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Spinal Cord Injury

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Spinal Cord Injury Sarah Crosby June 2010 C-Spine Epidemiology C-spine injuries occur in 2.0-6.6% of blunt trauma patients Co-existing head injury increases the ... – PowerPoint PPT presentation

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Title: Spinal Cord Injury


1
Spinal Cord Injury
  • Sarah Crosby
  • June 2010

2
C-Spine
3
Epidemiology
  • C-spine injuries occur in 2.0-6.6 of blunt
    trauma patients
  • Co-existing head injury increases the incidence
    of C-spine injury to 10
  • Injury to the cervical spinal cord in the absence
    of fracture occurs in 0.07-0.7 of trauma
    admissions
  • Missed or delayed diagnosis of cervical spine
    injury occurs in 4-8
  • Results in 10 x the incidence of secondary
    neurologic deficit compared to early diagnosis
  • Of the patients with missed or delayed diagnosis
    most have decreased GCS, hypotension or critical
    injuries
  • Obtunded patients unable to assist in
    demonstrating neurology
  • Lifetime healthcare and living costs for a
    quadriplegic patient 2.4-3.1 million AUD

4
EAST Guidelines (Eastern Association for the
Surgery of Trauma)
  • 1998 guidelines for evaluation of c-spine injury
    in trauma patients
  • 2009 update
  • CT largely replacing plain x-rays
  • Clinical clearance remains standard in awake,
    alert patients with no neurologic deficit,
    distracting injury, neck pain or tenderness
  • Cervical collars should be removed ASAP
  • Controversy still exists regarding cervical spine
    clearance in the obtunded patient
  • Who needs imaging
  • What imaging
  • How to exclude significant ligamentous injury

5
Removal of Cervical Collars
  • As soon as feasible (Level III)
  • Early removal is associated with
  • Decreased collar related pressure ulcers
  • Skin breakdown 6.8 after 24h
  • Decreased ICP
  • Fewer ventilator days
  • Fewer ICU and hospital days
  • Decreased incidence of delerium and pneumonia

6
Penetrating Brain Injury
  • Immobilisation is not indicated unless the
    trajectory suggests direct injury to the cervical
    spine

7
Clinical Clearance of the C-spine in the awake
patient
  • In awake, alert trauma patients without
    neurologic deficit or distracting injury, who
    have no neck pain or tenderness with full range
    of motion of the cervical spine, imaging is not
    necessary and the collar can be removed (Level
    II)
  • Meta-analysis of clinical clearance of the
    asymptomatic C-spine (2010)
  • GCS 14-15
  • No posterior cervical tenderness
  • No neurological deficit
  • No dangerous mechanism
  • No distracting Injury
  • Normal range of motion without pain or neurology
  • Sensitivity 98.1 NPV 99.8

8
NEXUS Study
  • Validated 5 Criteria for Low Probability of
    C-Spine Injury
  • (No imaging required if meet all criteria)
  • No posterior midline C-spine tenderness
  • No evidence of intoxication
  • Normal level of alertness
  • No focal neurologic deficit
  • No painful distracting injury
  • Long bone fracture, visceral injury requiring
    surgical consultation, large laceration,
    degloving injury, crush injury, large burns

Hoffman et al. Validity of a set of clinical
criteria to rule out injury to the cervical spine
in patients with blunt trauma. NEJM
200034394-99.
9
Canadian Cervical Spine Rule Study
1. Are there any high risk factors present that
require imaging
GCS 15
YES
NO
2. Are there any low risk factors present to
allow for safe assessment by using active range
of motion
NO
Image C-Spine
NO
YES
3. Can the patient actively rotate the neck 45º
left and right
No imaging of C-spine needed
YES
Stiell, I. et al. The Canadian C-spine rule for
radiography in alert and stable trauma patients.
JAMA 20012861841-1848
10
Canadian Cervical Spine Rule Study
  • High risk factors that require imaging
  • Age 65 yo
  • Dangerous mechanism of injury
  • Fall from 1m (5 stairs)
  • Axial load to the head (eg. Diving)
  • MVA- high speed (gt100kph, rollover, ejection)
  • Motorised recreational vehicles
  • Bicycle collision
  • Paraesthesia in extremities
  • 2. Low risk factors that allow safe assesment of
    range of motion
  • Sitting position in the emergency department or
  • Simple rear end MVA or
  • Ambulatory at any one time or
  • Delayed onset of neck pain or
  • Absence of midline C-spine tenderness

