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Spinal Cord Injuries

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Spine Instability Slide 33 Slide 34 Slide 35 Cervical Spine Clearance Treatment Steroids: blunt trauma Surgical Management Surgical Management Surgical Management ... – PowerPoint PPT presentation

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Title: Spinal Cord Injuries


1
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2
Spinal Cord Injuries
  • Bradley J. Phillips, MD
  • Burn-Trauma-ICU
  • Adults Pediatrics

3
Incidence
  • 8,000-10,000 per year
  • Mechanisms
  • MVC 48
  • Falls 21
  • Assaults 15
  • Sport-related 14 (majority diving)

4
Incidence
  • 50 involve cervical spine (C5-6)
  • 40 lead to quadriplegia
  • Co-morbidity
  • Limb fractures - 67
  • Intrathoracic - 53
  • Head injury - 33

5
Cervical Spine Fractures
6
Anatomy Biomechanics
  • Spine stability dependents
  • bone
  • ligaments
  • joints
  • applied force
  • axial
  • extension
  • rotation

7
Biomechanics
  • Upper cervical spine
  • C1 - vulnerable to axial load (Jeffersons fx)
  • C2 - vulnerable to hyperextension (Hangmans fx)
  • Lower cervical spine
  • C5-C7 - most common fx and dislocation
  • highly mobile
  • vulnerable to hyperextension
  • significant neurologic injury

8
Biomechanics
  • Rotation Flexion
  • unilateral locked facet
  • severe - bilateral locked facet
  • usually stable and no sig ligamentous disruption
    or neurologic injury
  • Thoracic spine
  • direct blows or extreme hyperflexion
  • axial loading - compression or burst fx
  • T12- L1 vulnerable to hyperflexion/axial force
  • severe ligamentous injury, retropulsion of
    fragments

9
Pathophysiology
  • Actual mechanical transection rare
  • Neural action potentials will not cross
  • Immediate vascular disruption
  • Leads to necrosis
  • Rapid swelling of cord tissue
  • Histologic changes max at 72 hours
  • May extend for two segments proximally and
    distally !!!

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11
Diagnosis
  • History
  • mechanism
  • associated injuries
  • head and spine injury 6-15 of patients
  • Physical exam
  • MUST BE
  • conscious and alert
  • non-intoxicated
  • no distracting injury

12
Risk Factors for Cervical Injury
  • Blunt
  • potentially any blunt mechanism of injury
  • Penetrating
  • low risk

13
Diagnosis
  • Physical
  • palpate entire spine
  • thorough neuro exam including
  • sensory (pinpoint, position)
  • sacral function (rectal,bulbocavernosus reflex)
  • Complete or incomplete
  • Clinical level is lowest nerve root providing
    good sensation/motor function

14
Markers of Nerve Root Function
  • C4-sensation to nipple motor to trapezius
  • C5-sensory lat arm motor deltoid/biceps
  • C6-sensory thumb/index motor wrist extension
  • C7-sensory ring finger motor wrist flex/triceps
  • C8- sensory little finger motor finger flexors
  • T1-sensory medial arm motor hand intrinsic
  • L1 - sensory pubis/lower abdomen
  • L2 - sensory ant thigh motor flexion at hip
  • L3 - sensory knee and motor knee extension
  • L4 - sensory medical calf motor dorsiflex ankle
  • L5 - sensory lat calf and motor dorsiflex toes
  • S1 - sensory fifth toe/heel motor plantar flex
    toes
  • S2/3 -sensory back thigh/buttock motor anal
    spinchter contraction
  • S4 - sensory perineum
  • S5 - sensory perianal

15
Incomplete Syndromes
16
Pitfall
  • Unwise to predict neurologic outcome
  • within 48 hours
  • of apparently complete spinal cord injury

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19
Xrays needed?
  • Cervical
  • neck tenderness, intoxication, abnormal neuro
    exam, distracting injury, difficult clinical exam
  • Thoracolumbar
  • spine tenderness, MVC ejections, MCC, falls gt 10
    ft, neurologic deficit, difficult clinical exam

