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Michael, Daniel

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  • 1. Spine Trauma: Surgical Management Professor of Neurological Surgery Oakland University William Beaumont School of Medicine Chief of Neurotrauma and Critical Care Beaumont Health System; Royal Oak, MI Director of Michigan Head and Spine Institute, PC Daniel B. Michael M.D., Ph.D. [email_address]
  • 2.  
  • 3.  
  • 4. Spinal Cord Injury: Demographics 2-5/100,000 M:F 1-5/1 2nd-3rd decade
  • 5. Mechanisms of SCI secondary injury
    • Excitatory amino acid receptor binding
    • Endogenous opioid receptor binding
    • Increased cholinergic activity
    • Increased monoamine activity
    • Platelet activating factor; ischemia & edema
    • Cytokines & inflammation
    • Ion flux
    • Free radical production
    • Genomic alterations
    • Gliosis & scar formation
  • 6. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries Neurosurgery (Supplement) March 2002 50:3 Hadley MN Walters BC Grabb PA Oyesiku NM Przybylski GJ Resnick DK Ryken TC
  • 7. Methods
    • Medline review – http://www.ncbi.nlm.nih.gov/PubMed/
    • Degrees of certainty
      • Standards , Guidelines , Options
      • High , Moderate , Low Quality evidence
    • Classification of evidence
      • Class I : prospective, randomized, controlled trials
      • Class II : prospective data collection, retrospective analysis
      • Class III : retrospective data analysis
  • 8. Cervical Spine Immobilization Before Admission to the Hospital Standard : none Guideline : none Option : all potential patients should be immobilized at scene with rigid collar & backboard with straps
  • 9. Transportation of Patients with Acute Cervical Spine Injuries Standard : none Guideline : none Option : “Expeditious and careful” transport to “nearest capable definitive care medical facility”
  • 10. Clinical Assessment After Acute Cervical Spine Injuries Standard Neuro & Functional  none Guideline Neuro  none Functional  use Functional Independence Measure (FIM) Option Neuro  American Spinal Injury Association (ASIA) standards Functional  Modified Barthel Index
  • 11. History & Physical
    • ETOH, drugs, allergies
    • Look for associated injuries (20%)
    • Use American Spinal Injury Association (ASIA) terms
      • Motor grades 0-5
      • Level=lowest myotome with grade 3 (anti-gravity) function
      • Impairment Scale A-E (complete-normal)
  • 12. ASIA Myotomes
    • C5-elbow flexors (biceps)
    • C6-wrist extensors
    • C7-elbow extensors (triceps)
    • C8-finger flexors
    • T1-small finger abductors
    • L2-hip flexors (iliopsosas)
    • L3-knee extensors
    • L4-ankle dorsiflexors
    • L5-long toe extensors (EHL)
    • S1-ankle plantar flexors
  • 13. Dermatomes
  • 14.
