Spine Emergencies: Spinal Cord Injury (SCI) - The Basics

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The document discusses the anatomy, mechanisms, evaluation, and management of spinal cord injuries.

The document discusses that spinal injuries can involve the anterior, middle or posterior spinal columns and discusses compression, flexion, extension etc as common mechanisms of injury.

The document mentions that factors like completeness and level of injury, age and presence of intermedullary hemorrhage can affect prognosis with complete high cervical injuries having a poorer prognosis and younger patients faring better.

Spine Emergencies

Spinal Cord Injury (SCI) – The Basics


Oleh : HAY
Small vertebral bodies
 less weight to carry

Extensive joint surfaces


 greater ROM
 Rib bearing vertebrae

 Designed to remain stiff and straight


 Weight bearing vertebrae

 Lamina, facets and SPs are major


parts of posterior elements
•Anterior column = anterior 2/3 of the vertebral body,
disc, and annulus, and the anterior longitudinal ligament)

•Middle column = posterior 1/3 of the vertebral body,


disc, annulus, and the posterior longitudinal ligament

•Posterior column = pedicles, laminae, facets, capsule,


and the interspinous and supraspinous ligament.

injury is said to be stable if only one of the columns is


involved.
damage to two or more columns or risking neurological
injury (ie damage to the middle column)  unstable.
Spinal Cord
Spinal Cord
Epidemiology
• Incidence: 10,000 new cases/year
• Prevalence: 191,000 cases and rising
• Prime occurrence: males, peak of their productive lives
Common Mechanism
• Compression
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
• Penetration
Suspect spinal injury with...
• Sudden decelerations (MVCs, falls)
• Compression injuries (diving, falls onto feet/buttocks)
• Significant blunt trauma (football, hockey, snowboarding, jet skis)
• Very violent mechanisms (explosions, cave-ins, lightning strike)
• Unconscious patient
• Neurological deficit
• Spinal tenderness
• Missed or delayed diagnosis most often attributed to:
• failure to suspect injury
• inadequate radiology
• incorrect interpretation of radiographs
• A missed spinal injury can have devastating long term consequences
• As such, spinal column injury must therefore be presumed until it is
excluded
Patophysiology
• Primary
• results from focal injuries (egavulsion, contusion, laceration and intra-parenchymal
hemorrhage) and diffuse lesions (e.g. concussive and diffuse axonal injury)
• Further mechanical disruption can result from external compression or
angulationand ischemic damage from occlusion of arterial supply.
• Secondary
• Immediately after an acute spinal cord injury major reduction in blood flow occurs
at the level of the lesion
• Becomes progressively worse over the first few hours if left untreated.
• Pathophysiology underlying this ischaemia is unclear but involves both systemic
and local effects
Patophysiology
Evaluation
• History – Mechanism of injury, decreased level of consciousness

• Inspection and palpation: Occiput to Coccyx


• Tenderness
• Gap or Step
• Edema and bruising
• Spasm of associated muscles

• Neurological
• Motoric
• Sensory
• Reflexes (pathological, physiological)
• Rectal examination
• Motoric
• Muscle Tone
• Resistance to passive range of motion:
• Move patient arm without any resistance provided by the patient.
• Assessment must be made at all major joints sequentially:
That is, wrist → elbow → shoulder.
• Hypertonia:
• Excessive contraction and stiffness to passive movement.
• Pathology involving upper motor neurons.
• Hypotonia
• No muscular contractions or resistance during passive movement.
• Pathology involving lower motor neurons.
• No muscular contractions or resistance during
• Muscle Strength
Neurological Assassement:
Reflexes

• Hyperreflexia, spasticity, and clonus indicative of


Some reflexes are physiologic, and some are
upper motor neuron pathology causing poor lower
pathologic:
motor neuron inhibition:
◦ Deep tendon reflex, cutaneous, and sacral
reflexes are physiologic.
− Hyperreflexia defined as increased brisk reflex with
◦Babinski’s and occasionally Hoffman’s
contraction of muscles not directly being assessed:
reflexes are pathologic.
-- Example: contraction of thigh adductors during
patellar tendon reflex.
Five-point grading scale for deep tendon
−− Clonus is involuntary rhythmic muscular
reflexes:
contractions and relaxation, often
−− 5+: sustained clonus.
accompanied with spasticity.
−− 4+: hyperreflexic with clonus.
−− 3+: slightly hyperreflexic.
−− 2+: normal reflex.
−− 1+: weak normal.
−− 0: no contraction/reflex.
Neurological Assassement:
Reflexes