11
Clinical Clearance of the C-Spine in the Awake
Patient
  • NEXUS
  • Sensitivity 90.7
  • Specificity 36.8
  • Radiography Rate 55.9
  • CCR
  • Sensitivity 99.4
  • Specificity 45.1
  • Radiography Rate 66.6

Stiell IG, et al. The Canadian c-spine rule
versus the nexus low-risk criteria in patients
with trauma. NEJM 20033492510-2518
12
Radiographic Examination of the C-Spine
  • Plain C-spine X-Rays
  • 3-view (lateral, AP, odontoid)
  • Supplemented by swimmers views and CT for poorly
    visualised areas
  • CT C-Spine
  • Occiput to T1 with saggital and coronal
    reconstruction
  • More time efficient and cost-effective in
    moderate and high risk cases
  • More accurate
  • Sensitivity 98 (vs c-spine x-ray 52)

13
Radiographic Examination of the C-Spine
  • Indicated for
  • Pain or tenderness in the neck
  • Neurological deficit
  • Altered mental status
  • Distracting Injury
  • The Primary screening modality is axial CT from
    the occiput to T1 with sagittal and coronal
    reconstructions (Level II)
  • Plain radiographs contribute no additional
    information and should not be obtained (Level II)
  • If there is neurological deficit attributable to
    a c-spine injury an MRI should be obtained

14
Neck Pain with negative CT in the neurologically
intact patient
  • 3 options (Level III)
  • Continue collar
  • Remove collar after negative MRI (lt72h)
  • Remove collar after negative and adequate flexion
    extension films
  • Picks up c-spine instability in 6.75-8 of normal
    c-spine films
  • Incidence of isolated ligamentous injury is rare
    (0.6 of traumatic c-spine injuries)

15
C-spine Clearance in the Obtunded Trauma Patient
with a Negative CT C-Spine and no Gross
Neurological Deficit
  • EAST Recommendations 2009
  • Flexion/Extension radiographs should NOT be
    performed (Level II)
  • The risk/benefit ratio of obtaining an MRI in
    addition to CT is not clear (individualise to
    each institution) (Level III)
  • Options are
  • Continue cervical collar immobilisation until a
    clinical examination can be performed
  • Remove the cervical collar on the basis of CT
    alone
  • Obtain an MRI and if negative the collar can be
    safely removed (Level II)

16
? MRI in addition to CT?
  • Incidence of ligamentous injury with negative CT
    c-spine is very low (lt5)
  • Incidence of clinically significant injury is
    even lower (lt1)
  • Expensive
  • Difficult in the intubated patient
  • Limited availability
  • More sensitive for identification of soft tissue
    injuries (Gold standard for spinal cord injury)
  • Not reliable for identifying bony injury

17
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18
SCIWORA
  • Significant Cord Injury without obvious
    radiological abnormality
  • Incidence 3-5 (x-ray/CT)
  • Higher incidence in paediatric population (34.8)
  • The relatively large size of the head
  • inherent skeletal mobility
  • cord vulnerable to damage
  • Higher incidence above 60 yo
  • Posterior vertebral spurs due to spondylosis
  • Ligamentum flavum bulging due to loss of disc
    height
  • Risk of central cord syndrome after
    hyperextension injury

19
Thoracolumbar Spine Trauma
  • 4.4 of trauma patients have TLS fracture
  • 19-50 of these fractures are associated with
    spinal cord damage
  • Higher incidence of neurologic deficit when
    fracture identification was delayed (10.5 vs
    1.4)

20
EAST Recommendations (2007)
  • Level II Guidelines
  • Trauma patients should be examined by a qualified
    attending physician
  • Trauma surgeons, emergency physicians or spine
    surgeons (neurosurgery or orthopaedics)
  • Trauma patients who are awake, without any
    evidence of intoxication, with normal mental
    status, neurologic and physical examinations may
    be cleared clinically

21
EAST Recommendations (2007)
  • Radiographic Examination is required for
  • High energy mechanism of injury
  • Falls from gt10 feet
  • MVA/MBA crash with or without ejection
  • Pedestrians struck
  • Assault, Sport or Crush injury
  • Bicycle injury
  • Concomitant cervical spine fracture
  • Altered mental status, intoxication
  • Distracting injuries
  • Neurologic deficits
  • Spine pain or tenderness on palpation

