SPINAL CORD INJURIESSURGERY ON THE CERVICAL SPINE

Dr. UmakanthDr. Prabhu

Moderator : Prof. Rajeshwari

Introduction

• AnaesthesiologistResuscitation + management of trauma victims

• High index of suspicion

• Evaluation of C-spine

• Understanding the pathophysiology of SCI

• Evaluating the risks and benefts of various airway appliances

Epidemiology

• Age 15-35 years and >65 years (peak incidence)

• C.spine injuries- 1.8% of all trauma cases

• 20% more than one cervical spine fracture

• 20-70% unstable

• 30-70% associated neurological injury

• 3-25% of SCI are iatrogenic i.e. during field stabilization, transit or early management

Causes

• Motor vehicle accidents 50%

• Fall 20%

• Sports 15%

• Acts of violence 15%

Waters et al, spinal cord 1996

Mechanisms

• Hyper flexion

• Hyperextension

• Compression

• Rotation

• Combined

Hyper flexion

• Compression,

subluxation or

fracture dislocation

• Disruption of

posterior

longitudinal

ligament (PLL)

Hyperextension

• Result from frontal / facial

trauma

• Most common in cervical

region

• Reduce AP diameter of

spinal canal

• Disruption of anterior

longitudinal ligament (ALL)

• Damage to vertebral

arteries

Compression

• Result from forces

containing axial load

• Wedge compression and

burst fracture

• Serious damage due to

retropulsion of bone

• Most common in

thoracolumbar region

Rotation

• All parts of vertebral body and disc

• ‘Locked facets’- due to flexion rotation

• Most often seen in C5-C7

Combined

• Mainly cervical

region

• Whiplash injury

– Rapid acceleration –

decelaration forces

extreme

extension followed

by flexion

Pathophysiology

• Primary insult : direct injury

• Secondary insult: inflammation, edema,

microhemorrhages ,and diminished capillary blood flow to spinal cord at risk.

-free radicals

-vascular mechanism -apoptosis

Pathophysiology

Management of SCI

Goals

- To suspect C-spine injury

-To look for clinical pointers

– Protect spinal cord from further injury

– Indicators for securing airway

– Ensure hemodynamic stability

– Neuroprotection

– Attention to other injuries (thoracic,

faciomaxillary )

NEXUS criteria

• No midline cervical tenderness.

• No focal neurological deficit

• Normal alertness.

• No intoxication.

• No painful distracting injury.

Maintain immobilisation and proceed with cervical x rays

Films adequate Not adequate(C1 –T1 Visible) Consider repeating exam with swimmers and oblique view or CT Scan Normal Abnormality

C-spine cleared Maintain cervical immobiolisation and get CT Scan

Immobilization method

• No gold standard

• Soft collar

• Hard collar

• Short boards

• MILS

Soft collar

• Allows 96% of flexion, 73% of extension

Hard collar

• Allows 72-73% of normal flexion and extension

Short boards

• Reduce movement in all planes

• Good results if combined with hard collar in prehospital settings

MILS

Method C-spine

motion

Intubation

difficulty

Time

required

Rigid collar 0 -

MILS 0-

Axial

traction

- -

Radiological assessment

• Normal C-spine anatomy

• Choice

– Lateral, AP, open mouth- C-spine X-rays

– Combined plain film + CT 99% to 100%

sensitivity

– MRI very sensitive for soft tissue and

spinal cord

Normal lateral C-spine

Alignment

Predental space

Prevertebral soft tissue

AP view

Odontoid view

SUMMARY

• Adequacy- C1 to T1 visible

• Pseudosubluxation?

• Look for any widening of spaces and indices

• Spinal cord injury without radiographic abnormality: “SCIWORA”

Airway management

• Indication for securing airway– ? Apnoea– ? GCS <9/sustained seizure activity– ? Unstable midface trauma– ? Airway injuries– ? Large flail segment or respiratory failure– ? High aspiration risk– ? Inability to otherwise maintain an airway or

oxygenation

Clinical Predictors of Difficult Airway

Airway management (contd…)

• Goal: Tracheal intubation without

causing further injury to spinal cord

• Method depends on

– Patient’s condition

– Level of cooperation

– Skill of anaesthesiologist

Airway management (contd…)

•Effect of immobilization

technique on DL

–“We cannot stabilize the neck

without impairing the laryngeal

view”

ASA (2003) algorithm for C-spine injury

Failed intubation:Alternative techniques

• LMA

• Combitube

• Cricothyroidectomy

FOB

• Technique of choice in awake cooperative patient

• Some authors recommend FOB even as initial intubation choice with 100% success rate.

