Dr. Akshat GoelJR-2, Dept of Orthopaedics
Subharti Medical College, Meerut
Dr. Akshat GoelJR-2, Dept of Orthopaedics
Subharti Medical College, Meerut
Acute Spinal Cord Injury
- Management
Acute Spinal Cord Injury
- Management
OutlineOutline
• Epidemiology• Causes of SCI• Goal of spine trauma care• Pre-hospital management• Clinical and neurologic assessment• Acute spinal cord injury
– Term, type and clinical characteristic
• Common cervical spine fracture and dislocation
EpidemiologyEpidemiology
• Incidence: 10-12,000/ yr• 80-85% males (usually 16-30 y/o), 15-20%
female• 50% of SCI’s are complete• 50-60% of SCI’s are cervical• Immediate mortality for complete cervical
SCI ~ 50%
Causes of SCICauses of SCI
• Road Traffic accidents - 36%
• Domestic & Industrial accidents - 37%• Fall from stairs, Ladders• Crush injuries
• Injuries at sports - 20.5%• Diving, Horse riding, Rugby, Gymnastics
• Self harm & criminal assault - 6.5%
Associated injuriesAssociated injuries
• Head Injuries - 7%
• Chest injuries - 20%
• Abdominal injuries - 2.5%
• Skeletal and other injuries - 24%
Goal of spine trauma careGoal of spine trauma care
• Protect further injury during evaluation and management
• Identify spine injury or document absence of spine injury
• Optimize conditions for maximal neurologic recovery
Goal of spine trauma careGoal of spine trauma care
• Maintain or restore spinal alignment
• Minimize loss of spinal mobility
• Obtain healed & stable spine
• Facilitate rehabilitation
Suspected Spinal InjurySuspected Spinal Injury
“Safe assumptions”
– Neurological deficit
– High speed crash
– Multiple injuries
– Unconscious
– Spinal pain/tenderness
Pre-hospital managementPre-hospital management
• Protect spine at all times during the management of patients with multiple injuries
• Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine
• Ideally, whole spine should be immobilized in neutral position on a firm surface
• PROTECTION PRIORITY• Detection Secondary
“Log-rolling”
Pre-hospital management Pre-hospital management
• Cervical spine immobilization
• Transportation of spinal cord-injured patients
Cervical spine immobilizationCervical spine immobilization
• Rigid cervical collar
• Neutral position
• Hard backboard
• Lateral support (sand bag)
Philadelphia hard collarPhiladelphia hard collar
Transportation of spinal cord-injured patientsTransportation of spinal cord-injured patients
• Emergency Medical Systems• Paramedical staff• Primary trauma center• Spinal injury center
Clinical assessmentClinical assessment
• Advance Trauma Life Support (ATLS) guidelines
• Adequate airway and ventilation are the most important factors
• Supplemental oxygenation
• Early intubation is critical to limit secondary injury from hypoxia
• Suction vagal reflex stimulation aggravate pre-existing bradycardia
Physical examinationPhysical examination
• Information
• Mechanism
energy, energy
• Direction of Impact
• Associated Injuries
Is the patient awake or “unexaminable”?Is the patient awake or “unexaminable”?
• What’s the difference ?– Awake
• ask/answer question• pain/tenderness• motor/sensory exam
– Not awake• you can ask (but they won’t answer)• can’t assess tenderness• no motor/sensory exam
OW!
------
AnalgesiaAnalgesia
• Control of pain is important.
• Titrated i.v. opioids used with caution, because of their central depressant effect.
• Narcotic analgesics should be avoided if possible in patients with cervical and upper thoracic injuries.
• I.M. or rectal NSAIDs provide background analgesia.