22
Mode of Imaging of TLS
  • Multidetector CT with axial reconstruction is
    superior to plain films for screening of TLS for
    bony injury (II)
  • CT scout films can be used for spine assessment
    (II)
  • CT scan may be associated with less overall
    radiation exposure than plain films (III)
  • Plain films are adequate for the examination of
    the TLS if the patient does not require CT scan
    for any other reason (III) (Not if they have a
    major trauma mechanism)
  • MRI is indicated for patients with neurologic
    deficits, abnormal CT scans or clinical suspicion
    despite normal radiographic evaluation suggesting
    an unstable injury (III)
  • Early decompression of traumatic lesions improves
    outcome

23
Plain Film vs CT of TLS
  • Ballock et al. (1992)
  • plain radiography of the thoracolumbar spine
    would have missed 25 of fractures
  • Gestring et al. (2002)- CT protocol for examining
    TLS
  • Anterior, posterior and lateral scout films and
    axial images
  • 100 sensitivity and specificity
  • Hauser et al. (2003)-prospective study 222
    patients
  • Plain radiography of the TL spine vs Helical CT
    (5mm images)
  • CT scan accuracy 99 vs plain radiographs 87
  • CT could also differentiate acute vs old
  • Sheridan et al. (2003)
  • Reformatted helical T (2.5mm images) vs plain
    x-ray
  • Sensitivity for Thoracic - CT 97 vs x-ray 62
  • Sensitivity for Lumbar - CT 95 vs x-ray 86

24
Clearing the Spine
  • The ultimate evaluation of all radiographic
    studies is the responsibility of the attending
    radiologist.
  • Other persons qualified to interpret TLS
    radiographs
  • Trauma surgeon
  • Emergency medicine physician
  • Neurosurgeons
  • Orthopaedic spine surgeons
  • These may clear the spine after interpretation of
    the images and clinical evaluation of the patient

25
Obtunded Patient
  • No level I evidence
  • Level II
  • Multidetector CT with axial reconstruction is
    superior to plain films for screening of the TLS
    for bony injury
  • Level III
  • The obtunded patient (intoxicated or head injury)
    presenting to a centre without CT scan capability
    should be transferred to the nearest available
    trauma centre

26
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27
Primary Management
  • A - Airway control with C-spine immobilisation
  • B- Avoid hypoxaemia- will further worson the
    prognosis of an injured spinal cord
  • - Injury above C5 will cause respiratory
    insufficiency
  • - 50 of C3 tetraplegics need permanent
    ventilation
  • C- Need to minimise secondary ischaemic injury to
    the cord - Aim MAP gt 100mmHg
  • - SCI above C6 associated with loss of cardiac
    sympathetic supply leading to hypotension
    bradycardia
  • - Loss of sympathetic vasoconstriction leads to
    vasodilation venodilation
  • - relative hypovolaemia needing plasma volume
    expansion and vasoconstrictors

28
Secondary Survey of Spine
  • Assessment of the cervical soft tissue for
    swelling
  • Log roll and palpation of the spinous processes
    of the entire spinal column
  • Neuro exam
  • Motor, sensory and reflexes
  • Perianal sensation, rectal sphincter tone and
    sacral reflexes
  • Absence of the bulbocavernosus reflex indicates
    spinal shock
  • Signs of SCI in unconscious patient
  • Response to pain above but not below a level
  • Flaccid areflexia in arms/legs
  • Elbow flexion with the inability to extend
    (cervical SCI)
  • Paradoxical breathing
  • Inappropriate vasodilation
  • Unexplained bradycardia, hypotension
  • Priapism
  • Loss of anal tone and reflexes

29
Spinal Cord Injury
  • Complete SCI
  • muscle paralysis
  • somatic and visceral sensory loss below a
    discrete segment
  • Spinal shock
  • Additional features of
  • Muscle flaccidity
  • Absence of tendon reflexes
  • Vaso and venodilation
  • Loss of bladder function
  • Paralytic ileus
  • Due to temporary loss of somatic and autonomic
    reflex activity below the neurological level of
    the injury
  • Lasts 1-3 weeks

