Surgical Treatment of Spinal Cord Injury.ppt

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Surgical Treatment of Spinal Cord Injury.ppt

  1. 1. Surgical Treatment ofSurgical Treatment of Spinal Cord InjurySpinal Cord Injury Presenter: RiPresenter: Ri 蕭儒鴻蕭儒鴻 2003/02/242003/02/24
  2. 2. Spinal Cord Injury (1)Spinal Cord Injury (1)  cervical >50%, thoracic 20~29%, lumbarcervical >50%, thoracic 20~29%, lumbar 15%, sacral 4%.15%, sacral 4%.  Initial management: ATLSInitial management: ATLS  Complete vs Incomplete injuryComplete vs Incomplete injury  Complete: absence of sensory and motorComplete: absence of sensory and motor function below injury levelfunction below injury level  Incomplete: preservation of either one, suchIncomplete: preservation of either one, such as anterior cord syndrome, central cordas anterior cord syndrome, central cord syndrome and cauda equina syndrome.syndrome and cauda equina syndrome.
  3. 3. Spinal Cord Injury (2)Spinal Cord Injury (2)  Significant recovery of complete injurySignificant recovery of complete injury after 24 hours is less than 3%; after 48after 24 hours is less than 3%; after 48 hours, 0%.hours, 0%.  Distinguish spinal shock from completeDistinguish spinal shock from complete injury—injury—  Suppressed function below injury level withSuppressed function below injury level with paralysis, anesthesia and areflexia.paralysis, anesthesia and areflexia.  Systemic hypotension with low heart rate.Systemic hypotension with low heart rate.  Not last for more than several hours.Not last for more than several hours.
  4. 4. Spinal Cord Injury (3)Spinal Cord Injury (3)  Primary injury: occur at the scene ofPrimary injury: occur at the scene of accident, result in contusion, hemorrhage,accident, result in contusion, hemorrhage, shear and laceration.shear and laceration.  Secondary injury: process followingSecondary injury: process following primary injury, including microcirculationprimary injury, including microcirculation disruption, loss of autoregulation, edema,disruption, loss of autoregulation, edema, and ischemia.and ischemia.  Therapeutic modulationTherapeutic modulation
  5. 5. Pharmacological ManagementPharmacological Management  NASCIS I,II,III---randomized, prospective,NASCIS I,II,III---randomized, prospective, double-blinded---Methylprednisolonedouble-blinded---Methylprednisolone sodium succinate (MPSS)sodium succinate (MPSS)  Within 3 hours, MPSS 30mg/kg bolus +Within 3 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours.5.4mg/kg/hr infusion for 24 hours.  During 3~8 hours, MPSS 30mg/kg bolus +During 3~8 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours.5.4mg/kg/hr infusion for 48 hours.  Effect of neurogenic improvement: suppressEffect of neurogenic improvement: suppress inflammatory response and vasogenic edema.inflammatory response and vasogenic edema.
  6. 6. Surgical Decompression (1)Surgical Decompression (1)  Cervical spinal cord injury----Cervical spinal cord injury----  During complete injury, no neurologicalDuring complete injury, no neurological improvement in early or later decompression.improvement in early or later decompression.  During incomplete injury, controversial inDuring incomplete injury, controversial in surgical decompression.surgical decompression.  Laminectomy may result in neurologicalLaminectomy may result in neurological deterioration.deterioration.  Anterior cervical decompression may improveAnterior cervical decompression may improve function in incomplete quadriplegics.function in incomplete quadriplegics.
  7. 7. Surgical Decompression (2)Surgical Decompression (2)  Experimental models-- rapid decompressionExperimental models-- rapid decompression better than later intervention.better than later intervention.  Human model— early reduction within 8 hoursHuman model— early reduction within 8 hours brings significant recovery in one study;brings significant recovery in one study; however, some others against it.however, some others against it.  Increased risk such as pulmonary morbidityIncreased risk such as pulmonary morbidity associates early surgery.associates early surgery.
  8. 8. Surgical Decompression (3)Surgical Decompression (3)  Thoracic spinal cord injury---Thoracic spinal cord injury---  During complete injury, no neurologicalDuring complete injury, no neurological improvement in early or later decompression.improvement in early or later decompression.  During incomplete injury of cord compression,During incomplete injury of cord compression, decompression brings benefit.decompression brings benefit.  Early decompression–great improvement, butEarly decompression–great improvement, but increased blood loss, more dangerous.increased blood loss, more dangerous.