    • Traumatic Spinal Cord Syndromes
  • 15. Coincidence of Head and Cervical Spine Injury
    • Coincident injuries occur because of similar mechanisms
    • A primary injury (most obvious) is identified
    • Incidence of primary HI with CSI is 6%
    • Incidence of primary CSI with HI is 24%
    • Mortality of coincident HI & CSI is 13.6%
    • 2.4% of comatose patients harbor CSI
    • Patients with coincident injuries have unique rehab needs
    Michael DB et al. J Neurotrauma 1989;6(3):177-189
  • 16. Radiographic Assessment of the Cervical Spine in Asymptomatic Trauma Patients
    • Standard : studies not required in awake, alert, patients without neck pain if not intoxicated or distracted by associated injuries
  • 17. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients
    • Standard
      • AP, Lateral, odontoid x-rays
      • supplement w/ CT as needed
    • Guideline
      • none
    • Option
      • d/c collar in awake pts w/ pain after flex-ex or MRI
      • d/c collar in obtunded pts after flouro flex-ex, MRI
      • “ discretion of treating physician”
  • 18. Initial closed reduction of Cervical Spine Fracture-Dislocation Injuries
    • Standard : none
    • Guideline : none
    • Option :
    • -Use early closed reduction in awake patients
    • -Avoid in patients with associated rostral injuries
    • -MRI 1st if patient cannot be examined during reduction (rupt disc relative indication for ventral decompression)
    • -MRI if reduction failed
    • -½ to 1/3 patients with fx dislocation have disc rupture; pre reduction MRI usefulness in awake patients unclear
  • 19. Management of Acute Spinal Cord Injuries in an Intensive Care Unit or Other Monitored Setting Standard : none Guideline : none Option : Management in ICU with cardiac, hemodynamic & respiratory monitoring
  • 20. Blood Pressure Management after Acute Spinal Cord Injuries Standard : none Guideline : none Option : avoid SBP<90mm Hg; maintain MAP 85- 90 mm Hg for 1st 7 days post injury
  • 21. Pharmacological Therapy after Acute Spinal Cord Injuries Standard : none Guideline : none Option : 24 or 48 hour methylprednisolone protocol per NASCIS II & III or GM-1 ganglioside treatment “ ...most controversial of the Guidelines.”- M.L.J. Apuzzo
  • 22. NASCIS 3
    • All pts received methylprednisolone bolus:20mg/kg
    • Randomized to 24 or 48 hour methylprednisolone drip: 5.4mg/kg/hour or q6 hour tirilazad bolus for 48 hours
    • Outcome at 6 months: neuro grade, FIM, complications
    • Conclusion: pts starting Rx 0-3 hours post injury should receive 24 hour infusion of methylprednisolone; 3-8 hours: 48 hour infusion
    Bracken et al. JAMA 1997; 277:1597-1604
  • 23. Deep Venous Thrombosis and Thromboembolism in Patients with Cervical Spinal Cord Injuries Standard : use prophylaxis with LMW heparin, roto beds, adjusted dose heparin, or low dose heparin with compression stockings Guideline : low dose heparin alone or oral anticoagulation not recommended Option : monitor with Doppler u/s, impedance plesmethography or venogram, Prophylax for 3 months post injury, consider cava filters in non responders or non anticoagulation candidates
  • 24. Nutritional Support after Spinal Cord Injury Standard : none Guideline : none Option : provide support based on indirect calorimetry
  • 25. Management of Pediatric Cervical Spine and Spinal Cord Injuries Diagnostic Standard : none Guideline -If child conversant, use adult radiographic criteria -If not, obtain AP & Lateral x-rays Option - <9y obtain x-rays - >9y use adult criteria - Supplement with CT, flex-ex, or MRI
  • 26. Management of Pediatric Cervical Spine and Spinal Cord Injuries Standard : none Guideline : none Option : -Account for head-spine size difference in children < 8y when immobilizing -Closed reduction and halo immobilization for C2 injuries < 7y -Consider surgery for ligamentous injuries Treatment
  • 27. Spinal Cord Injury without Radiographic Abnormality SCIWORA
    • Standard : none
    • Guideline : none
    • Option :
    • Diagnosis may be aided by entire spine x-rays, CT, &/or MRI; angiography & myelography not recommended
    • Consider external mobilization (12 wks) and avoidance of high risk activities (6 mo)
    • MRI may provide prognostic info
  • 28. Diagnosis and Management of Traumatic Atlanto-occipital Dislocation Injuries
