Spinal Cord Injuries

Dr.Ihssan SubhiAssistant Professor In Neurosurgery

F.I.B.M.S2015

SPINAL CORD INJURY (SCI)

FAST FACTS Occurs primarily in young males (> 75% of cases) Half of these injuries result from MVAs 2/3 of patients are < 30 years old Other sources of SCI: Falls, sporting and

industrial accidents, gunshot wounds. Most common vertebrae involved are C5, C6, C7,

T12, and L1 because they have the greatest ROM

Anatomy

Type of Injury

Transient concussion - is due to extreme vibration of the cord and may cause temporary loss of function lasting 24 to 48 hours. No neuropathologic changes are present.

Contusion - is a bruising that includes bleeding, subsequent edema, and possible necrosis from the edematous compression. • The neurological involvement depends on the severity of

contusion and necrosis Laceration Compression of cord substance Complete transection of the cord

Pathophysiology

Hemorrhage: Blood flows into the extradural, subdural, or subarachnoid spaces of the spinal cord

Injury to spinal cord vasculature causes nerve fibers to swell and disintegrate

Blood circulation to the gray matter of the spinal cord is impaired

Secondary chain of events: Ischemia, hypoxia, edema, and hemorrhagic lesions

These secondary events result in destruction of

myelin and axons.

Pathophysiology Cont’d

These secondary reactions, are believed to be the principal causes of spinal cord degeneration .

The damage may be reversible within the first 4 to

6 hours after the injury. The consequence of spinal cord injury depends

on• The type of injury (concussion, contusion,

laceration, compression, transection) • The neurologic level (lowest level at which

sensory and motor functions are normal)

The Effects of SCI

The exact effects of a SCI vary according to the type and level injury, and can be organized into two types:•Complete injury•Incomplete injury

Complete injury

There is no function below the "neurological" level, defined as the lowest level that has intact neurological function.

If a person has some level below which there is no motor and sensory function, the injury is said to be "complete".

Recent evidence suggest that less than 5% of people with "complete" SCI recover locomotion.

Incomplete injury

The person retains some sensation or movement below the level of the injury.

The lowest spinal cord level is S4-5, representing the anal sphincter and perianal sensation.

So, if a person is able to contract the anal sphincter voluntarily or is able to feel peri-anal pinprick or touch, the injury is said to be "incomplete".

Recent evidence suggest that over 95% of people with "incomplete" SCI recover some locomotory ability.

clinical syndromes associated with incomplete SCIs.

The Central cord syndrome is associated with greater loss of upper limb function compared to lower limbs.

The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing:• Weakness & loss of proprioception on the side of the

injury • loss of pain & thermal sensation of the other side.

The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing:• Motor Weakness• loss of pain &thermal sensations below the injury site

clinical syndromes associated with incomplete SCIs.

Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing:• loss of touch• proprioceptive sensation.

Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1 vertebra.

Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.

Management of Spinal Cord Injuries

Immediate management at the scene is critical. Improper handling can cause further damage and loss of

functioning Always assume there is a spinal cord injury until it is ruled

out• Immobilize• Prevent flexion, rotation or extension of neck• Avoid twisting patient

If conscious, patients will usually mention acute pain in back or neck which may radiate along the involved nerve.

Management cont’d

Management is aimed at preventing further injury and observing for progression of neuro deficits

Consists of emergency treatment following an A-B-C-D-E sequence.

Airway Management

First priority. Open airway with jaw-thrust maneuver. Use bag-valve-mask devise initially for

airway compromise and if necessary to prepare for intubation.

High concentration of 02 will prevent bradycardia or asystole for patients exhibiting signs of neurogenic shock.

Breathing

Lesions above C5 level will cause partial to complete diaphragmatic paralysis (the diaphragm is innervated at C3-5 levels).

Any lesion above T12 may cause some airway compromise.

Lesions at C5 and below will allow full diaphragmatic movement, but intercostal muscles (innervated at T1) and abdominal muscles (innervated at T12) are affected.

Circulation

Cardiac output is affected by external or internal hemorrhage and neurogenic shock.

Two signs of internal bleeding from abdominal trauma are abdominal pain and muscular rigidity. However, these signs may be masked in a patient with sensory and motor deficits.

Other usual signs of shock from internal bleeding are absence of urine and/or classic signs of shock (decreased BP and increased HR)

Disability

Neurological Examination Lateral C-Spine X-ray CT scan MRI ECG - bradycardia and asystole are

common with acute cervical injury Search for other injuries - spinal trauma is

often accompanied by other injuries, particularly of the head and chest.

