - Vitamin deficiency M - Amyloidosis - Myxoedema E] Neoplastic: - Myeloma T F] Toxic: - Alcoholism - Lead G] Drugs: various Others H] IDIOPATHIC Chief complain: ‘sensory disturbance’: - numbness, burning, shooting pain,, - Weakness, clumsiness - Loss of balance in walking - Usually, pathology on the distal part, before proximal part. - Compression Mononeuropathy: a) Median nerve : Pronator syndrome Anterior interosseus syndrome Carpal Tunnel syndrome b) Ulnar nerve : Cubital Tunnel syndrome Ulnar Tunnel syndrome c) Radial nerve : Posterior interosseous syndrome Radial Tunnel syndrome Cheiralgia paresthetica (Superficial Radial nerve syndrome) d) Others: Thoracic Outlet syndrome Suprascapular nerve syndrome Meralgia paresthetica (Lat Femoral Cut nerve) Anterior tarsal tunnel Syndrome (Deep peroneal nerve) Tarsal Tunnel syndrome (Tibial nerve) 43rd EDITION by Anika A Alhambra BRACHIAL PLEXUS INJURY 53rd EDITION by Anika A Alhambra Elbow flexion (biceps, C5 dysfunction)____ can be restored w/ latissimus dorsi flexeroplasty (ZANCOLLI) or pectoralis major & minor transfer Elbow extension ____ can be restored w/ transfer of the posterior 3rd of the deltoid to the trapezius ANATOMIC - Root level avulsion Æ involves BOTH anterior (plexus) & posterior (dorsal sensory) region, whereas plexus injury spare posterior areas. - C4-7 nerve root WELL SECURED to their respective vertebrae & are less prone to avulsion inj. C8-T1 roots are NOT. - T1-level preganglionic inj. often includes a Horner syndrome because of disrupting the 1st sympathetic ganglion. - Traction inj are most common Æ C5 & C6 level - Proximal cord lesion Æ injure supraclavicular branches as well as the distal plexus and lead to winging of the scapula (Long thoracic nerve) TREATMENT - Controversy - Mostly observation Æ 3 mo w/ passive ROM & bracing No improvement o Neurolysis o Grafting o Nerve transfer (usually w/ neurotization of intercostals nerve) o Muscle/ tendon transfer LEFFERT classification I. OPEN (usually from stabbing) II. CLOSED (usually from motorcycle accident) a. SUPRACLAVICULAR i. PREGANGLIONIC _____ Avulsion of nerve roots, usually from high-speed injuries w/ o/ inj. & loss of consciousness. NO proximal stump, NO neuroma formation (negative TINEL’s sign), pseudomeningocele, denervation of dorsal neck muscles ARE common sequelae. Horner’s sign (APEM anhydrosis, ptosis, enopthalmus, miosis) ii. POSTGANGLIONIC _____ Roots remain intact; usually due to traction inj. There are proximal stump & neuroma formation (positive TINEL’s sign); deep dorsal neck muscles intact; NO pseudomeningocele (does not develop) 63rd EDITION by Anika A Alhambra b. INFRACLAVICULAR ______ Usually involves branches from the trunks (Suprascapular). Function is affected based on trunk involved. Trunk injured Functional loss Upper biceps, shoulder muscles Middle wrist & finger extension Lower wrist & finger flexion III. Radiation therapy induced IV. Obstetric Injury a. ERB’s (upper root C5-6) --- waiter’s tip hand b. KLUMPKE (lower root C8-T1) c. Mixed MOI : Open injury Close (traction injury): pre/post ganglion Radiation injury Obstetrical injury ## ] Open Injury: o Life or limb threatening vascular injury o Pro: immediate operative exploration (just markering and mapping) o After the wound has healed and no infection Æ repair o If failed Æ plan to tendon transfer. ##] Close Injury: o Caused by stretch on the elements of the plexus. o Determined there was pre or post ganglion o Post ganglion the prognosis is better. o At first treat with conservatively, if after 3-6 month no recovery Æ need operative-exploration. Diagnose Preganglioner Postganglioner LOOK Fail arm, winged scapula, Horner-Sy Fail arm Muscle test Paralysis: Ser.ant,rhomboid,limb Limb muscle muscle Sensation Absent in involved dermatome Idem Tinnel sign Absent Present Myellografi Traumatic pseudomeningocele, and Normal obliteration of root EMG Paravertebral muscle & limb muscle Limb muscle denervation denervatio NCV Motor conduction absent ± sensory Motor & sensory conduction conduction absent Axon response Normal Absent (histamine test) 73rd EDITION by Anika A Alhambra ##] Radiation Injury: o Radiation neuropathy o Neoplastic brachial plexopathy o Prognosis is not good o Operative treatment: Neurolysis, with omentum transplant o Prevention: long term of low dose radiation ##] Birth palsy (Obstetrical Injury): o Cause: traction injury during labor. o Lesion: C 5-6 : Erb paralysis C 8-Th 1 : Klumpke palsy Entire plexus or diffuse partial involvement o Tx: conservative, after 3 month : EMG-NCV Manual muscle chart Myelogram Exercise & splinting If no contraction of biceps: need exploration-operative o Complication : Posterior dislocation of glenohumeral. Fixed contracture Posterior subluxed of radial head Urinating contracture of the forearm o Management: Open reduction of the joint (if any dislocation) Need astronomy prox humeri Tendon transfer (4-5 years old) Nerologic reconstruction (3 – 6 mo) Operation Technique: − Microsurgery. Need operating microscope/loupes − Landmark of approach: mid point of the posterior border of the sternocleido- masteoid and downward to the clavicula (angle at the medial portion) − Location of plexus: between anterior and middle part of scalene muscle. − Timing of operation: more than 6 month after injury. Advantage: minimize scarring and muscle atrophy. 83rd EDITION by Anika A Alhambra Kinds of ‘NEUROLOGICAL RECONSTRUCTION’ 1. NEUROLYSIS. For distal rupture not avulsion type (per ganglion) Release neuroma & fibrotic tissue in continuity 2. NERVE GRAFTING There is a gap Source : Sural nerve / Medial coetaneous nerve 3. NEUROTIZATION Indc: a totally fail, unaesthetic limb as a result of complete avulsion. Primer: like a nerve graft Secondary: insertion as new motor end plate Source: n. intercostals /n. thoracalis longus /n. accessories /n. phrenicus Kinds of ‘RECONSTRUCTIVE SURGERY OF IRREPAIRABLE INJURIES’ − Timing: more than 1-year post injuries, without any recovery/improvement. − Need Tendon transfer !!!!!!!!! a. SHOULDER reconstruction : • SAHA procedure: transfer of the trapezius to the proximal humerus. • L’Episcopo procedure: insertions of latissimus dorsi & teres mayor are transposed poster laterally to enhanced active lateral rotation. • If no chance for tendon transfer Î Arthrodhesis ! • Position : Abduction : 20-30o Flexion : 30o Endorotation : 30-40o b. ELBOW Flexion restoration: 1. STEINDLER Flexorplasty. Principle: Flexor-pronator muscle arising from the medial epicondyle are transposed
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