spinal cord injury by Alihussein kassam
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SPINAL CORD INJURIES
Dr. ALIHUSSEIN KASSAM,
INTERN DOCTORMNAZI MMOJA HOSPITAL, ZANZIBAR
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DEFINITION
Insult to spinal cord resulting in a change, in the normal motor, sensory or autonomic function. This change is either temporary or permanent.
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Mechanisms:
i) Direct traumaii) Compression by bone fragments /
haematoma / disc material iii) Ischemia from damage / impingement on
the spinal arteries
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Statistics:
National Spinal Cord Injury Database { USA Stats }• MVA 44.5%• Falls 18.1%• Violence 16.6%• Sports 12.7%
• 55% cases occur in 16 – 30yrs of age• 81.6% are male!
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South African Statistics (GSH Acute Spinal Cord Injury Unit 2007)
• MVA 56%• Falls 16%• Gunshot Injuries 11%• Blunt Assault 6%• Diving Accidents 5% • Stab Wounds 4%• Sport Injuries 3%
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Other causes:• Vascular disorders• Tumours• Infectious conditions• Spondylosis• Iatrogenic• Vertebral fractures secondary to osteoporosis • Development disorders
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ANATOMY :
Spinal cord:
• Extends from medulla oblongata – L1
• Lower part tapered to form conus medullaris
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On the surface :• Deep anterior median fissure • Shallower posterior median sulcus
Spinal cord segment :• Section of the cord from which a pair of
spinal nerves are given off
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Hence: 31 pairs of spinal nerves:8 cervical12 thoracic 5 lumbar5 sacral1 coccygeal
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• Dorsal root – sensory fibres
• Ventral root – motor fibres
• Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve
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PHYSIOLOGY AND FUNCTION
• Grey matter – sensory and motor nerve cells
• White matter – ascending and descending tracts
• Divided into - dorsal- lateral
- ventral
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Tracts :
1) Posterior column: • Fine touch• Light pressure• Proprioception
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2) Lateral corticospinal tract :
• Skilled voluntary movement
3) Lateral spinothalamic tract :
• Pain & temperature sensation
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• Posterior column and lateral corticospinal tract crosses over at medulla oblongata
• Spinothalamic tract crosses in the spinal cord and ascends on the opposite side
NB to understand this as it helps to understand the clinical features of injury patterns and the neurological deficit
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Dermatomes
• Area of skin innervated by sensory axons within a particular segmental nerve root
• Knowledge is essential in determining level of injury
• Useful in assessing improvement or deterioration
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Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)© 2007 Elsevier
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Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)© 2007 Elsevier
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Myotomes : • Segmental nerve root innervating a muscle• Again important in determining level of injury
• Upper limbs:C5 - Deltoid C 6 - Wrist extensorsC 7 - Elbow extensorsC 8 - Long finger flexors T 1 - Small hand muscles
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• Lower Limbs : L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
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Spinal Cord Injury Classification
• Quadriplegia :injury in cervical regionall 4 extremities affected
• Paraplegia :injury in thoracic, lumbar or sacral segments2 extremities affected
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Injury either:
1) Complete
2) Incomplete
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Complete: i) Loss of voluntary movement of parts
innervated by segment, this is irreversibleii) Loss of sensation
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Incomplete:
i) Some function is present below site of injury
ii) More favourable prognosis overalliii) Are recognisable patterns of injury, although
they are rarely pure and variations occur
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Injury defined by ASIA Impairment Scale
ASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function preserved in sacral segments S4 – S5
B – Incomplete: sensory, but no motor function in sacral segments
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C – Incomplete: motor function preserved below level and power graded < 3
D – Incomplete: motor function preserved below level and power graded 3 or more
E – Normal: sensory and motor function normal
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Muscle Strength Grading
• 5 – Normal strength• 4 – Full range of motion, but less than
normal strength against resistance• 3 – Full range of motion against gravity • 2 – Movement with gravity eliminated • 1 – Flicker of movement• 0 – Total paralysis
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SPINAL SHOCK
• Spinal shock was first defined by Whytt in 1750 as a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transection
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Spinal Shock vs Neurogenic Shock
Spinal Shock : • Transient reflex depression of cord function below level of