20
Radiology Exam
  • Radiography bony deformation ? full bony
    excursion and damage at time of injury
  • Films
  • Cervical spine
  • lateral
  • odontoid
  • AP
  • Flexion/extension
  • ? obliques

21
Lateral View
  • Adequate film C1-T1 top
  • Column alignments
  • Anterior line of vertebral body
  • Posterior line of vertebral body
  • Junction of laminae with spinous process
  • Tips of spinous process
  • Curvature overall

22
Lateral View - Helpful Measurements
2.
  • 1. prevertebral space
  • lt 5 mm
  • 2. atlantodental interval
  • 2.5-3 mm
  • 3. sup-inf vertebral align
  • lt 2.7 mm
  • 4. ant-post body height
  • lt 3 mm
  • 5. spinal canal width
  • gt 13 mm

1.
3.
4.
5.
23
Test - Whats Abnormal
24
Whats abnormal ?
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26
Cervical Views
Obliques
Odontoid
AP
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29
Pitfalls
  • Absence of typical signs of spinal fracture on
  • plain radiograph does not guarantee the
  • absence of a fracture or predict stability

30
Focused CT
31
CT better than plain Xray?
  • Superior for Occiput - C3 in altered mental
    status patients (Schenarts, J Trauma, 2001)
  • recommend obtain at time of CT Head
  • Helical CT plain films increased accuracy of
    detecting cervical spine injury from 54 to 100
    (Barba, J Trauma, 2001)
  • recommend full Cervical CT at time of CT Head
  • Conclusion CT with plain films better in
    altered mental status and should be obtained with
    CT Head

32
Spine Instability
  • Indicators of instability on plain radiographs
  • gt 5 mm subluxation
  • bilateral jumped facets
  • burst fractures with bone fragments in canal
  • widening of interspinous space
  • fractures of posterior element
  • Columns - 2 of 3 damaged
  • Flexion/extension
  • plain radiographs - no pain active full motion

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35
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36
Cervical Spine Clearance
Intubated and Difficult Exam
Yes
No
Yes
Yes
Consult Spine Spine CT/MRI
Meets Clinical Criteria (A)
Abnormal Plain Films
Clear Clinically
No
No
Yes
Clinical exam within 72 hours
Consult Spine Spine CT/MRI
Abnormal Plain Films
No
No
Yes
Yes
Yes
Consult Spine Fluoroscopic Flex/Ex
Abnormal Neurologic Exam
Consult Spine MRI
OR within 72 hours
No
No
Yes
Yes
Posterior Cervical Midline Tenderness
Meets High-Risk Criteria (B)
Consult Spine MRI
Hard Collar F/U Spine Service
No
No
Consult Spine Spiral CT
Occiput-C3
D/C Collar after Period of
Observation
Criteria B High speed MVC (gt35mph)
MVC with death at scene
Fall gt
10 feet
Significant closed head injury
Referred cervical neurologic
signs/symptoms Pelvic or
multiple extremity fractures
Criteria A No midline tenderness
No focal neurologic deficit
Normal alertness Negative toxicology
screen No painful,
distracting injury
37
Treatment
  • Immobilization
  • Drug Therapies
  • Steroids
  • GM-1 Gangliosides
  • Surgical management
  • Rehabilitation

38
Steroids blunt trauma
  • Standard of Care
  • National Acute Spinal Cord Study
  • within 8 hours of injury
  • methylprednisolone 30mg/kg load, 5.4 mg/hr x23
    hrs.
  • result slight but significant improvement in
    motor function and sensation at 6 months
  • NASCS 2nd trial
  • some benefit of 48hrs of steroids, but
    significant morbidity (severe sepsis and
    pneumonia)

39
Surgical Management
  • Subluxation/angulation
  • immobilization with traction
  • not recommended with fractures
  • Braces
  • Halo brace
  • Minerva jacket/vest