Exposure

Patients with SCI become poikilothermic, meaning that their body temperature will increase and decrease with the temperature of the environment.

Because they lose the ability to regulate core body temperature through vasodilatation and vasoconstriction, they can become dangerously hyperthermic or hypothermic.

Medical Management

High dose corticosteroids (Methylprednisolone) - improves the prognosis and decreases disability if initiated within 8 hours of injury. Patient receives a loading dose and then a continuous drip.

High dose steroids, Mannitol, Dextran Naloxone - has shown promise in use on humans,

minimal side effects, may promote neurological improvement

Spinal shock

Spinal Shock

Management: • monitor patient for respiratory difficulty,

bladder and bowel management, abrupt onset of fever (as patient loses ability to perspire in areas of paralysis).

• May last from weeks to months. When it ends, flaccid muscles become spastic.

Neurological/Orthopedic Management

Neurological/orthopedic management includes methods a surgeon may use to treat unstable spinal cord injuries:

• Reduction

• Fixation

• Fusion

Reduction

With reduction, the spine is realigned through the application of a skeletal traction devise, such as Gardner-Wells tongs or Halo traction.

Fixation and Fusion

Fixation involves stabilizing vertebral fractures with wires, plates,screws and other types of hardware.

Fusion involves attaching injured vertebrae to uninjured vertebrae with bone grafts, and steel rods to help maintain structural integrity.

Complications of SCI - Pulmonary

Pulmonary complications - Function compromise, Airway compromise, infection, decreased vital capacity, atelectasis, retention of secretions, respiratory failure, pulmonary edema

Acute respiratory failure is the leading cause of death in high cervical injuries.

Deep Vein Thrombosis (DVT)

The incidence of DVT is extremely high in SCI patients due to pressure on their calf muscles, loss of the skeletal muscle pump, and the hypercoagulability of their blood.

Treatment :DVT prophylaxis - pneumatic compression hose, low dose Heparin, and vena cava filters.

Orthostatic Hypotension

Caused by venous pooling in the legs and abdomen, loss the skeletal muscle pump, and impaired sympathetic nervous system control of BP.

May occur with position changes and can result in syncope, bradycardia, or asystole.

Treatment consists of quickly returning the patient to a supine position, administering oxygen, and if necessary, atropine to increase heart rate.

GI and GU dysfunction

Assess for bowel distention, ileus or gastrointestinal bleeding - may require an NGT

During acute injury phase, the bladder is atonic so the patient is unable to void voluntarily or spontaneously - also increases risk of UTI

Maintain strict Intake and Output Begin bladder training.

Skin Integrity

Below the level of SCI, the patient cannot sense discomfort from pressure, skin irritants, or temperature extremes.

Patient will remain at high risk for pressure ulcers, serious skin injury and infection.

During acute phase, inspect skin for redness or other signs of breakdown - pressure ulcers can occur within 6 hours

May use special bed to turn patient.

Rehab and Long-Term Issues

Mobility - initially may require a brace or halo. Needs to bear weight as soon as possible because it helps decrease disuse atrophy, decrease the opportunity for osteoporosis, decrease the possibility of renal calculi, and enhances metabolic processes

Exercise - to strengthen unaffected parts and promote self-care.

Rehab and Long-Term Issues cont’d

Urinary and Bowel Programs - will have to develop and maintain programs. Will need to learn how/when to self-cath, check residual urine. Will need to know how to stimulate a bowel movement. Will need to be able to recognize an impaction or ileus.

Spastic Muscles - maximum spastic activity is usually 2 years out and then minimizes some. May require long-term use of anti-spasmodic drugs such as valium, baclofen or dantrium

Rehab and Long Term Issues cont’d

Contractures - Needs to understand the importance of exercise and maintaining function.

UTI’s and sepsis - needs to recognize signs and symptoms of UTI and sepsis.

Heterotropic ossification - overgrowth of bone in hips, knees, shoulders elbows. This causes pain and decreased ROM for pain, thus decreasing mobility.

Self-Esteem - May need counseling to deal with changes in self-identity, sexual function, social and emotional roles. Needs to feel strong, lovable and loved.

Psychosocial Behavior

Denial, anger and depression are common reactions to SCI.

Ultimately the SCI patient will ask the question of walking again. Often this question cannot be answered in the immediate post-injury phase. The goals are to provide honest and realistic communication about the nature of the injury and help the patient develop short-term goals.