Dr Matt Wiles
Consultant in Neuroanaesthesia & Neurocritical Care
Sheffield Teaching Hospitals NHS Foundation Trust
@STHJournalClub http://sthjournalclub.wordpress.com/
Management of Spinal Cord Injury (in Critical Care by an Anaesthetist)
Objectives
• Describe the physiological basis, and evidence for, the treatment strategies in the spine cord injured patient, including:
– Immobilisation
– Steroids
– Blood pressure optimisation
– Surgery
Dürer’s Rhinoceros
Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981
• Incidence 15-40 per million per annum cf TBI 4000 per million
• Median age 47.2 years
Year Number Median age % aged > 50 years
Traumatic Coma Data Bank 1984-1987 746 25 15
UK Four Centre Study 1986-1988 988 29 27
EBIC Core Data Survey 1995 1005 38 33
Rotterdam Cohort Study 1999-2003 774 42 39
Austrian Severe TBI Study 1999-2004 492 48 (mean) 45
TARN Review 2003-2009 15 173 39 (mean) Not reported
Italian TBI Study 2012 1366 45 44
RAIN Study (UK) 2008-2009 2975 44 Not reported
Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981
0
5
10
15
20
25
30
35
40
45
50
RTC Fall>2m Fall<2m Sports Other
AllInjuries CordInjuries
Epidemiology of SCI
Incidence by location
Cervical 75%
Thoracic 10%
Lumbar 10%
Incidence of fractures with SCI
Cervical 40-50%
Thoracic >95%
Lumbar > 85%
Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981
• Median age 47.2 years
• 66% male
• 3.5% had cervical spine injuries
– 10.3% in those with GCS 3 to 8
– only 23% had neurological symptoms [0.8% of total]
– 25% had injuries to other regions
• 16% head
• 16% extremities
• 14% chest
SCIWORA Hendrey et al. J Trauma Acute Care Surg 2002; 53:1-4
• NEXUS data
• n=34,069; 2.4% cervical spine injury
• 27 patients SCIWORA [0.08% of total]
SCIWORA Hendrey et al. J Trauma Acute Care Surg 2002; 53:1-4
• NEXUS data
• n=34,069; 2.4% cervical spine injury
• 27 patients SCIWORA [0.08% of total]
• Included > 3000 children
– None had SCIWORA
Distribution of Bony Injuries Goldberg et al. Ann Emerg Med 2007; 38:17-21
• 1496 cervical spine injuries (2.4%)
• 30% clinically insignificant
• Fractures:
Spinal Level % of total
C1 8.8
C2 23.9
C3 4.3
C4 7.0
C5 15.0
C6 20.3
C7 19.1
} C1-2=33%
} C5-7=54%
Distribution of Bony Injuries Goldberg et al. Ann Emerg Med 2007; 38:17-21
• 1496 cervical spine injuries (2.4%)
• 30% clinically insignificant
• Dislocations/subluxations:
Spinal Interspace
% of total
C1-C2 10.0
C2-C3 9.1
C3-C4 10.0
C4-C5 16.5
C5-C6 25.1
C6-C7 23.4
C7-T1 3.9
} C5-7=58%
Airway & Cervical Spine
• Cervical spine 5% & Spinal cord 2.5%
• Triggers for intubation: – Inability to maintain and protect own airway regardless of
conscious level
– Inability to maintain adequate oxygenation with less invasive manoeuvres (PaO2 < 13kPa)
– Inability to maintain normocapnia (spontaneous PaCO2 <4.0 kPa or > 6.0kPa)
– GCS ≤8
– Patients undergoing transfer with: • Deteriorating conscious level (≥2 points on motor scale)
• Significant facial injuries
• Seizures.
Manual In-line Stabilisation
• Origin uncertain – ATLS guidance 1984
• Data from cadaveric studies, healthy volunteers and case series (n=96)
• Direct laryngoscopy/intubation cause less cervical movement than a jaw thrust
• Several studies suggest MILS has no effect on cervical segment movement
Method Grade 1 Grade II Grade III
Optimal positioning 129 26 2
MILS 75 48 34
Cervical Collars Sundstrøm et al. Journal of Neurotrauma 2014
• Most spinal injuries are stable; – those that are unstable have already caused irreversible
damage
• Collars do not immobilise the cervical spine • Exaggerated rate of secondary SCI without collars • Numerous associated complications
• Authors suggest: – Spinal board with head blocks & straps – Collars only for difficult extrication – Unconscious, nonintubated trauma patients should be transported in
modified left lateral
Clearing the Spine
Why bother?
