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THIS GUY MAY NEED EMERGENCY SPINAL SURGERY…….

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RECOGNIZING SPINAL CORD EMERGENCIES

• Spinal cord injuries are uncommon but:

1)  they must be recognised early,

2)  to make the correct diagnosis,

3)  so that the correct treatment can be instituted,

4)  to possibly prevent permanent loss of function.

• Differential diagnosis includes: (Spinal cord compression 2ndry to) 1)  Vertebral fractures 2)  Space occupying lesion 3)  Spinal infection 4)  Abscess 5)  Vascular / haematological

damage 6)  Severe disc herniation 7)  Spinal stenosis

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RECOGNIZING SPINAL CORD EMERGENCIES

• Most important information comes from the history & clinical evaluation…..

• Physicians / health care workers must look for red flags

• CT & MRI can clearly define anatomy but have a high false positive rate

• Early consultation with a Spinal / Neuro specialist indicated

IN THE HISTORY:

•  1) Pain: Location, radiation, duration, severity, Night pain? What exacerbates or relieves it?

•  2) Morning stiffness: Rheumatological arthropathy?

•  3) Paresthesia, numbness, weakness

•  4) Bowel & bladder symptoms

•  5) B & B symptoms associated with peri-anal numbness – think Cauda Equina Syndrome

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CLASSIFYING SPINAL CORD “INJURIES”

• TRAUMATIC – PENETRATING – NON-PENETRATING

• NON-TRAUMATIC – CAUDA EQUINA – INFECTIONS – TUMOURS

• SPINAL EMERGENCIES: – Can be life threatening

– Can be limb threatening e.g. Paralysis

– In Traumatic injuries: - Not always obvious - Often associated with other injuries

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How do we broadly classify spinal emergencies?

TRAUMATIC VS NON-TRAUMATIC NON-TRAUMATIC TRAUMATIC

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TRAUMATIC CAUSES SUB-DIVIDED INTO:

NON-PENETRATING PENETRATING

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NON-TRAUMATIC CAUSE SUB DIVIDED IN:

CAUDA EQUINA TUMOUR & INFECTIONS

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GENERAL RULES WHY WE PERFROM SPINAL SURGERY

•  1) INSTABILITY -  If we suspect that the spine

will not be able to withstand physiological loading

•  2) NEUROLOGY -  If the patient has significant

neurological fall-out or if the neurology is progressing

•  3) DEFORMITY -  If we predict that the patients’

spine will deform in the near future secondary to the underlying pathology

SURGICAL STRATEGY THEREFORE IS:

1) STABILIZE THE SEGMENT

2) DECOMPRESS THE NEUROLOGICAL STRUCTURES

3) CORRECT THE DEFORMITY

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GENERAL INDICATIONS FOR SURGERY

1) Infectious

2) Neoplastic

3) Myelopathy

4) Progressive neurologic deficit

5) Stable neurological deficit with radicular pain

6) Refractory to non-operative therapy

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WHAT IS EMERGENCY VS URGENT? ABSOLUTE EMERGENCY SURGERY: – IMMEDIATELY, e.g. Bi-facet dislocation or Cauda Equina Syndrome

EMERGENT SURGERY:

– WITHIN 6 HOURS, e.g. Spinal Infection, systemically sick

URGENT SURGERY:

- NEXT AVAILABLE LIST, e.g. successfully reduced Bi-facet dislocation

DELAYED EMERGENT SURGERY:

- PLANNED 24-48+ HOURS DELAY, e.g. Burst fracture

SEMI-ELECTIVE:

- NEXT WEEK, e.g. tumour / TB surgery without progressive neurology

ELECTIVE:

– NEXT MONTH, e.g. stable spinal stenosis

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Some case examples of traumatic vs non-traumatic spinal injuries and the indications for surgery

• TRAUMATIC – PENETRATING – NON-PENETRATING

• NON-TRAUMATIC – CAUDA EQUINA – INFECTIONS – TUMOURS

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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Cervical Vertebral dislocation C5/C6

•  PATHOLOGY: Complete dislocation with bilateral vertebral artery occlusion

•  SURGERY: Anterior or Posterior decompression & fusion

•  TIMING: Absolute Emergency – ASAP

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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Lumbar Burst fracture at L3

•  PATHOLOGY: Unstable Burst with retro-pulsion of bone into the canal, no neurology

•  SURGERY: Posterior +/- Anterior instrumented fusion

•  TIMING: Delayed Emergent Surgery

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Example of a scoring system to decide on surgery in Traumatic Cases

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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Epidural Haematoma

•  PATHOLOGY: Bleeding in a confined space resulting in a “space occupying lesion” with neurological fall-out

•  SURGERY: Laminectomy, evacuate haematoma

•  TIMING: Emergency list

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PENETRATING TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Low velocity GSW T9/T10

•  PATHOLOGY: Stable fracture, bullet in canal, no neurological fall-out

•  SURGERY: Laminectomy & removal only indicated if on-going neurology

•  TIMING: Often delayed for 2 weeks – pseudo capsule

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PENETRATING TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Stab wound Thoracic spine

•  PATHOLOGY: Stable injury, in-complete neurological fall- out, no CSF leak

•  SURGERY: Not indicated unless CSF leak or progressive neurological fall out

•  TIMING: Immediate if acute change in neurology, otherwise no surgery

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NON-TRAUMATIC SPINAL CORD “INJURIES”

•  EXAMPLE: Lumbar L3/L4 Spinal Infection

•  PATHOLOGY: Acute Pyogenic Discitis vs Chronic infection (Fungal / TB)

•  SURGERY: Tissue biopsy / washout

•  TIMING: Pyogenic = Urgent – next available list, Chronic (e.g. TB) = semi-elective

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NON-TRAUMATIC SPINAL CORD “INJURIES”

•  EXAMPLE: Epidural Abscess

•  PATHOLOGY: Pyogenic Epidural Abscess with neurological fall-out

•  SURGERY: Laminectomy, decompression, wash out & tissue biopsy

•  TIMING: Emergency list

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NON-TRAUMATIC SPINAL CORD “INJURIES”

•  EXAMPLE: Spinal Tumour

•  PATHOLOGY: Intra-dural, extra-medullary mass, patient gradually became myelopathic

•  SURGERY: Laminectomy, decompression, & tissue biopsy

•  TIMING: Semi-Elective list unless sudden onset myelopathy

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NON-TRAUMATIC SPINAL CORD INJURIES

•  EXAMPLE: Cauda Equina Syndrome

•  PATHOLOGY: Large lumbar disc herniation with loss of bowel & bladder function, saddle anaesthesia and bilateral lower limb weakness

•  SURGERY: Laminectomy, discectomy & decompression

•  TIMING: Absolute Emergency (Delayed surgery = risk of permanent neurological deficit)

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IN SUMMARY Every spinal referral should be treated as an absolute emergency

and then down graded as more information becomes available

When dealing with a spinal emergency:

1) History and mechanism of injury important

2) Rapid clinical examination

3) Appropriate imaging to identify the pathology

4) Urgent refer to a spinal surgeon if progressive neurology or instability

Don’t let the sun go down on progressive neurology

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