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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