injury• Initially hypertension due to release of catecholamines• Followed by hypotension• Flaccid paralysis • Bowel and bladder involved• Sometimes priaprism develops • Symptoms last several hours to days
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Neurogenic shock: • Triad of i) hypotension
ii) bradycardia iii) hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic outflow from T1 – L2
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• Loss of vasomotor tone – pooling of blood• Loss of cardiac sympathetic tone – bradycardia • Blood pressure will not be restored by fluid infusion
alone• Massive fluid administration may lead to overload
and pulmonary edema • Vasopressors may be indicated• Atropine used to treat bradycardia
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TYPES OF INCOMPLETE INJURIESi) Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome
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i) Central Cord Syndrome : • Typically in older patients• Hyperextension injury• Compression of the cord anteriorly by
osteophytes and posteriorly by ligamentum flavum
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• Also associated with fracture dislocation and compression fractures
• More centrally situated cervical tracts tend to be more involved hence flaccid weakness of arms > legs
• Perianal sensation & some lower extremity movement and sensation may be preserved
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ii) Anterior cord Syndrome: • Due to flexion / rotation• Anterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal• Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia of blood supply (anterior spinal arteries)
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Clinically: • Loss of power• Decrease in pain and sensation below lesion• Dorsal columns remain intact
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ii) Posterior Cord Syndrome: Hyperextension injuries with fractures of the posterior elements of the vertebrae
Clinically: • Proprioception affected – ataxia and
faltering gait • Usually good power and sensationMonday, May 1, 2023 46COPYRIGHT DR ALIHUSSEIN
KASSAM
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iv) Brown – Sequard Syndrome: • Hemi-section of the cord• Either due to penetrating injuries: i) stab wounds
ii) gunshot wounds• Fractures of lateral mass of vertebrae
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Clinically: • Paralysis on affected side (corticospinal)• Loss of proprioception and fine discrimination
(dorsal columns)• Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
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v) Cauda Equina Syndrome:• Due to bony compression or disc protrusions
in lumbar or sacral region
Clinically • Non specific symptoms – back pain
- bowel and bladder dysfunction- leg numbness and weakness- saddle parasthesia
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SACRAL SPARING
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The concept of sacral sparing
• Well laminated fibers ?
• Anatomical relation?
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CERVICAL SPINE INJURY
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TRAVELING IN RURAL AFRICA
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CLASSIFICATION OF C/SPINE INJURIES
1. Flexion injuries
2. Flexion and rotation injuries
3. Extension injuries
4. Compression injuries
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Causes of flexion / flexion-rotation injuries• Motor cycle spills• Diving in shallow water• Pole vaulting• Rugby football• Blows at the back of the head• Rapid deceleration as in head-on car collisions
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• Blow at the back of the head
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Hyperextension injuries
• Often due to a blow on the forehead..look for a bruise on the brow
• Rear impact car accidents, the head overextends
• Susceptible people are:Pathological spines..spondylotic spines, middle and elderly aged people, congenital anomalies
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The pathology of hyper-extension injury
• Neck hyperextends (1)• Stretching and tearing of the
anterior longitudinal ligament (2)• Stretching of the cord (3)• Nipping of the cord by
osteophytes (4)• Stretching and kinking of spinal
vessels leading to spreading thrombosis (5)
• Contusion and hemorrhage inside the cord (6)
• Spontaneous reduction is the rule, Xrays may be normal
• A tear drop fracture when present may be the only tale-tell sign, or a increased retropharyngeal shadow
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Clinical features of hyperextension injuries
• Diffuse cord damage that does not correspond with the level of injury
• Anterior cord syndrome..motor paralysis• Rarely central cord syndrome..and if so..mostly motor
signs… and lower limbs more severely affected than the upper limbs
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SOFT TISSUE INJURIES OF THE NECK
Whiplash injuriesTerminology loosely used to denote soft tissueinjuries without fracture sustained inroad traffic accidents
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SOFT TISSUE INJURIES OF THE NECK, WHIPLASH INJURIES
• Consist of hyperflexion and hyperextension mechanisms
• Often no radiologic lesions are demonstrable• Mostly soft tissue strains• No neurological lesions• Resolve slowly up to 3 years
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Compression fracturesof the cervical spine
Mechanisms
• A blow to the vertex of the head e.g in a car accident the vertex strikes the roof of the car.