30
Early Surgical Management of Spine Injuries
  • Cervical Spine Injuries
  • Acute stabilisation with a halo ring allows
    further diagnostic evaluation and treatment of
    other injuries without further neurologic
    deterioration
  • Thoracolumbar Spine Fractures
  • McLain Benson compared urgent spinal
    stabilisation (/- decompression within 24h) vs
    early treatment (24-72h)
  • No statistical difference in outcomes
  • the urgent group had a non-statistical better
    neurological recovery
  • Kerwin et al.
  • Early stabilisation (lt3 days) shortens ICU and
    hospital LOS but increased number of
    perioperative deaths and pneumonia
  • Spinal cord compression with neurologic
    involvement as a result of spinal malalignment
    should be remedied as soon as possible (esp facet
    subluxations or dislocation)

31
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32
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33
Medical Management of Acute Spinal Cord Injury
  • Primary Injury
  • Primary cell death that occurs at time of injury
  • Due to direct mechanical forces causing
    structural disruption of neuronal, glial and
    vascular structures
  • Secondary Injury (days to weeks) (10 of injury)
  • Variety of chemical pathways including hypoxia,
    ischaemia, ionic shifts, lipid peroxidation, free
    radical production, excitotoxicity, eicosanoid
    production, protease activation, prostaglandin
    production and apoptosis
  • Medical strategies for treatment of SCI are
    directed at minimising the degree of secondary
    injury

34
Spinal Cord Perfusion Pressure
  • Most important medical management of spinal cord
    injury is to maintain arterial oxygenation and
    blood pressure support
  • Class III evidence to suggest optimising spinal
    cord perfusion improves clinical outcome
  • Maintain SBP between 85-90mmHg for first week

35
Steroids
  • NASCIS II (1992)
  • Prospective randomised double blind controlled
    multicentre trial (487 patients)
  • High dose Methylprednisolone vs Naloxone Vs
    Placebo given within 24h of SCI
  • No difference in neurologic outcome between the 3
    groups
  • Post hoc analysis showed patients treated with
    Methylpred within 8h had statistically
    significant improvement in motor and sensory
    scores at 6 months, but only improved motor
    scores at 1 year
  • Steroid group had increased pulmonary emboli,
    wound infections (non-significant), myopathy
  • NASCIS III
  • 48h Methylprednisolone was associated with severe
    pneumonia, severe sepsis.

36
GM-1 Ganglioside
  • Compound normally found in cell membranes of CNS
    tissue in mammals
  • Antiexcitotoxic activity
  • Promotes neuritic sprouting
  • Potentiates the effects of nerve growth factor
  • Prevents apoptosis
  • Initial promising results, not reproduced in long
    term follow-up
  • Not used in clinical practice

37
Future Directives
  • Stem cell transplantation
  • Electric Field gradients to influence nerve
    growth after injury
  • Neuroprotective strategies
  • Monoclonal antibodies
  • Minocycline
  • Rho inhibitor
  • Macrophage injection

38
References
  • Ackland, H. et al. Magnetic Resonance Imaging for
    clearing the cervical spine in unconscious
    intensive care trauma patients. J. Trauma
    200660668-673
  • Practice Management Guidelines for identification
    of cervical spine injuries following trauma-
    update from the Eastern Association for the
    Surgery of Trauma Practice Managament Guidelines
    Committee. J.Como, J.Diaz, M Dunham
  • J Diaz et al. Practice Management Guidelines for
    the Screening of Thoracolumbar Spine Fracture. J
    Trauma 200763709-718
  • Harris, M. et al. The initial assessment and
    management of the Multiple-Trauma patient with an
    associated spine injury. Spine 200631S9-S15
  • Hurlbert, R. Strategies of Medical Intervention
    in the Management of Acute Spinal Cord Injury.
    Spine 200631S16-S21
  • Rechtine G. Nonoperative Management and Treatment
    of Spinal Injuries. Spine 200631S22-S27
  • Stiell IG, et al. The Canadian c-spine rule
    versus the nexus low-risk criteria in patients
    with trauma. NEJM 20033492510-2518
  • Stiell, I. et al. The Canadian C-spine rule for
    radiography in alert and stable trauma patients.
    JAMA 20012861841-1848
  • Hoffman et al. Validity of a set of clinical
    criteria to rule out injury to the cervical spine
    in patients with blunt trauma. NEJM
    200034394-99.
  • Richards, P. Cervical Spine Clearance a review.
    Injury, Int. J. Care Injured. 200536248-269
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