• Some emphasize its limitations -technical difficulty -success rate only 73% in

ED.• Bullard laryngosope vs FOB

Airway management techniques and their effect on C-spine

Acute phase (4-6 weeks)

• Spinal shock

• Flaccid paralysis of muscles

• Loss of sympathetic tone

• Hypo reflexia

• Urinary retention

Acute phase (4-6 weeks)

Management

• Treat associated life threatening conditions– Tension pneumothorax– Chest / pelvic/ orthopedic injuries

• Treatment of hypotension

• Pharmacological neuroprotection

Steroids

• Suspected/ known blunt injury of spinal cord

• Methyl prednisolone.• Dose: 30mg/kg over 15 min followed by

infusion of 5.4mg/kg/hr for 24 – 48 hrs.• Started within 8 hrs of injury.• Contra indications: -penetrating injury -cauda equina syndrome

Patient coming in chronic phase

• After recovery from spinal shock• Concerns

– Autonomic hyperreflexia– Supersensitivity of cholinergic receptors

• Autonomic hyper-reflexia– Chronic spinal cord lesion above T6– 85% of patients have this at some time during

the course of living– Uncontrolled reflex arc below the level of lesion

Supersensitivity

• Denervation• Cholinergic receptor proliferation beyond the

motor end plate• Muscle contracts for a minimal Ach (10-4 to 10-5)• K+ released suddenly along entire length of

muscle fibre• Sch

– 4 to 10 meq/L increase in K+– Duration of supersensitivity: From 1 week upto 6

months to 2 years

• So Sch is safe in the first days of paraplegia, avoid it after 3rd or 4th day

References

1. Rogers LF. Fractures and dislocations of the spine. In: Garfin’s Spine Trauma? Jefferson’s Series, 2006.

2. Jefferson G. Discussion on spinal injuries. Proc R Soc Med 1927;21:625–628.

3. Lali HS, Sehko MB, Fehlings MG. Epidemiology, demographics,and pathophysiology of acute spinal cord injury.Spine 2001; 26:S2–S12.

4. Vale, FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess merits of aggressive medical resusitation and blood pressure measurement. J Neurosurg1997; 87:239–246.

5.Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343:94–99[Erratum, N Engl J Med 2001; 344:464]

6. A.U.Ghafoor et al,Caring for the patients with cervical spine injuries: what we have learned? Jounal of clin anesthesia (2005) 17 , 640-649.

7. Grande CM, Stene JK. Anesthesia for trauma. In: Miller RD, ed.Anesthesia. Philadelphia, Churchill Livingstone. 1994:2164.

8. Wilson WC. Trauma: airway management. ASA Difficult Airway Algorithm Modified for Trauma—and Five Common Trauma Intubation Scenarios. ASA Newsletter 2005; 69(11):10.

9. ASA Task Force: Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2003; 98(5):1269–1277.

10. Segal JL, Brunnemann SR.Clinical pharmacokinetics in patients with spinal cord injuries.Clin pharmacokinet: 17:109-29. 1989

11. Konishi A, Sakai T, Nishiyama T etal.Cervical spine movement during orotracheal intubation using McCoy laryngoscope compared with the Macintosh and Miller Laryngoscope.Masui 46:124-7, 1997.

12. Hasting RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology 80:825-831, 1994.

13. Fitzgerald RD etal.Excursion of the cervical spine during tracheal intubation: blind oral intubation compared with direct laryngoscopy.Anesthesia 49:111-115,1994

14.Cohn AI, Zornow MH: Awake endotracheal intubation in patients with cervical spine disease: a comparison of the Bullard laryngoscope and fiberoptic bronchoscope.Anesth Analg 81:1283-1286, 1995.

15. Crosby Et, Lui A: The adult cervical Spine: implication for airway management.Can J Anaesth 37:77-93, 1990.

16. Saha AK et al: Comarision of awake endotracheal intubation in patients with cervical spine disease: The lighted intubating stylet vs.Fibreoptic bronchoscope.Anesth Analg 87:477-479,1998.

17. Hastings RH et al.Cervical spine movement during laryngoscopy with the Bullard, Macintosh, and Miller laryngoscope. Anesthesiology 82:859-869, 1995.

18.Wangeman BU, Jantzen JP. Fibreoptic intubation of neurosurgical patients. Neurochirurgia (Stuttg)

1993;36:117-22.19.Ovassapian A, Dykes M. The role of fibreoptic

endoscopy in airway management. Semin Anesth

1987;6:93-104.20.Mlinek EJ et al. Fiberoptic intubation in

emergency department. Ann Emerg Med 1990;19:359-62.

21. Afialo M et al. Fiberoptic intubation in the emergency department: A case series. J Emerg Med 1993;11:387-91.