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Compression fractures, clinical features• There is a bruise or hematoma at the vertex• There is a quadriplegia often mostly motor and upper limbs more
severely affected than the lower limbs• There may be loss of temperature and pain modalities• Proprioception and touch could be spared• On X-ray: There is a fracture of the vertebral body which can be a
fissure, a burst type or compression
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Fractures of the upper 2 cervical vertebrae (the atlas, axis)
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FRACTURE OF THE PEDICLE OF C2 = HANGMAN’S FRACTURE
This can occur in 2 ways:1.Traction and a hyperextension jerk or2. Vertical compression and a hyperextension jerk
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ODONTOID FRACTURES
• Best imaged by through open mouth X-ray views
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The odontoid process and the transverse ligament of the axis
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When there is a rupture of the transverse ligament the cord is in a more perilous
situation
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Fracture-dislocations of the atlas and axis
• Treatment: first by skull traction and later by surgical fusion
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Fractures of the odontoid process, 3 types
1=apical fractures2 =waist fractures (bad prognosis
due to high frequency of non-union)
3=base fractures
Other diagram showsimmobilisation by skull halo -body orthosis
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diagnosis
Suspect c/spine injury when patient:1. Complains of neck pain, occipital,
shoulder after trauma2. Has torticollis (wry neck)3. Complains of restricted neck
movements4. Supports head with the hands5. Unconscious after head injury
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• Palpate the neck for tendernessand muscle spasm
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diagnosisPatient supports head by the hands
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Diagnosis - radiologyX-rays: AP and Lateral views, C7-T1 junction must be seen. If necessary be in the Xray
room to pull down the shouldersSpecial views:• Flexion / extension views to assess stability• Oblique views will show the intervertebral foramina; good to assess
facetal locking, radicular symptoms and nerve roots compressions• Open mouth views are good for assessing C1, C2 lesions• CT-scan• MRI scan
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Diagnosis, radiology
In the X-ray department support the headwhen Xrays are being taken to obtain good views
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Initial Management of spinal cord injury
• Immobilization– Rigid collar– Sandbags and straps– Spine board– Log-roll to turn
• Prevent hypotension– Pressors: Dopamine, not Neosynephrine– Fluids to replace losses; do not overhydrate
• Maintain oxygenation– O2 per nasal canula– If intubation is needed, do NOT move the neck
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Management in the hospital• NGT to suction
– Prevents aspiration– Decompresses the abdomen (paralytic ileus is common in the first
days)• Foley
– Urinary retention is common• Methylprednisolone (Solu-Medrol)
– Only if started within 8 hours of injury– Exclusion criteria
• Pregnancy• Age <13 years• Patient on maintenance steroids
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CT scan
• Good in acute situations• Shows bone very well• Soft tissues (discs, spinal cord) are poorly
visualized• Do NOT give contrast in trauma patients
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MRI
• Almost never an emergency• Shows tumors and soft tissues (e.g., herniated
discs) much better than CT scan• May be used to clear c-spine in comatose
patients
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Treatment of Spinal Injuries• No Current Effective Treatment• Prevention is Key
– all current medical and surgical treatments aimed to prevent further injury to the spinal cord.
ATLS principles• A irway; protect Cspine• B reathing• C irculation• D isability, Dx and Rx shock• E xpose patient• Treat (IV, XR chest/Cspine)• Secondary surveyMonday, May 1, 2023 84COPYRIGHT DR ALIHUSSEIN
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Complex spinal traumaCervical spineRadiological evaluation
X-ray Guidelines (cervical)• AAdequacy, AAlignment• BBone abnormality, BBase
of skull• CCartilage, CContours• DDisc space• SSoft tissue
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Immediate Management-Goals:
• Resuscitation according to ATLS guidelines• Determination of neurological injury• Prevention of neurological deterioration• Ongoing ID & Tx of assoc injuries• Prevention of complications • Initiation of definitive management for
vertebral column injury or SCI
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Decision to Intubate: • Need for Artificial Airway is Usually Related to Resp Compromise e.g.
– Loss of innervation of the diaphragm (C 3-4-5 keep the diaphragm alive)– Fatigue of innervated resp muscles – Hypoventilation– V/Q mismatch– Secretion retention– Associated injuries
• Occiput - C3 Injuries (ASIA A & B)
– Require immediate intubation and ventilation due to loss of innervation of diaphragm
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Decision to Intubate Related to Neurological Level
cont’d
• C4-C6 Injuries (ASIA A & B)– Serious consideration for prophylactic
intubation and ventilation if: • Ascending injury (requires serial M/S assessment
by a trained clinician)• Fatigue of unassisted diaphragm• Inability to clear secretions
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Co-Morbidities to Consider…• Advanced age• Premorbid conditions • Chest trauma• Hx of aspiration• Head injury or substance
abuse• Acute ileus
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• SCI Respiratory Sequale– Atelectasis– Ventilatory failure
• (PaCO2 > 50mmHg and pH < 7.30)– Increased secretions– Pneumonia– Pulmonary emboli– Pulmonary edema
• Baseline Resp AssessmentFirst Impression; -Distress?
– Increased WOB?– Increased secretions?– Difficulty with clearing secretions?