Sensory Motoric Deep tendon Reflex


C5 Lateral shoulder and arm Deltoid (shoulder abduction) Biceps tendon / BPR
C6 Lateral arm, forearm and thumb Biceps (elbow flexion) Brachioradialis
C7 Index and middle finger Triceps (elbow extension) Triceps tendon / TPR
C8 Fourth and fifth digits Hand intrinsics (finger -
abduction)
T1 Medial forearm and arm Hand intrinsics (finger
abduction)
Sensory Motoric Deep tendon Reflex
L1 Inguinal crease Transversus abdominis -
and internal oblique (trunk
flexion)
L2 Upper thigh Psoas (hip flexion) -
L3 Anterior to medial thigh Quadriceps (leg extension) Patellar tendon
L4 Lower anterior thigh and medial Quadriceps and tibialis Patellar tendon
leg anterior (ankle dorsiflexion)
L5 Posterolateral thigh and lateral Extensor hallucis longus Medial hamstrings
leg, plantar foot, first web space (rarely used)
S1 Lateral foot, lateral posterior Gastrocnemius (ankle Achilles’ tendon
thigh and leg plantarflexion)
S2-S4 Medial posterior thigh and leg, External and sphincter Anal wink reflex and
and perianal region bulbocavernosus reflex
Neurological assessment: Rectal

• Tone: the presence of rectal tone in itself


does not indicate an incomplete injury

• Sensation
• Volition: A voluntary contraction of the
sphincter or the presence of rectal
sensation supports the presence of a
communication between the lower spinal
cord and supraspinal centers – favorable
prognosis

• Bulbocavernosus reflex:
• Negative: absent in spinal shock
The injury is complete if there is
• No voluntary anal contraction
• S4-5 sensory scores = 0
• no anal sensation = No

Otherwise, the injury is incomplete.


Type of lession
• Complete

• Incomplete
• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome
• Posterior cord syndrome

• Conus medullaris syndrome


• Cauda equina syndrome
Complete Spinal Cord Injury
• Complete paraplegia is described as permanent loss of motor and
nerve function at T1 level or below, resulting in loss of sensation and
movement in the legs, bowel, bladder, and sexual region. Arms and
hands retain normal function.

Spinal shock  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

Cervical spinal shock  Hypotension  Interruption of sympathetic


Loss of vascular tone
Parasympathetic >>  bradycardia
Loss of muscle tone due to skeletal muscle paralysis  venous pooling  relative hypovolemia
Spinal cord tracts
Anterior Cord Syndrome

• Kehilangan fungsi motorik, suhu dan


nyeri

• Fungsi propriosepsis dan sensoris


persendian masih terpreservasi
Brown-Sequard Syndrome

Kehilangan fungsi motorik dan


propriosepsis ipsilateral

Kehilangan fungsi perasa nyeri dan suhu


di sisi kontralateral
Central Cord Syndrome

Kelemahan Motorik:
atas > bawah

Kehilangan fungsi sensoris yang bervariasi

Sacral sparing   incomplete spinal injuries to sacral


level, as the motor function pathways are spared in the
injury
Cervical Trauma
• The overall prevalence of C-Spine Injury in all trauma patients was 3.7%

• Alert patients  prevalence was 2.8%

• Clinically unevaluable patients  increased risk (7.7%)

• Traumatic Brain Injury  Increased risk cervical spine injury, compared with nonhead-related blunt
trauma injury

• 1 in 20 patients with moderate and severe head injury will sustain a cervical spine injury

• Vehicular-related accidents and/or initial GCS score of 8 or less  HIGHEST RISK

• 41.9% of all C-Spine Injury were unstable


Thoracolumbal Trauma
• The thoracolumbar junction is the most common injury site for thoracic
and lumbar trauma.
• Most patients are young males involved in high-energy accidents
• Complete neurologic injuries occur in about 20%, and incomplete
neurologic injuries occur in about 15% of patients.
• Associated injuries—including fractures, head trauma, pulmonary
injuries, and intraabdominal injuries—occur more than 50% of the
time.
• Noncontiguous spine injuries remote from the site of the primary injury
occur in 5% of patients.
Conus medullaris syndrome

• Symptoms
– Back pain
– Unilateral or bilateral leg pain
– Bladder dysfunction
– Bowel dysfunction
– Sexual dysfunction
– Diminished rectal tone
– Perianal sensory loss
– Lower extremity weakness
Cauda equine syndrome

• Symptoms
– Back pain
– Radicular pain
• Bilateral
• Unilateral
– Motor loss
– Sensory loss – saddle back anasthaesia
– Urinary dysfunction
• Overflow incontinence
• Inability to void
• Inability to evacuate the bladder completely
– Decrease in perianal sensation
Imaging
• The standard 3 view plain film series is the lateral, antero-posterior, and open-
mouth view
• The lateral cervical spine film must include the base of the occiput and the top
of the first thoracic vertebra
• The lateral view alone is inadequate and will miss up to 15% of cervical spine
injuries.
• If lower cervical spine difficult to see, caudal traction on the arms may be used
to improve visualization
• Repeated attempts at plain radiography are usually unsuccessful
• If the lower cervical spine is not visible, a CT scan of the region is then indicated
Imaging
• Who need an xray??