“Unexaminable”
≠
“No exam”
Physical examinationPhysical examination
• Inspection and palpation – Occiput to Coccyx– Soft tissue swelling and bruising– Point of spinal tenderness– Gap or Step-off– Spasm of associated muscles
• Neurological assessment– Motor, sensation and reflexes– PR
• Do not forget the cranial nerves
Neurogenic ShockNeurogenic Shock
• Temporary loss of autonomic function of the cord at the level of injury– results from cervical or high thoracic injury
• Presentation– Flaccid paralysis distal to injury site– Loss of autonomic function
• hypotension• vasodilatation• loss of bladder and bowel control• loss of thermoregulation• warm, pink, dry below injury site• bradycardia
22
Neurogenic Hypovolemic
Etiology Loss of sympathetic outflow
Loss of blood volume
Blood pressure
Hypotension Hypotension
Heart rate Bradycardia Tachycardia
Skin temperature
Warm Cold
Urine output
Normal Low
Comparison of neurogenic and hypovolemic shock
Definitions of termsDefinitions of terms
• Neurologic level– Most caudal segment with normal sensory and
motor function both sides
• Skeletal level– Radiographic level of greatest vertebral damage
• Complete injury– Absence of sensory and motor function in the
lowest sacral segment
• Incomplete injury– Partial preservation of sensory and/or motor
function below the neurologic level
Neurologic assessmentNeurologic assessment
• Spinal shock– Bulbocavernosus reflex
• Complete VS incomplete cord injury– Spinal shock– Sacral sparing
• Voluntary anal sphincter control• Toe flexor• Perianal sensation• Anal wink reflex
Neurologic assessmentNeurologic assessment
• American Spinal Injury Association grade– Grade A – E
• American Spinal Injury Association score– Motor score (total = 100 points)
• Key muscles : 10 muscles
– Sensory score (total = 112 points)• Key sensory points : 28 dermatomes
Incomplete cord injuryIncomplete cord injury
• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome
Anterior cord syndromeAnterior cord syndrome
• Loss of motor, pain and temperature
• Preserved propioception and deep touch
• Flexion-rotation force causing anterior dislocation or compression #
• Compression of Ant. Spinal artery ischemia of corticospinal and spinothalamic tracts.
Central cord syndromeCentral cord syndrome
• Weakness : – UL (LMN) > LL(UMN)
• Variable sensory loss• Sacral & B/B sparing
• Older patients (cervical spondylosis)
• Hyperextension injury
Posterior cord syndromePosterior cord syndrome
• Loss of propioception Ataxia• Preserved motor, pain and temperature
• Hyperextension injuries with # of posterior elements
Brown-Sequard syndromeBrown-Sequard syndrome
• Loss of ipsilateral motor and propioception
• Loss of contralateral pain and temperature
Radiographic imagingRadiographic imaging
• Who needs an x- ray of the spine ?
NEXUS -The National Emergency X- Radiograph Utilization Study– Prospective study to validate a rule for the decision to obtain
cervical spine x- ray in trauma patients– Hoffman, N Engl J Med 2000; 343:94-99
Canadian C-Spine rules– Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a decision as to the need for subsequent cervical spine radiography
– Stiell I. JAMA. 2001; 286:1841-1846
NEXUSNEXUS
• NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
NEXUSNEXUS
• Patient who fulfilled all 5 of the criteria were considered low risk for C-spine injury
No need C-spine X-ray
• For patients who had any of the 5 criteria radiographic imaging was indicated ( AP, lateral and open mouth views)
The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern.The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a concern.