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Breathing cont’d
• Intervention– O2 therapy – Assisted ventilation PRN– Medications
(bronchodilators)– Positioning and
mobilizing– Chest physio– Assisted Cough
Baseline Resp Assessment• Clinical Observations
– RR– Type of ventilation and
FiO2
– Resp muscle activity– Skeletal Integrity– Breathing pattern– Chest mobility– Cough Function
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CirculatorySpinal Shock
• Temporary suppression of all reflex activity below the level of injury
• Occurs immediately after injury
• Intensity & duration vary with the level & degree of injury
• Once BCR returns, spinal shock is over
Neurogenic Shock
• The body’s response to the sudden loss of sympathetic control
• Distributive shock
• Occurs in people who have SCI above T6 (> 50% loss of sympathetic innervation)
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Hemodynamic State
Unopposed parasympathetic outflow can lead to cardiac dysrhythmias and hypotension (most common within first 14 days)
• Hypotension is due to loss of vasomotor tone-peripheral pooling of blood and decreased preload
• Most common dysrhythmia is bradycardia
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Circulatory Assess• Level of SCI?• Complete or
incomplete?• Heart rate and rhythm?• B/P? Premorbid
hypertension?• LOC?• U/O?• Volume status?
• First Line: Volume |Resuscitation (1-2 L)
• Second line: Vasopressors- (dopamine/norepinephrine) to counter loss of sympathetic tone and provide chronotropic support to the heart
Hemodynamic Instability: Intervention
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Bradycardia: Intervention
• Prevention:– Avoid vagal stimulation– Hyperventilate and hyperoxygenate prior to
suctioning– Pre-medicate patients with known hypersensitivity
to vagal stimuli• Treatment of Symptomatic Bradycardia:
– Atropine 0.5 - 1.0 mg IV
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GI System
• Risk of aspiration is high d/t: – cervical immobilization– local cervical soft tissue
swelling– delayed gastric emptying
• Parasympathetic reflex activity is altered, resulting in:
– decreased gut motility and – often prolonged paralytic
ileus.
• Minimizing Risk for Aspiration:
– Nasogastric tube
• Minimizing Risk of Gastric Ulceration:
– IV Ranitidine 50mg IV q8h
GI Intervention
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GU System
• All ASCI patients initially managed with indwelling urinary catheter
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Skin Care: Common Sites of Pressure Sores
OcciputOcciputSacrumSacrumTrochanterTrochanterIschiumIschiumAnkleAnkleHeelHeel
• Remove spine board
• Turn or reposition individuals with SCI initially every 2 hours in the acute phase if the medical condition allows.
Skin Intervention
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Pain Management Proposed 2 Broad Types:
NociceptiveNociceptive: Musculoskeletal and Visceral
– Responds well to opioids and NSAIDS
• NeuropathicNeuropathic: Above Injury/At Injury Level/Below Injury Level
– Somewhat sensitive to Morphine– More sensitive to anticonvulsants
(gabapentin) and tricyclics (nortryptiline)
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Pharmacologic Therapy• Option: Methylprednisolone
• NASCIS II (1992)NASCIS II (1992) (National Acute Spinal Cord Injury Study)
– 30mg/kg IV loading dose + 5.4 mg/kg/hr (over 23hrs) effective if administered within 8 hours of injury
• NASCIS III (1997)NASCIS III (1997)
– If initiated < 3hrs continue for 24 hrs, if 3-8 hrs after injury, continue for 48hrs (morbidity higher - increased sepsis and pneumonia)
Both studies criticized for methodologyBoth studies criticized for methodology
MPSS Evidence
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• Meta-analysis showed insufficient evidence to support use of high dose MPSS in ASCI as a treatment standard or guideline for treatment.
• Weak clinical evidence to support MPSS as per NASCIS NASCIS II but not NASCIS III II but not NASCIS III protocol as an option for treatment.
MPS Clinically Effective?
Canadian Association of Emergency Physicians Jan 2003
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Transfer ChecklistSpinal immobilisationAirway risk is identified
ETT if PaCO2 = 50mmHg or greater
Supplemental O2
Assisted ventilation PRNMPSS in progress if
appropriate
NG insitu Foley catheterSkin is protectedLevel of SCI documentedX-rays, CT, MRI
accompany patientFamily contacts
documented
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Cervical Traction• Gardner-Wells tongs• Provides temporary stability of the cervical spine
– Contraindicated in unstable hyperextension injuries
• Weight depends on the level (usually 5lb/level, start with 3lb/level, do not exceed 10lb/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
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Gardner-Wells tongs
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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)
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Soft and hard collars
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Minerva vest and halo-vest
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Long term care
• Rehab for maximizing motor function• Bladder/bowel training• Psychological and social support
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