-Spinal Cord Injury ppt

7/28/2019 -Spinal Cord Injury ppt

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Spinal Cord Injury


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Incidence

8,000-10,000 per year

Mechanisms

MVC 48%

Falls 21%

Assaults 15%

Sport-related 14% (majority diving)


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Incidence

50% involve cervical spine (C5-6)

40% lead to quadriplegia

Co-morbidity

Limb fractures - 67%

Intrathoracic - 53%

Head injury - 33%


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Anatomy

NETTER'S CONCISE ORTHOPAEDIC ANATOMY


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Spine stability dependents

bone

ligaments

joints applied force

axial

extension

rotation


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Pathophysiology

Initial insult to cord

Local deformation

Energy transformation


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ASIA Sco re

Based on key muscle strength & key sensory points

Useful for following improvement or deterioration


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Spinal shock:

transient flaccid paralysis areflexia (incl. lack of bulbocav. reflex)

while present (usu


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Classification

Complete

absence of sensory & motor function in lowest

sacral segment

Incomplete presence of sensory & motor function in lowest

sacral segment (indicates preserved function

below the defined neurological level)


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Incomplete Syndromes

E. Posterior Cord

Syndrome


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Frankel Classification

Grade A: Absent motor and sensory function

Grade B: Absent motor function, sensation

present

Grade C: Motor function present, but not useful(2 or 3/5), sensation present Grade

D: Motor function present and useful (4/5),

sensation present Grade

E: Normal motor (5/5) and sensory function


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Xrays

Cervical neck tenderness, intoxication, abnormal neuro

exam, distracting injury, difficult clinical exam

Thoracolumbar

spine tenderness, MVC ejections, falls > 10 ft,

neurologic deficit, difficult clinical exam


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Spine Instability

Indicators of instability on plain radiographs

> 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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Treatment

Immobilization

Drug Therapies

Steroids

GM-1 Gangliosides

Surgical management

Rehabilitation


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Steroids

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 functionand sensation at 6 months

NASCS 2nd trial

some benefit of 48hrs of steroids, but significant morbidity

(severe sepsis and pneumonia)


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Surgical Management

Subluxation/angulation immobilization with traction

not recommended with fractures

Braces

Halo brace

Minerva jacket/vest


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Surgical Management

C1 rotatory subluxation- after reduction treatmentwith Halo 3 months

C1 fx (Jefferson) - usually stable treat with hardcollar (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


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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

ORIF


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Complications

*Cardiovascular

hemodynamics

sinus bradycardia

*Venous Thromboembolism

*Pulmonary problems

Skin breakdown (most avoidable)

Autonomic Hyperreflexia (usually above T6) Muscle spasiticity (trial of baclofen)


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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


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Prognosis

Depends severity and location of injury

age

comprehensive rehab facilities

Mortality

Early mortality

< 50 = 11% > 50 = 39%

Quadriplegia - 15-37% die within first year


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Prognosis

Cause of death pulmonary - 21%

20% who require vent assistance die within 3 mos

cardiovascular - 15%

accidents, poisoning, or violence -10%

infections - 9%


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Prognosis

Up 7% have progressive decrease neurologic function

develop painful dysesthesias

syrinx - fluid in injured necrotic cavity compress surrounding

tissue


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Thank You

Documents

-Spinal Cord Injury ppt