• Any high-risk factor that mandates radiography?• Age>65yrs or• Dangerous mechanism or• Paresthesia in extremities
Any low-risk factor that allows safeassessment of range of motion?• Simple rear-end MVC, or• Sitting position in ER, or• Ambulatory at any time, or• Delayed onset of neck pain, or• Absence of midline C-spine tenderness
Able to actively rotate neck?• 45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE
National Emergency XRadiography Utilization Study
(NEXUS)
National Emergency XRadiography Utilization Study
(NEXUS)
Both have:• Excellent negative predictive value for
excluding patients identified as low risk
The Canadian C-spine rule
&
Cervical Spine Imaging OptionsCervical Spine Imaging Options
– Plain films• AP, lateral and open mouth view
– Optional: Oblique and Swimmer’s
– CT• Better for occult fractures
– MRI• Very good for spinal cord, soft tissue and
ligamentous injuries
– Flexion-Extension Plain Films• to determine stability
Radiolographic evaluationRadiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
• Adequacy, Alignment• Bone abnormality, Base of skull• Cartilage• Disc space• Soft tissue
AdequacyAdequacy
• Must visualize entire C-spine • A film that does not show the
upper border of T1 is inadequate
• Caudal traction on the arms may help
• If can not, get swimmer’s view or CT
Swimmer’s viewSwimmer’s view
AlignmentAlignment
• The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities
• Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation
• A step-off of >3.5mm issignificant anywhere
Lateral Cervical Spine X-RayLateral Cervical Spine X-Ray
• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a vertebral
body unilateral facet dislocation
– > 50% bilateral facet dislocation
BonesBones
DiscDisc
• Disc Spaces– Should be uniform
• Assess spaces between the spinous processes
Soft tissueSoft tissue
• Nasopharyngeal space (C1)– 10 mm (adult)
• Retropharyngeal space (C2-C4)– 5-7 mm
• Retrotracheal space (C5-C7) – 14 mm (children)– 22 mm (adults)
AP C-spine FilmsAP C-spine Films
• Spinous processes should line up
• Disc space should be uniform
• Vertebral body height should be uniform. Check for oblique fractures.
Open mouth viewOpen mouth view
• Adequacy: all of : all of the dens and the dens and lateral borders of lateral borders of C1 & C2C1 & C2
• Alignment: lateral : lateral masses of C1 and masses of C1 and C2C2
• Bone: Inspect dens for lucent fracture lines
CT ScanCT Scan
• Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film
MRIMRI
• Ideally all patients with abnormal neurological examination should be evaluated with MRI scan
Management of SCIManagement of SCI
• Primary Goal– Prevent secondary injury
• Immobilization of the spine begins in the initial assessment– Treat the spine as a long bone
• Secure joint above and below
Management of SCIManagement of SCI
• Spinal motion restriction: immobilization devices• ABCs
– Increase FiO2
– Assist ventilations as needed with c-spine control– Indications for intubation :
• Acute respiratory failure• GCS <9• Increased RR with hypoxia• PCO2 > 50 • VC < 10 mL/kg
– IV Access & fluids titrated to BP ~ 90-100 mmHg
Management of SCIManagement of SCI
• Look for other injuries: “Life over Limb”• Transport to appropriate SCI center once
stabilized• Consider high dose methylprednisolone
– Controversial as recent evidence questions benefit– Must be started < 8 hours of injury– Do not use for penetrating trauma– 30 mg/kg bolus over 15 minute – After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatmentPrinciple of treatment
• Spinal alignment– deformity/subluxation/dislocation reduction
• Spinal column stability– unstable stabilization
• Neurological status– neurological deficit decompression
Jefferson FractureJefferson Fracture
• Burst fracture of C1 ring
• Unstable fracture
• Increased lateral ADI on lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view
• Need CT scan
Burst FractureBurst Fracture
• Fracture of C3-C7 from axial loading
• Spinal cord injury is common from posterior displacement of fragments into the spinal canal
• Unstable
Clay Shoveler’s FractureClay Shoveler’s Fracture
• Flexion fracture of spinous process
• C7>C6>T1
• Stable fracture
Flexion Teardrop FractureFlexion Teardrop Fracture
• Flexion injury causing a fracture of the anteroinferior portion of the vertebral body
• Unstable because usually associated with posterior ligamentous injury
Bilateral Facet DislocationBilateral Facet Dislocation
• Flexion injury• Subluxation of dislocated
vertebra of greater than ½ the AP diameter of the vertebral body below it
• High incidence of spinal cord injury
• Extremely unstable
Hangman’s FractureHangman’s Fracture
• Extension injury
• Bilateral fractures of C2 pedicles
(white arrow)
• Anterior dislocation of
C2 vertebral body (red arrow)
• Unstable
Odontoid Fractures Odontoid Fractures
• Complex mechanism of injury• Generally unstable• Type 1 fracture through the tip
– Rare
• Type 2 fracture through the base– Most common
• Type 3 fracture through the base and body of axis– Best prognosis
Odontoid Fracture Type IIOdontoid Fracture Type II
Odontoid Fracture Type IIIOdontoid Fracture Type III
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