• Avoidance of skin damage secondary to collars (6-67%)
– Ulceration
– Sepsis
• 30 degree head-up tilt to reduce pneumonia
• Exacerbation of raised ICP
• Increased demands on nursing care
• Exacerbation of agitation especially in TBI
Clearing the Spine
• 7 missed injuries of which 3 unstable
• Sensitivity/Specificity of CT >99.9% (cf NEXUS 99%)
• -ve LR < 0.001%
• 1 in every 4776 patients have missed injury
(My) Rules for Clearing the Spine
• HRCT CT of C-spine (1-2 mm slices) – C0 – T2 (but T4 better)
– Reported by consultant MSK/neuroradiologist
– Discussed with spinal/neurosurgical consultant
• [Consider AP/lateral C-spine radiographs]
• CT reconstructions of thoracolumbar spine
• AP/Lateral radiographs thoracolumbar views
• NB. Semi-rigid collar (Aspen/Philadelphia) in interim
Neurological Deterioration after Surgery
• Due to prolonged deformation and/or hypotension
– Hyperflexion worse than hyperextension
• Both are unlikely during DL
• AFOI may not be safer
– Several claims in US Closed Claims Database
• 5% patients with SCI will deteriorate
– Early (24 h)
– Later (1-7 days)
– Late (weeks [post-traumatic ascending myelopathy])
Steroids for Acute SCI Bracken MB; Cochrane Database 2012
NASCIS II
• Design – Multicentre, prospective, randomised, double-blind trial.
• Patients – 487 patients with acute spinal cord injury (95% follow up)
• Exclusions – Injuries below L1, children
• Randomisation – Treatment 1: Methlyprednisolone 30 mg kg-1 bolus, then
5.4 mg kg-1 h-1 for 23 hours
– Treatment 2: Naloxone 5.4 mg kg-1 bolus, then 4.5 mg kg-1
h-1 for 23 hours
– Treatment 3: Placebo
NASCIS II
• Assessment
– Motor scale (0-5) in 14 muscle groups (total 70)
– Sensory (Pin prick & touch) in 29 dermatomes (total 58)
• (Author’s) Results
– Patients receiving steroids within 8 h had a statistically significant improvement of 5 points on the motor score at 6 months and 1 year (P=0.03)
• Safety
– Wound infection & PE doubled in steroid group (NS)
NASCIS II
• All +ve results are from post hoc analyses
• Time cut off (8 h) is arbitrary
• 78 discrete post hoc tests
• 60 t-tests for neurological outcomes
• Correct hypotension (SBP <90mmHg) ASAP (III)
• Target MAP 85-90 mmHg for 7 days post injury (III) – Compared to historical controls
– >50% with cervical injuries will require vasopressors
– Complications common in first 7 days post injury • Hypotension, bradycardia
• Ventilatory failure on average 4.5 days post injury
• Intubation rates: ≥C5 100% cf 79% ≤ C6
Breathing
1. Fatigue of innervated muscles
2. Chest trauma
3. Ascension of the spinal lesion
4. Retained secretions
5. Abdominal distension splinting diaphragm
• Close observation
• Physiotherapy plus humidified oxygen
• Early tracheostomy
Circulation
1. Spinal shock
2. Coexisting (missed) traumatic injuries
• If lesion > T6, may need vasopressor support
• Caution with excessive fluids
• Target MAP > 80 mmHg
• ? Role of relative hypercarbia
General ICU Care • Normoglycaemia
– <10 mmol/l associated with improved outcome
• Feeding – Enteral ideally, within 72 hours, full rate by 1/52
• VTE prophylaxis – 15-20% risk of VTE; IPC then LMWH after 72 hours
• Stress ulcer prophylaxis – 10% risk of stress ulcers
• Chest physiotherapy – 70% pneumonia rate
• Pressure area/eye care
• Specialised mattresses or beds
• Removal of hard collars
Summary
• Avoid hypotension & hypoxia
• Hypotension in SCI is bleeding until proved otherwise
– Trust no-one, believe nothing, give oxygen
• There is no place for steroid therapy
• Much of the best care is supportive & “SHO work”
– LMWH
– Stress ulcer prophylaxis
– Aperients
• Surgical timing is still uncertain
Any questions.....
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