Screening Tool

NEXUS CCR
NEXUS

NEXUS mnemonic :
N : Neuro deficit/defisit Neurologis
E : EtOH/Ethanol/Intoksikasi
X : eXtreme distracting injury (ies)
U : Unable to provide history
S : Spinal Tendernes
CCR
(Canadian C-Spine Rule)
Imaging
• Computed tomography (CT) scan: sagittal and coronal
reconstructions:
• Improves visualization of occipital-cervical and cervicothoracic junctions, bony
structures, and occult fractures.
• Thin cut CT scanning should be used to evaluate abnormal, suspicious or
poorly visualized areas on plain radiology

• Magnetic resonance imaging (MRI):


• Required in cases of neurologic impairment.
• Improves visualization of ligamentous structures.
SCIWORA

• SCIWORA (spinal cord injury without radiologic abnormality) originally


referred to spinal cord injury without radiographic or CT evidence of
fracture or dislocation
• However with the advent of MRI, the term has become ambiguous
• MRI findings  intervertebral disk rupture, spinal epidural
hematoma, cord contusion, and hematomyelia
Management
 Pre – Hospital Management
 Hospital Management
Pre-Hospital Management

• Initial treatment of patients with cord injury focuses on two aspects


-preventing further damage and resuscitation.
• Immobilization with a hard cervical collar (in case of cervical spine
injuries) and care in transportation of patient is of paramount
importance if the spine is unstable.
• Resuscitations aimed at airway maintenance, adequate oxygen
saturation of peripheral blood, restoring blood pressure to acceptable
limits, preventing bradycardia, done simultaneously to prevent any
ischemic damage to the already compromised cord.
Hospital

• Primary Survey and Resuscitation—ATLS, Assessing Spine Injuries


• Secondary Survey — Neurologic Assessment
• Examination for Level of Spinal Cord Injury
• Laboratory and Spinal Imaging
• Treatment Principles for Patients with Spinal Cord Injuries
Primary Survey and Resuscitation—ATLS

Ventilatory Function
• A – Airway  C1 - C7 = accessory muscles
• Risk Associated with Level of Injury  C3 - C5 = diaphragm
“C3-4-5 keeps the diaphragm alive!”
• Decision to Intubate  T1 - T11 = intercostals
• Airway Intervention  T6 - L1 = abdominals

Occiput - C3 Injuries Decision to Intubate C4-C6 Injuries (ASIA A & B)


(ASIA A & B) Need for Artificial Airway is Usually Related to • Serious consideration for
 Require immediate Respiratory Compromise e.g. prophylactic intubation and
intubation and  Loss of innervation of the diaphragm ventilation if:
ventilation
 Fatigue of innervated resp muscles • Ascending injury (requires
 Hypoventilation serial M/S assessment by a
 V/Q mismatch trained clinician)
 Secretion retention • Fatigue of unassisted
 Associated injuries diaphragm
• Inability to clear secretions
Primary Survey and Resuscitation—ATLS

• B - Breathing
Primary Survey and Resuscitation—ATLS

• C - Circulation
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

Hemodynamic Instability: Bradycardia: Intervention


Intervention - Prevention:
- First Line: Volume | Resuscitation (1-2 L) • Avoid vagal stimulation
- Second line: Vasopressors- • Hyperventilate and hyperoxygenate prior to
(dopamine/norepinephrine) to counter loss of suctioning
sympathetic tone and provide chronotropic • Pre-medicate patients with known
support to the heart hypersensitivity to vagal stimuli
- Options:
• Avoid hypotension - Treatment of Symptomatic Bradycardia:
• Maintain MAP 85-90mmHg for first 7 days • Atropine 0.5 - 1.0 mg IV
if possible (Vale et al, 1997)
Risk of aspiration is high due to:
 cervical immobilization
 local cervical soft tissue swelling
 delayed gastric emptying

Minimizing Risk for Aspiration:


 Nasogastric tube

Minimizing Risk of Gastric Ulceration:


 IV Ranitidine 50mg IV q8h
Pain management

• IASP Proposed 2 Broad Types:


Nociceptive: Musculoskeletal and Visceral
• Responds well to opioids and NSAIDS

Neuropathic: Above Injury/At Injury Level/Below Injury Level


• Somewhat sensitive to Morphine
• More sensitive to anticonvulsants (gabapentin) and tricyclics (nortryptiline)
Pharmacology therapy

• Option: Methylprednisolone (MPS)


Cervical traction…

• To realign and stabilize the spine


• Fastest method of increasing the diameter of the spinal canal
• Muscle relaxants and the reverse Trendelenberg position may facilitate reduction
• Considerable controversy exists regarding the role of pretraction MRI in patients
with cervical fracture dislocations
• Absolute contraindications:
• Occipitoatlantal dislocations
• Concomittant open skull fracture
• Most neurosurgeons believe that prompt restoration of the diameter of the
spinal canal plays an important role in neurologic recovery
Indication for surgery

• Deformity correction
• Stabilization of the spine
• Decompression of neurologic elements (controversial)
• Does decompression improve neurologic outcome?
• Does timing of spinal cord decompression after trauma in patients with
complete SCI’s improve outcome?
Prognostic factors..

• Patients with complete cervical injuries that remain complete within


the first 24 hours of admission are unlikely to regain significant
ambulatory function (1% to 3%)
• Cervical injuries have a higher potential for recovery than do thoracic
or thoracolumbar injuries
• Younger patients fare much better than older folks
• Intermedullary hemmorrhage signifies a worse neurologic and functional
outcome.
Thank you

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