DISCUSS THE CLINICAL MANIFESTATIONS AND

MANAGEMENT OF ACUTE SPINAL CORD INJURY

Dr. Arojuraye S.A National Orthopaedic Hospital

Dala - Kano23/04/2015

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Outline Introduction Clinical Manifestations Management

History Physical Examination Investigations Treatment

Non-operative Operative

Complications Conclusion References

Introduction

Definition: SCI is defined as damage to the spinal cord, resulting in

transient or permanent loss of usual sensory, motor & autonomic functions.

SCI is a medically complex and life-disrupting & frustrating clinical condition.

SCI rarely occurs in isolation: 80% have concurrent multiple system injuries 41% have associated head injury

Introduction…

Epidemiology: 10,000 cases per year in the United States M:F = 4:1 Traumatic SCI is common < 40yrs 5% of SCI occur in children

SCIWORA is common in children (immature skeleton)

Introduction…

Management is multidisciplinary ∆ morbidity & mortality Functional, medical & social burdens

Improved rehabilitation & spinal stabilization Regain mobility Improve quality of life Achieve prolonged survival

NO cure for complete paralysis!

Introduction…

Aetiology: MVA Fall Violence Blast injuries Sports e.g diving

Mechanisms: Direct trauma Bone fragments Hematoma Disc prolapse Spinal arteries damage

Introduction…

Common site of SCI Cervical (50% to 64%) Lumbar (20% to 24%) Thoracic cord (17% to 19%)

Most common vertebrae involved are C5, C6, C7, T12, and L1

Cervical injuries are more often incomplete neurologic deficits, whereas thoracic injuries are more often complete

Anatomy

Spinal cord: Foramen magnum L1/L2. Gray matter: central White matter: peripheral Dorsal (sensory) & ventral (motor) roots spinal nerves

31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5

sacral & 1 coccygeal

Anatomy…

Anatomical Levels

Cervical spine Segmental level of cord transection corresponds to the

level of bony damage.

T1 and T10 vertebrae The first lumbar cord segment in the adult is at the

level of the T10. Cord transection at that level spares the thoracic cord.

Anatomical Levels… Below T10 vertebra

The cord forms conus medullaris between T10 & L1 vertebrae & tapers to end at the L1/L2.

The L2 to S4 nerve roots arise from the conus medullaris & stream downwards in a bunch (cauda equina) to emerge at successive levels of the lumbosacral spine.

Clinical ManifestationsComplete paralysis of: Motor

UMN LMN

Sensory pain, temperature, touch Position & discrimination

Autonomic Vasomotor control (above

T5) Temperature control

Incomplete Anterior cord syndrome Central cord syndrome Posterior cord syndrome Brown – sequard syndrome

Clinical Manifestations…

Central Cord Syndrome Due to hyperextension of C-spine Disproportional greater UL weakness Sensory loss is usually minimal Some control over the bowel & bladder Recovery is possible

Clinical Manifestations…

Anterior Cord Syndrome Due to compression of anterior SC Damage to corticospinal & spinothalamic tract Impaired pain, temperature & touch sensations Pressure & position sensation may be preserved Motor paralysis Some recovery is possible

Clinical Manifestations…Brown-Sequard Syndrome Hemisection of the SC. Ipsilateral

Impaired or loss of movement Preserved pain and temperature sensation

Contralateral Normal movement, Impaired pain & temp. sensation

Clinical Manifestations…

Posterior Cord Syndrome Damage is towards the back of the spinal cord. Good muscle power, pain & temperature sensation Difficulty in coordinating movement of the limbs.

Clinical Manifestations…

Conus medullaris syndrome Bladder dysfunction Bowel dysfunction Sexual dysfunction Low back pain Unilateral or bilateral leg pain Diminished rectal tone

Clinical Manifestations…

Caudal equina syndrome Injury to nerve roots Muscle weakness Decreased sensation Decreased bowel & bladder control

Clinical Manifestations…

Neurogenic Shock Seen in cervical injuries Due to interruption of the sympathetic input from hypothalamus Hallmark:

Hypotension Bradycardia

Avoid over-enthusiastic use of IVF Rx: Atropine & vasopressors

Clinical Manifestations…

Spinal Shock Temporary complete cessation of spinal cord function Occurs immediately after injury Complete loss of all reflexes Flaccidity of all muscles Duration:

Rarely last for > 48hrs May be delayed up to 6–8 weeks

Clinical Manifestations…

Hypovolaemic shock Tachycardia Peripheral shutdown Hypotension

Clinical Manifestations…

Clinical Manifestations…Frankel Classification of SCI

A. Complete: Absent motor & sensory function B. Sensation present, motor power absent C. Sensation present, motor power not useful D. Sensation present, motor power present & useful E. Normal Sensory & Motor Frankel observed that 60% of patients with partial cord lesions

improved spontaneously by one grade regardless of the treatment type & a significant number are able to walk again.

Clinical Manifestations…

ASIA Classification A. Complete: No sensory or motor function preserved in the

sacral segments S4 & S5 B. Incomplete: Sensory but not motor function preserved

below neurological level including S4 and S5 C. Incomplete: Sensory and motor function preserved below

neurological level but more than half of the muscles have a grade of 3/5 or less

D. Motor function preserved below neurological level and at least half of muscles have better than grade 3/5 function

E. Normal motor and sensory function

Management Pre-hospital care All trauma patients are at risk of SCI

Proper extrication & immobilization of the C – spine Cervical collar, sandbags Fore-head Tape & spine board

Transportation Log-rolling Avoid cervical extension To level I trauma centre

Management…

Hospital care ATLS Protocol

Primary survey: ABCDE Secondary survey

Inappropriate movement & examination can

irretrievably change the outcome for the worse!