    • Standard : none
    • Guideline :none
    • Option :
    • Diagnosis: use lateral x-ray supplemented (upper STS) by CT &/or MRI
    • Traction risks neuro deterioration (10%)
    • Surgical fixation and arthrodesis recommended
  • 29. Occipital Condyle Fractures Standard : none Guideline : CT for dx Option : Diagnosis may be aided by &/or MRI external mobilization
  • 30. Isolated Fracture of the Atlas in Adults
    • Standard : none
    • Guideline : none
    • Option :
    • If transverse ligament intact (Spence excursion < 6.9 mm) immobilize
    • If transverse ligament ruptured consider surgery
    Jefferson Fracture
  • 31. Isolated Fracture of the Axis in Adults Standard : none Guideline : consider surgery in Type II, >50 y Option : Initial treatment of Type I, II, III with external immobilization; Consider surgery if >5mm displacement, comminution or inability to stabilize in external device Odontoid
  • 32. Odontoid Fracture Due to GSW
  • 33. Traumatic spondylolisthesis of the axis (Hangman’s Fracture) Standard : none Guideline : none Option : Initial treatment with external immobilization in most cases; Consider surgery if severe angulation, c2-3 disc disruption or inability to stabilize in external device Isolated Fracture of the Axis in Adults
  • 34. Isolated Fracture of the Axis in Adults Standard : none Guideline : none Option : external immobilization Miscellaneous Fractures of the Axis Body
  • 35. Management of Combination Fractures of the Atlas and Axis in Adults
    • Standard : none
    • Guideline : none
    • Option :
    • External immobilization for most
    • Consider surgery if odontoid >5mm displacement, or C2 angulation >11 degrees
  • 36. Os Odontoideum
    • Standard : none
    • Guideline : none
    • Option :
    • Image with x-ray, flex-ex, CT &/or MRI
    • Asymptomatic: surveillance
    • C1-C2 unstable or neuro symptoms: C1-C2 surgery
    • Use post op halo unless transarticular screws placed
    • Occipital cervical fusion if cervico-medullary compression
    • Consider transoral decompression
  • 37. Treatment of Subaxial Cervical Spine Injuries Subaxial cervical facet dislocation injuries
    • Standard : none
    • Guideline : none
    • Option :
    • Closed or open reduction
    • External immobilization, internal anterior or posterior fixation and fusion
    • Prolonged bed rest in traction
  • 38. Cervical Spine Stability White & Punjabi
  • 39. Cervical Spine Stability White & Punjabi
  • 40. Unilateral Facet Fracture
  • 41. Cervical Flexion-Distraction Injuries
  • 42. Cervical Flexion-Distraction Injuries
  • 43. Treatment of Subaxial Cervical Spine Injuries Sub axial cervical injuries excluding facet dislocation injuries
    • Standard : none
    • Guideline : none
    • Option :
    • Closed or open reduction
    • External immobilization, internal anterior or posterior fixation and fusion
  • 44. Cervical Axial Loading Injuries
  • 45. Management of Acute Central Cervical Spinal Cord Injuries
    • Standard : none
    • Guideline : none
    • Option :
      • ICU care
      • Maintain MAP 85-90 mm Hg for 1st 7d post injury
      • Early reduction of fracture dislocation injuries
      • Surgical decompression for focal or anterior lesions
  • 46. Management of Vertebral Artery Injury after Non-penetrating Cervical Trauma Standard : none Guideline : none Option : -Angiography or MRI in complete cord injuries, fx thru f. transversarium, facet dislocation or vertebral sublux -IV anticoagulation if evidence of posterior circulation stroke -Observe or anticoagulate if evidence of ischemia -Observe if no evidence of stroke or ischemia
  • 47. Thoracic Spine Stability White & Punjabi
  • 48. A 40 y/o unlimited hydroplane driver injured at the 2003 Detroit Gold Cup race. Injuries: concussion, thoracic compression fxs and left ankle fx.
  • 49. T2-3 Fracture, Complete paraplegia
  • 50. T2-3 Fracture, Complete paraplegia
  • 51. Unstable T4-5 complete - MVA
  • 52. Motorcycle Accident T3-4 100% Sublux (complete)
  • 53. T3-4 100% Sublux (complete) Nine days post injury
  • 54. Snowmobile Injury
  • 55. L2-3 complete-assault rifle injury (AK-47) 2000
  • 56. L2-3 complete-assault rifle injury (AK-47) 2003
  • 57. Sacral Injuries
  • 58. Prevention: ThinkFirst