  9. 9. Surgical Decompression (4)Surgical Decompression (4)  Anterior approach is favored; posteriorAnterior approach is favored; posterior laminectomy has no benefit and worse cordlaminectomy has no benefit and worse cord compression.compression.  As a consensus, the only accepted indicationAs a consensus, the only accepted indication for emergent surgical treatment is progressivefor emergent surgical treatment is progressive neurological deterioration--- such as fractureneurological deterioration--- such as fracture displacement, epidural hematoma, spinal corddisplacement, epidural hematoma, spinal cord edema or infarction.edema or infarction.
  10. 10. Surgical Decompression (5)Surgical Decompression (5)  Better recovery in cauda equina andBetter recovery in cauda equina and conus medullaris syndromes.conus medullaris syndromes.  Surgical decompression is favored.Surgical decompression is favored.  Same prognosis in early or lateSame prognosis in early or late decompression.decompression.  Surgery on 7~10 days after injury allows forSurgery on 7~10 days after injury allows for hematoma resolution, local reaction decreasehematoma resolution, local reaction decrease and healing of small meningeal laceration.and healing of small meningeal laceration.
  11. 11. Stabilization (1)Stabilization (1)  In incomplete lesion, early stabilizationIn incomplete lesion, early stabilization prevent repetitive injury of the spinal cordprevent repetitive injury of the spinal cord and improve neurological outcome.and improve neurological outcome.  Delayed neurological deterioration--- 5%.Delayed neurological deterioration--- 5%. Improper immobilization.Improper immobilization.  Early mobilization and rehabilitation.Early mobilization and rehabilitation.  Stabilization had benefit in all spinal injuryStabilization had benefit in all spinal injury patients.patients.
  12. 12. Stabilization (2)Stabilization (2)  Immediate correction with external orthoticImmediate correction with external orthotic device or operative fixationdevice or operative fixation  External orthoses vs surgical interventionExternal orthoses vs surgical intervention  Surgical stabilization better than externalSurgical stabilization better than external orthoses onlyorthoses only  Early stabilization better than late stabilizationEarly stabilization better than late stabilization in post-surgical neurological deteriorationin post-surgical neurological deterioration
  13. 13. Conclusion (1)Conclusion (1)  No indication for complete injury of spinalNo indication for complete injury of spinal cord decompressioncord decompression  Controversial in necessity and timing ofControversial in necessity and timing of surgical decompression of cervical andsurgical decompression of cervical and thoracic spine.thoracic spine.  Surgical decompression for cauda equinaSurgical decompression for cauda equina and conus medullaris compression--delayand conus medullaris compression--delay surgery showed the same benefit.surgery showed the same benefit.
  14. 14. Conclusion (2)Conclusion (2)  Progressive neurological deficit in cordProgressive neurological deficit in cord compression needs early surgicalcompression needs early surgical decompression.decompression.  Anterior decompression is better.Anterior decompression is better.  Early surgical intervention for instabilityEarly surgical intervention for instability prevents deterioration.prevents deterioration.  A large, prospective, randomized trial isA large, prospective, randomized trial is needed for outcome and timing of surgicalneeded for outcome and timing of surgical intervention.intervention.
  15. 15. ReferenceReference  Surgical controversies in the management of spinal cordSurgical controversies in the management of spinal cord injury,injury, Journal of American Surgeon:188Journal of American Surgeon:188,1999 May,1999 May  Acute management of spinal cord injury.Acute management of spinal cord injury. Journal of theJournal of the American Academy of Orthopaedic SurgeonsAmerican Academy of Orthopaedic Surgeons. 7(3):166-. 7(3):166- 75, 1999 May-Jun.75, 1999 May-Jun.  Operative and nonoperative management ofOperative and nonoperative management of spinalspinal cordcord injury. A review.injury. A review.ParaplegiaParaplegia. 32(6):375-88, 1994 Jun. 32(6):375-88, 1994 Jun  The acute and chronic management ofThe acute and chronic management of spinalspinal cordcord injury,injury, Journal of the American College of Surgeons.Journal of the American College of Surgeons. 190(5):603-18, 2000 May.190(5):603-18, 2000 May.
  16. 16. Thanks for yourThanks for your attention!attention!

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