CME Spinal Cord Injury

8/11/2019 CME Spinal Cord Injury

1/49

Spinal Cord Injuries


2/49


3/49

What is the anatomy of the spinal cord on

cross section?


4/49

What is the anatomy of the spinal cord on

cross section?


5/49


6/49


7/49


8/49

What are the clinically important descending

tracts and where do they cross over?


9/49

At what level does the spinal cord end and

why is it important?


10/49

What are the differences between UMN and

LMN? (e.g., cauda equina vs. myelopathy)


11/49

SPINAL TRAUMA


12/49

Acute vs. chronic injuries;

complete vs. incomplete injuries

Acute=sudden onset of symptoms

Complete ?


13/49

What is a completespinal cord injury?

Complete = absence of sensory and motor

function in the perianal area (S4-S5)


14/49

Terminology

Plegia = complete lesion

Paresis = some muscle strength is preserved

Tetraplegia (or quadriplegia)

Injury of the cervical spinal cord

Patient can usually still move his arms using the segmentsabove the injury (e.g., in a C7 injury, the patient can still flexhis forearms, using the C5 segment)

Paraplegia

Injury of the thoracic or lumbo-sacral cord, or cauda equina

Hemiplegia

Paralysis of one half of the body

Usually in brain injuries (e.g., stroke)


15/49

Motor: how do you test each segment?


16/49

Motor: how do you grade the strength?


17/49

Sensory: how do you determine the level?


18/49

What are the important vegetative

functions and when are they affected?


19/49

Reflexes

Deep Tendon Reflexes

Arm

Bicipital: C5

Styloradial: C6

Tricipital: C7

Leg

Patellar: L3, some L4

Achilles: S1

Pathological reflexes

Babinski (UMN lesion)

Hoffman (UMN lesion at or above cervical spinal cord)

Clonus (plantar or patellar) (long standing UMN lesion)


20/49

What is and how do you determine the level

of injury?

Motor level = the last level with at least 3/5

(against gravity) function NB: this is the most important for clinical purposes

Sensory level = the last level with preservedsensation

Radiographic level = the level of fracture on

plain XRays / CT scan / MRI

NB: spine level does not correspond to spinal cord

level below the cervical region


21/49

Case scenario

25 y/o male

Fell off the roof (20 feet)

Had to be intubated at the scene by EMS

Consciousness regained shortly thereafter

Could not move arms or legs

Could close and open eyes to command

Not able to breathe by himselftotallydependent on mechanical ventilation


22/49

High cervical injuries (C3 and above)

Motor and sensory deficits involve the entire

arms and legs

Dependent on mechanical ventilation for

breathing (diaphragm is innervated by C3-C5levels)


23/49


24/49


25/49

What is the difference between spinal shock

and neurogenic shock?

Spinal shock is mainly a loss of reflexes (flaccid

paralysis)

Neurogenic shock is mainly hypotension and

bradycardia due to loss of sympathetic tone


26/49


27/49


28/49


29/49

Case scenario

22 y/o female

Motor vehicle accident (hit a pole at 60mph)

+ for ethanol and Tetrahydrocannabinol

Short term loss of consciousness (10)

Not able to move or feel her legs

Deep Tendon Reflexes 2+ in both upper

extremities, 0 in both lower extremities No bladder / bowel control or sensation

Sensory level at the umbilicus


30/49


31/49


32/49


33/49

What is the difference between cauda equina and

conus medullaris syndrome?


34/49

What is an incompletelesion?


35/49


36/49


37/49


38/49


39/49


40/49


41/49

Lumbar Puncture

Sedate the patient and make your life easier

Measure opening pressure with legs straight

Always get head CT prior to LP to r/o

increased ICP or brain tumor


42/49

Cervical Spine Clearance

Occiput to T1 need to be cleared ER, Neurosurgery or Orthopedics physician

If the patient Is awake and oriented

Has no distracting injuries

Has no drugs on board

Has no neck pain

Is neurologically intact

then the c-spine can be cleared clinically, without any need forXRays

CT and/or MRI is necessary if the patient is comatoseor has neck pain

Subluxation >3.5mm is usually unstable


43/49

Cervical Traction

Gardner-Wells tongs

Provides temporary stability of the cervical spine

Contraindicated in unstable hyperextension injuries

Weight depends on the level

Cervical collar can be removed while patient is in

traction

Pin care: clean q shift with appropriate solution, then

apply povidone-iodine ointment

Take XRays at regular intervals and after every move

from bed


44/49


45/49

Surgical Decompression and/or Fusion

Indications

Decompression of the neural elements (spinal cord/nerves)

Stabilization of the bony elements (spine)

Timing Emergent

Incomplete lesions with progressive neurologic deficit

Elective

Complete lesions (3-7 days post injury)

Central cord syndrome (2-3 weeks post injury)


46/49


47/49


48/49

Long term care

Rehab for maximizing motor function

Bladder/bowel training

Psychological and social support


49/49

THANK YOU!

CME Spinal Cord Injury

Documents

Transcript of CME Spinal Cord Injury