Acute Spinal Cord Injury

- Management

Dr. Akshat Goel

JR-2, Dept of Orthopaedics Subharti Medical College, Meerut

Outline
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

Epidemiology
Incidence: 10-12,000/ yr 80-85% males (usually 16-30 y/o), 15-20% female 50% of SCIs are complete 50-60% of SCIs are cervical Immediate mortality for complete cervical SCI ~ 50%

Causes of SCI
Road Traffic accidents 36% 37%

Domestic & Industrial accidents Fall from stairs, Ladders Crush injuries

Injuries at sports

20.5%

Diving, Horse riding, Rugby, Gymnastics

Self harm & criminal assault

6.5%

Associated injuries

Head Injuries
Chest injuries Abdominal injuries

7%
20% 2.5% 24%

Skeletal and other injuries -

Goal 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 care

Maintain or restore spinal alignment Minimize loss of spinal mobility

Obtain healed & stable spine

Facilitate rehabilitation

Suspected Spinal Injury

Safe assumptions
Neurological deficit High speed crash Multiple injuries Unconscious Spinal pain/tenderness

Pre-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
Cervical spine immobilization Transportation of spinal cord-injured patients

Cervical spine immobilization

Rigid cervical collar
Neutral position Hard backboard Lateral support (sand bag)

Philadelphia hard collar

Transportation of spinal cord-injured patients

Emergency Medical Systems Paramedical staff Primary trauma center Spinal injury center

Clinical 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 examination
Information

Mechanism
energy, energy

Direction of Impact
Associated Injuries

Is the patient awake or unexaminable?

Whats the difference ?
Awake ask/answer question pain/tenderness motor/sensory exam Not awake you can ask (but they wont answer) cant assess tenderness no motor/sensory exam

OW!

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Analgesia
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 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 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

Comparison of neurogenic and hypovolemic shock

Neurogenic Etiology Hypovolemic

Loss of sympathetic Loss of blood volume outflow

Blood pressure
Heart rate
Skin temperature

Hypotension
Bradycardia Warm Normal

Hypotension
Tachycardia Cold Low 22

Urine output

Definitions 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 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 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 injury

Anterior cord syndrome

Brown-Sequard syndrome Central cord syndrome

Anterior 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 syndrome

Weakness :
UL (LMN) > LL(UMN)

Variable sensory loss Sacral & B/B sparing Older patients (cervical spondylosis) Hyperextension injury

Posterior cord syndrome

Loss of propioception Ataxia Preserved motor, pain and temperature Hyperextension injuries with # of posterior elements

Brown-Sequard syndrome
Loss of ipsilateral motor and propioception
Loss of contralateral pain and temperature

Radiographic 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

NEXUS
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

NEXUS
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.

Any high-risk factor that mandates radiography? Age>65yrs or Dangerous mechanism or Paresthesia in extremities

NO
Any low-risk factor that allows safe assessment 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

YES
NO Radiography

YES
Able to actively rotate neck? 45 degrees left and right

UNABLE

ABLE No Radiography

National Emergency X Radiography Utilization Study (NEXUS)

&
The Canadian C-spine rule
Both have: Excellent negative predictive value for excluding patients identified as low risk

Cervical Spine Imaging Options

Plain films
AP, lateral and open mouth view
Optional: Oblique and Swimmers

CT

Better for occult fractures Very good for spinal cord, soft tissue and ligamentous injuries to determine stability

MRI

Flexion-Extension Plain Films

Radiolographic evaluation
X-ray Guidelines (cervical)

AABBCDS
Adequacy, Alignment Bone abnormality, Base of skull Cartilage Disc space Soft tissue

Adequacy
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 swimmers view or CT

Swimmers view

Alignment
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 is significant anywhere

Lateral 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

Bones

Disc

Disc Spaces
Should be uniform

Assess spaces between the spinous processes

Soft 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 Films

Spinous processes should line up Disc space should be uniform Vertebral body height should be uniform. Check for oblique fractures.

Open mouth view

Adequacy: all of the dens and lateral borders of C1 & C2 Alignment: lateral masses of C1 and C2 Bone: Inspect dens for lucent fracture lines

CT Scan
Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film

MRI
Ideally all patients with abnormal neurological examination should be evaluated with MRI scan

Management 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 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 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 treatment
Spinal alignment
deformity/subluxation/dislocation reduction

Spinal column stability

unstable stabilization

Neurological status
neurological deficit decompression

Jefferson 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 Fracture
Fracture of C3-C7 from axial loading Spinal cord injury is common from posterior displacement of fragments into the spinal canal Unstable

Clay Shovelers Fracture

Flexion fracture of spinous process C7>C6>T1 Stable fracture

Flexion 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 Dislocation

Flexion injury Subluxation of dislocated vertebra of greater than the AP diameter of the vertebral body below it High incidence of spinal cord injury Extremely unstable

Hangmans Fracture
Extension injury Bilateral fractures of C2 pedicles (white arrow) Anterior dislocation of C2 vertebral body (red arrow) Unstable

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 II

Odontoid Fracture Type III

THANK YOU