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DISCUSS THE CLINICAL MANIFESTATIONS AND
MANAGEMENT OF ACUTE SPINAL CORD INJURY
Dr. Arojuraye S.A National Orthopaedic Hospital
Dala - Kano23/04/2015
FGYFBED
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.