2007 04 12-Sacks-Spinal Cord Syndromes

8/18/2019 2007 04 12-Sacks-Spinal Cord Syndromes

1/54

Spinal Cord Syndromes

Resident RoundsApril 12, 2007

Juliette Sacks


2/54

Anatomy•Spinal cord ends as

conus medullaris at

level of first lumbarvertebra

•lumbar and sacral

nerve roots exit belowthis and form the

cauda equina


3/54

Neuroanatomy•Corticospinal tracts

•Spinothalamic tracts

•Dorsal (posterior) columns


4/54

Corticospinal Tract•Descending motor pathway

•Forms the pyramid of the medulla

•In the lower medulla, 90% of fibers decussateand descend as the lateral corticospinal tract

•Synapse on LMN in the spinal cord

•10% that do not cross descend as the ventral

corticospinal tract•Damage to this part cause ipsilateral UMNfindings


5/54

Spinothalmic Tract•Ascending sensory tract from skin andmuscle via dorsal root ganglia to cerebral

cortex•Temperature and pain sensation

•Damage to this part of the spinal cord causes:

–Loss of pain and temperature sensation in thecontralateral side

–Loss begins 1-2 segments below the level of thelesion


6/54

Dorsal (Posterior) Columns•Ascending neurons that do not synapse untilthey reach the medulla at which point they

cross the midline to the thalamus•Transmits vibration and proprioceptiveinformation

•Damage will cause ipsilateral loss of vibrationand position sense at the level of the lesion


7/54


8/54

Complete vs Incomplete•Incomplete:–Sensory, motor or both functions are partiallypresent below the neurologic level of injury

–Some degree of recovery

•Complete:–Absence of sensory and motor function below thelevel of injury

–Loss of function to lowest sacral segment

–Minimal chance of functional motor recovery


9/54


10/54

Light touch…•Transmitted through both the dorsalcolumns and the spinothalamic tracts

•Lost entirely ONLY if both tracts aredamaged


11/54

Case #1•33 yo F fell off a 20’ cliff snowboarding

•C/o inability to move both legs

•GCS 15 BP 130/68 HR 89 regular•Normal UE exam

•No power in LE

•Vibration and position sense normal in LE

•Sensation normal in LE

•No rectal tone or perianal sensation


12/54


13/54

Anterior Cord Syndrome•Damage to the corticospinal andspinothalamic tracts

•Dorsal column function is intact•Loss of:

–Motor function

–Pain and temperature sensation•Vibration, position and crude touch aremaintained


14/54

ACS cont’d•Causes:

–Direct injury to anterior spinal cord

–Flexion injury of cervical spine causing acord contusion

–Bony injury causing secondary cord injury

–Thrombosis of anterior spinal artery


15/54

Symptoms•Complete paralysis below the level ofthe lesion with loss of pain and

temperature sensation•Preservation of proprioception andvibration sense


16/54

What to do?•Urgent CT/MRI

•Surgical decompression may be an

option

•Prognosis: POOR


17/54

Case #2•24 y.o. M came off motorcycle at high speed

•Wore no helmet and sustained severe head

injury•C-spine films were unremarkable apart from anarrow spinal canal

•Once conscious, he was quadriparetic with2/5 power in most muscle groups

•No other neurological findings


18/54

Where is the lesion?


19/54


20/54

What’s the deal?•MRI:

–Mild swelling of the cord at C3/4

–Prevertebral soft tissue swelling anddisruption of anterior longitudinal ligament

•Prognosis:

–Within 48h, power in UE 3/5 and LE 4/5–At 2/12, further but not full recovery


21/54


22/54

Central Cord Syndrome•Older patients•Preexisting central

spondylosis

•Hyperextension injury•Injury affects central cord>

peripheral cord

•Damage to corticospinaland spinothalamic tracts

•Upper extremities>thoracic

>lower extremities>sacral


23/54

CCS•Present with:

–Decreased strength

–Decreased pain and temperature sensation–Upper>lower extremities

–Spastic paraparesis/quadriparesis

–Maintain bladder and bowel control

•Prognosis: GOOD–Although fine motor recovery of the upperextremities is rare


24/54

Case #3•24 y.o. M stabbed in the

neck during stampede

argument over whosedoolie tires were bigger

•No LOC

•C/o inability to pick up his hat with his lefthand

•Unaware of his girl holding his right arm


25/54


26/54

Brown-Séquard Syndrome•Hemisection of the cord

•Ipsilateral loss of:

–Motor function

–Proprioception and vibration sense

•Contralateral loss of:

–Pain and temperature sensation


27/54

BSS•Caused by:

–Penetrating injury

–Lateral cord compression from:•Disk protrusion

•Hematomas

•Bone injury•Tumours

•Prognosis: GOOD


28/54

Case #4•76 y.o. Grandpa says he’s got “therheumatism some bad in his legs” with the

crazy weather these days•His wife tells you “he’s wetting himself” whichis unlike him

•He seems to be having lots of trouble riding

his bike because he thinks the bike seat isn’tunder him when it actually is


29/54

Cauda Equina Syndrome•Peripheral nerve injury to lumbar, sacral andcoccygeal nerve roots

•Symptoms:–Variable motor and sensory loss in lowerextremities

–Sciatica

–Bowel and bladder dysfunction

–Saddle anaesthesia

•Prognosis: GOOD


30/54

ED Stabilization•ABCs

•Airway:

–Low threshold for definitive airway inpatient with cervical spine injury especiallyif higher then C5

–Spinal immobilization very important


31/54


32/54

Spinal Shock•Loss of neurological function andautonomic tone below level of lesion

•Loss of all reflexes

•Resolves over 24-48h but may last fordays

•Bulbocavernosus reflex returns first


33/54

Spinal Shock•Symptoms:

–Flaccid paralysis

–Loss of sensation–Loss of DTRs

–Bladder incontinence

–Bradycardia

–Hypotension

–Hypothermia

–Intestinal ileus


34/54

Hypotension•Must determine cause:–Spinal cord injury

–Blood loss

–Cardiac injury

–Combination of above

•Blood loss is the cause of hypotension until

proven otherwise!•Vitals are often non specific

•R/O other causes with: CXR, FAST, CT


35/54


36/54

Corticosteroids•Controversial

•Based on NASCIS trials

•Methylprednisolone improved bothmotor and sensory functional outcomesin complete and incomplete injuries

•Benefit dependent on dose and timingof dose


37/54

Corticosteroids• NASCIS recommends:1.Treatment must begin within 8h of injury

2.Methylprednisolone 30mg/kg bolus iv over 15 minutes

3.45 minute pause post bolus

4.Maintenance infusion 5.4mg/kg/h methylprednisoloneis continued x 23h

• Evaluated in blunt injury only

• Large doses of steroids in penetrating injury maybe detrimental to recovery of neurologicalfunction


38/54

Steroid Therapy as per NACSIS•Attributed to antioxidant effects

•Treat for 24h in patients treated within

3h of injury•Treat for 48h in patients treated within 3-8h of injury

•Worse outcome if started 8h post injury•Conflicting evidence re benefit thereforemore trials required


39/54

Pros Cons•Believed to inhibitformation of freeradical-induced

peroxidation•May increase spinalcord blood flow

•Increase extracellularcalcium

•Prevent potassium lossfrom cord

•Pneumonia

•Sepsis

•Wound infection•GIB

•Delayed healing

NASCISI


40/54

NASCIS IBracken et al. 1984. Efficacy of

methyprednisolone in acute spinal cord injury,

JAMA, 251:45-52•Prospective, randomized double blind trialwith 330 patients

•2 treatment arms:

–100 mg bolus MP, then 25 mg q6h x 10 d–1000 mg bolus, then 250 mg q6h x 10 d

•No sig difference in primary outcomes

•4x increase in wound infections in high dosegroup•“Trend” towards increased sepsis, PE, deathin higher dose group


