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Surgical Treatment of Spinal Cord Injury.ppt

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Surgical Treatment of Spinal Cord Injury.ppt Surgical Treatment of Spinal Cord Injury.ppt Presentation Transcript

  • Surgical Treatment of Spinal Cord Injury Presenter: Ri 蕭儒鴻 2003/02/24
  • Spinal Cord Injury (1)
    • cervical >50%, thoracic 20~29%, lumbar 15%, sacral 4%.
    • Initial management: ATLS
    • Complete vs Incomplete injury
      • Complete: absence of sensory and motor function below injury level
      • Incomplete: preservation of either one, such as anterior cord syndrome, central cord syndrome and cauda equina syndrome.
  • Spinal Cord Injury (2)
    • Significant recovery of complete injury after 24 hours is less than 3%; after 48 hours, 0%.
    • Distinguish spinal shock from complete injury—
      • Suppressed function below injury level with paralysis, anesthesia and areflexia.
      • Systemic hypotension with low heart rate.
      • Not last for more than several hours.
  • Spinal Cord Injury (3)
    • Primary injury: occur at the scene of accident, result in contusion, hemorrhage, shear and laceration.
    • Secondary injury: process following primary injury, including microcirculation disruption, loss of autoregulation, edema, and ischemia.
      • Therapeutic modulation
  • Pharmacological Management
    • NASCIS I,II,III---randomized, prospective, double-blinded---Methylprednisolone sodium succinate (MPSS)
      • Within 3 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours.
      • During 3~8 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours.
      • Effect of neurogenic improvement: suppress inflammatory response and vasogenic edema.
  • Surgical Decompression (1)
    • Cervical spinal cord injury----
      • During complete injury, no neurological improvement in early or later decompression.
      • During incomplete injury, controversial in surgical decompression.
      • Laminectomy may result in neurological deterioration.
      • Anterior cervical decompression may improve function in incomplete quadriplegics.
  • Surgical Decompression (2)
      • Experimental models-- rapid decompression better than later intervention.
      • Human model— early reduction within 8 hours brings significant recovery in one study; however, some others against it.
      • Increased risk such as pulmonary morbidity associates early surgery.
  • Surgical Decompression (3)
    • Thoracic spinal cord injury---
      • During complete injury, no neurological improvement in early or later decompression.
      • During incomplete injury of cord compression, decompression brings benefit.
      • Early decompression–great improvement, but increased blood loss, more dangerous.
  • Surgical Decompression (4)
      • Anterior approach is favored; posterior laminectomy has no benefit and worse cord compression.
      • As a consensus, the only accepted indication for emergent surgical treatment is progressive neurological deterioration--- such as fracture displacement, epidural hematoma, spinal cord edema or infarction.
  • Surgical Decompression (5)
    • Better recovery in cauda equina and conus medullaris syndromes.
      • Surgical decompression is favored.
      • Same prognosis in early or late decompression.
      • Surgery on 7~10 days after injury allows for hematoma resolution, local reaction decrease and healing of small meningeal laceration.
  • Stabilization (1)
    • In incomplete lesion, early stabilization prevent repetitive injury of the spinal cord and improve neurological outcome.
      • Delayed neurological deterioration--- 5%. Improper immobilization.
      • Early mobilization and rehabilitation.
    • Stabilization had benefit in all spinal injury patients.
  • Stabilization (2)
    • Immediate correction with external orthotic device or operative fixation
    • External orthoses vs surgical intervention
      • Surgical stabilization better than external orthoses only
      • Early stabilization better than late stabilization in post-surgical neurological deterioration
  • Conclusion (1)
    • No indication for complete injury of spinal cord decompression
    • Controversial in necessity and timing of surgical decompression of cervical and thoracic spine.
    • Surgical decompression for cauda equina and conus medullaris compression--delay surgery showed the same benefit.
  • Conclusion (2)
    • Progressive neurological deficit in cord compression needs early surgical decompression.
    • Anterior decompression is better.
    • Early surgical intervention for instability prevents deterioration.
    • A large, prospective, randomized trial is needed for outcome and timing of surgical intervention.
  • Reference
    • Surgical controversies in the management of spinal cord injury, Journal of American Surgeon:188 ,1999 May
    • Acute management of spinal cord injury. Journal of the American Academy of Orthopaedic Surgeons . 7(3):166-75, 1999 May-Jun.
    • Operative and nonoperative management of spinal cord injury. A review. Paraplegia . 32(6):375-88, 1994 Jun
    • The acute and chronic management of spinal cord injury, Journal of the American College of Surgeons. 190(5):603-18, 2000 May.
  • Thanks for your attention!