40
Surgical Management
  • C1 rotatory subluxation- after reduction
    treatment with Halo 3 months
  • C1 fx (Jefferson) - usually stable treat with
    hard collar (ligament injury- Halo)
  • Odontoid fx - depend on type
  • Type I and III usually hard collar/halo 3 mos
  • Type II - young (halo) and older (ORIF)
  • C2 fx (Hangmans) - Halo at least 3 months

41
Surgical Management
  • Lower cervical
  • fracture/dislocation - posterior ORIF
    with/without collar
  • compression/burst - anterior ORIF or halo
  • Thoracolumbar
  • compression without subluxation usually stable
    require brace only
  • severe subluxation/retropulsion bone fragments
    require ORI

42
Timing of Surgery
  • Early - Pro
  • provide better restoration of bone alignment
  • earlier decompression may improve neural function
  • early stabilization prevents secondary cord
    injury
  • early mobilization prevent pulm complications
  • Early - Con
  • adequate alignment by traction and closed
    manipulation
  • early removal of bone fragments does not improve
    outcome
  • benefits of early mobilization obtained by active
    PT
  • Injury made worse

43
Timing of Surgery
  • Axiom - indications for early surgery
  • progressively worsening deficit
  • persistent CSF leak
  • failure to achieve spinal alignment by closed
    methods

44
Complications
  • Cardiovascular
  • hemodynamics
  • sinus bradycardia
  • Venous Thromboembolism
  • Pulmonary problems
  • Skin breakdown (most avoidable)
  • Autonomic Hyperreflexia (usually above T6)
  • Muscle spasiticity (trial of baclofen)

45
Complications
  • Gastrointestional
  • ileus (acutely need gastric decompression!!!)
  • peritonitis
  • Malnutrition
  • Hyperkalemia crisis (avoid succinylcholine)
  • GU complications (infections)
  • Heterotopic ossification

46
Cardiovascular Instability
  • Injury above T1-T2
  • disruption of descending sympathetic fibers
  • Effects neurogenic shock (not spinal shock)
  • vasodilation
  • myocardial dysfunction
  • bradycardia

47
Cardiovascular Instability
  • Treatment
  • aggressive fluid resuscitation
  • rule-out injury with continued blood loss
  • vasopressors - alpha-agonists

48
Venous Thrombosis
  • Major risk factor
  • ? Eventually all develop DVTs
  • Significant PE in 10
  • Therapy
  • Mobilization/leg elevation
  • Heparin (LMW vs Standard)
  • Caval filters

49
Pulmonary Complications
  • Leading cause of death
  • pneumonia/atelectasis
  • as high as 40 in quadriplegia (older study)
  • Avoid intubation if possible
  • aggressive pulmonary toilet (suctioning, quad
    cough, avoid NGT/FT if possible)
  • positioning changes (manual, ROTO bed)
  • check spontaneous TV frequently
  • Ondines curse - ok awake, but lose respiratory
    drive asleep

50
Rehabilitation
  • Begins immediately
  • Objectives
  • maintain full range of motion of joints
  • use of orthotics to prevent contractures
  • muscle strenghtening
  • patient education
  • self-range techniques
  • activities of daily living

51
Prognosis
  • Depends
  • severity and location of injury
  • age
  • comprehensive rehab facilities
  • Mortality
  • Early mortality
  • lt 50 11 gt 50 39
  • Quadriplegia - 15-37 die within first year

52
Prognosis
  • Cause of death
  • pulmonary - 21
  • 20 who require vent assistance die within 3 mos
  • cardiovascular - 15
  • accidents, poisoning, or violence -10
  • infections - 9

53
Prognosis
  • Up 7 have progressive decrease
  • neurologic function
  • develop painful dysesthesias
  • syrinx - fluid in injured necrotic cavity
    compress surrounding tissue

54
Questions... ?
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