Clinical History

High index of suspicion

Every patient with a blunt injury above the clavicle or

a head injury (Cervical)

Every patient who fall from a height or a high-speed

deceleration accident (Thoracolumbar)

Mechanism of injury Initial care Change in neurologic status

Document Findings

Physical Examination

Head, neck & back Bones & soft tissues are

gently palpated for tenderness, bogginess or increased space btw the

spinous processes.

Neurological Examination Dermatome Myotome Reflexes

Rectal examination(mandatory) Complete Incomplete

Physical Examination…

Physical Examination…

C5: Elbow flexors C6: Wrist extensors C7: Elbow extensors C8: Finger flexors T1: 5th digit abductors

L2: Hip flexors L3: Knee extensors L4: Ankle dorsiflexors L5: Big toe extensors S1: Ankle plantarflexors

Physical Examination…

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 (long standing UMN lesion)

Level of Injury Motor level

The last level with at least 3/5 function This is the most important for clinical purposes

Sensory level The last level with preserved sensation

Radiographic level The level of fracture on plain X-rays / CT scan / MRI

Diagnostic Tests…

X-ray Indication: Neck or back pain following trauma Head or severe facial injuries (C-spine) Rib # or seat-belt bruising (Thoracic spine) Severe pelvic or abdominal injuries (Thoracolumbar)

Diagnostic Tests…

CT Scan Good in acute situations Shows bone very well Soft tissues are poorly visualized Avoid contrast in trauma patients

Diagnostic Tests…

MRI Usually not done as emergency Method of choice for

IVD Ligamentum flavum Neural structures

Indicated for patients with Neurological sign For surgery

Treatment

Goal of treatment Prevention of further injury Reduction & stabilization of bony injury Prevention of complications Rehabilitation

Treatment…

Prevent hypotension Volume expander Vasoressors Atropine

Maintain oxygenation

O2 supplement If intubation is needed,

do NOT move the neck

Hypotension & hypoventilation immediately following an acute traumatic SCI is not

only life threatening but may increase neurological

impairment!

Treatment…

NGT to suction Prevents aspiration Decompresses the abdomen

(Ileus is common)

Foley’s catheter Prevent bladder over

distention.

Methylprednisolone Within 8 hours of injury Exclusion criteria

Cauda equina syndrome

Pregnancy Age < 13 years Patient on steroids

Skull Traction Gardner-Wells tongsCrutchfield caliper Temporary stability of the cervical spine Weight: 5lb/level, start with 3lb/level, not exceed 10lb/level) Cervical collar can be removed while patient is in traction Pin care X-rays at regular intervals & after every move from bed

Halo vest, Minerva vest & jacket

Lumbar corset & Cast

Other Minerva orthosis

Surgical Decompression…

Indications: Deteriorating neurological status Caudal equina syndrome(Emergency) Compression of the cord is evident on MRI Penetrating cord injuries Gunshot injuries Bony fragments in the spinal canal Unstable vertebral body

Surgical Decompression

Timing Emergent

Incomplete lesions with progressive neurologic deficit Caudal equina syndrome

Elective Complete lesions Presence of life threatening conditions

Treatment…

Skin care Creases & crumbs in bed 2hrly turning, Special bed Dry & powdered

Bladder & Bowel care Intermittent catheterization Continuous closed drainage Bladder training Enema, laxatives

Muscles & Joints Passive ROM Splints & Calipers

Psychological support Doctors Physiotherapist Nurses

Complications

Pressure sores Pneumonia Osteoporosis & fractures Heterotrophic ossification Spasticity Urinary tract infection Autonomic dysreflexia Deep venous thrombosis Orthostatic hypotension Thermal instability

Prevention of SCI When SCI follows a traumatic incident, the transition is often

from good health to permanent disability in a matter of seconds. The good news is that a large proportion of these injuries are

preventable.

Primary prevention Avoid the cause

Secondary prevention Prompt diagnosis & Rx

Tertiary prevention Proper rehabilitation

Recent Advances“Get up! Pick up your mat and walk"

A cure for SCI while it is not yet available, is conceivable.

Regeneration Therapy transplanting of fetal tissue into the injured spinal cord in

hopes of regenerating the damaged tissue

Recently, four young men in the US who had been paralyzed for years were able to voluntarily move their legs as a result of epidural electrical stimulation of the spinal cord.

Conclusion SCI is commonly caused by MVA, falls and violence.

It disconnect the communication channel between the brain and the body, causing functional problems like sensory loss, neuropathic pain and lifetime paralysis.

Multidisciplinary management approach is a key to promising outcome

The most important – and sometimes frustrating – thing to know is that each person’s recovery from SCI is different.

References Stephen Eisenstein, Wagih El Masry. Injuries of the spine. Apley's System

of Orthopaedics & Fractures 9th Edition. Hodder Arnold 2010; 806– 28.

Andrew H. Kaye. Spinal injuries. Essential Neurosurgery. 3rd Edition. Chapter 16: Blackwell Publishing Ltd 2005; 225 – 34.

Sohail K, Carlo B, Jens R. Principles of Spine Trauma Care. Rockwood & Green's Fractures in Adults, 6th Edition. 2006; Chapter 37.

David Grundy, Andrew Swain. ABC of spinal cord injury. 4th Edition.

Jerome Bickenbach, Alana Officer, Tom Shakespeare, Per von Groote. International Perspectives on Spinal Cord Injury. The international spinal cord society(ISCOS). World health organization (WHO) 2013.