41/54

NASCIS IIBracken NEJM 1990; 322: 1405-11

•DBRCT of methylprednisone vs naloxonevs placebo (total N=487)

•Methylprednisone 30 mg/kg bolus then 5.4mg/kg/hr X 23 hours

•Outcome = neurological function at 6weeks and 6 months assess by a neurofunction score

•NO benefit of naloxone•NO benefit of steroids overall

•NO difference in mortality

•Trend to more infections and GI bleeds withsteroids


42/54

NASCIS II

•Post – hoc SUBGROUP ANALYSISshowed a benefit at 6 months in thesubgroup treated within 8 hrs–Improved motor score: 4 points (p < 0.03)

–Improved Touch score: 5 points (p < 0.03)–Improved pin-prick score: 5 points (p < 0.02)

•Concluded that steroids were indicated ifstarted within 8hrs

•One year data showed similar improvementin motor score but no difference in sensoryscores(Bracken. J Neurosurg 1992; 76; 23-31)


43/54

NASCIS IIIBracken JAMA 1997: 277(20); 1597-1604

•DBRCT of methylprednisone 24hrs vs 48hrs vs Tirilazad (total N=499)

•NO placebo arm

•Overall, NO difference between thethree groups

•Post-hoc subgroup analysis: 48 hoursteroid group showed improved motor

scores at 6 weeks and 6 months if startedbetween 3-8hrs–6 weeks: 5 points motor score (p


44/54

NASCIS III

•Adverse outcomes–Severe pneumonia higher in 48hr group•2.6% vs 5.8% (p


45/54

Cochrane Review•“the randomized trials of MPSS in thetreatment of acute SCI provide evidence for asignificant improvement in motor functionrecovery after treatment with the high doseregimen within 8 hours of injury”

•Bracken November 2000

•Update in Spine 2001 by Bracken

•4 trials and 797 patients randomized to get highdose methylpred vs placebo for 24 hours


46/54

Cochrane Review Results•Primary outcome = neurologicalimprovement at 6 weeks, 6 months, 1year

•Complicated motor and sensory exam

•High dose methylpred associated with4/70 point increase in motor function

at 6 weeks, 6 months but not one year


47/54


48/54

SCI and Steroids•Author consultant for Pharmacia (theymake methylprednisolone)

•Weak support for use of high dosemethylpred in acute SCI + may be

increased risk of severe adverseoutcomes.


49/54

Bottom Line•CAEP position statement : steroids are NOTSTANDARD OF CARE

•There is insufficient evidence to support the useof high dose methyprednisolone within 8 h ofacute SCI

•Significant harm to using steroids

•NASCIS subgroup data needs to be validated inprospective, randomized, blinded trials

•No new literature to argue for or against this


50/54

Neurological Examination

•LOC

•Deteriorating course

•Neck, back pain and/or bladder, bowel incontinenceshould increase suspicion of sc injury

•Define level of lesion

•Motor function

•Sensory level

•Proprioception testing

•DTRs

•Anogenital reflexes


51/54

DI•C-spine films as per c-spine rules/nexus

•CT

•MRI: better for visualizing neurological,muscular and soft tissue

–If CT negative and patient has positiveneurological findings, this is next step

–Important to image entire spine as 10%have 2nd injury


52/54

Treatment•Prevent secondary injury

•Alleviate cord compression

•Establish spinal stability•Assess the neurological deficit and spinalstability

•Imaging•Consult spine/neurosurgery


53/54

Other cord lesions…•Malignancy

•Epidural hematoma

•Abscesses


54/54

At the end of my rope…•Urgent care necessary

•MRI is better than CT for imaging spinal cord

•Comprehensive serial neurological examsimportant re management options

•Steroids are not the standard of care inCanada

•Consider spinal shock, neurogenic shock andother causes of shock in someone with aspinal cord injury

2007 04 12-Sacks-Spinal Cord Syndromes

Documents

Transcript of 2007 04 12-Sacks-Spinal Cord Syndromes