Initial Management of  Spine Cord Injury  Leslie Hutchins, MD Intern Conference November 11, 2008
The frog instantly dies when the spinal cord is pierced; and before this it lived without head, without heart or any bones...
Edwin Smith Surgical Papyrus  (2500 BC) <ul><li>Case Thirty-One   </li></ul><ul><li>Title:  </li></ul><ul><li>Instructions...
Hippocrates  (5 th -4 th  Century BC) <ul><li>Described chronic paralysis with </li></ul><ul><ul><li>Constipation </li></u...
Galen   (150 BC) <ul><li>“… it is obvious that the upper sections of the spinal marrow are more important than the lower.”...
World War I <ul><li>80% of individuals with spinal cord injury died within the first 2 weeks. </li></ul><ul><li>“ The cond...
14,000 Spinal Cord Injuries in  North America per year Lifshutz J. Colohan A.  A brief history of therapy for traumatic sp...
Level of Injury <ul><li>Some use the lowest level of completely normal function. </li></ul><ul><li>Most sources define the...
Spinal Cord Anatomy <ul><li>31  pairs of spinal nerves (Each formed by 2 roots) </li></ul><ul><li>The spinal nerves exit t...
Spinal Cord Anatomy <ul><li>Begins  </li></ul><ul><ul><li>Foramen Magnum as a continuation of the Medulla Oblongata </li><...
Incomplete Lesion <ul><li>Any residual motor or sensory function more than 3 segments below level of injury.  </li></ul><u...
 
 
 
Signs of Incomplete Lesion <ul><li>Sensation (including position sense) or voluntary movements in the lower extremities.  ...
Types of Incomplete Lesions: <ul><li>Central Cord Syndrome </li></ul><ul><li>Brown-Séquard   Syndrome </li></ul><ul><li>An...
Complete Lesion <ul><li>No preservation of any motor and/or sensory function more than 3 segments below the level of injur...
Spinal Shock <ul><li>Hypotension: </li></ul><ul><ul><li>Interruption of sympathetics </li></ul></ul><ul><ul><ul><li>Loss o...
Spinal Shock <ul><li>Transient loss of neurologic function </li></ul><ul><ul><li>(including segmental and polysynaptic ref...
Treated for SCI until proven otherwise: <ul><li>All victims of significant trauma </li></ul><ul><li>Trauma patients with L...
Initial Management of  Spine Cord Injury <ul><li>The major causes of death in spinal cord injury are aspiration and shock....
Stabilization &  Initial Evaluation <ul><li>Stabilization (medical & spinal) </li></ul><ul><ul><ul><li>Preliminary evaluat...
Immobilization Greenberg, M.  Handbook of Neurosurgery: Sixth Edition . 2006; 698-713. http://www.itim.nsw.gov.au/go/clini...
Hypotension <ul><li>Maintain SBP ≥ 90mm Hg.  </li></ul><ul><li>Pressors if necessary:  </li></ul><ul><ul><li>Dopamine is a...
Maintenance  <ul><li>MAP at 85 to 90 mm Hg for the first 7 days after acute spinal cord injury to improve spinal cord perf...
Spinal Cord Anatomy: Vasculature  <ul><li>Upper Cervical Spine </li></ul><ul><ul><li>Vertebral Artery: </li></ul></ul><ul>...
Spinal Cord Anatomy: Vasculature  <ul><li>Lower Third of C-Spine: </li></ul><ul><ul><li>Anterior Segmental Medullary (Radi...
<ul><li>1:  posterior spinal vein 2: anterior spinal vein 3: posterolateral spinal vein 4: radicular (or segmental medulla...
Spinal Cord Anatomy: Vasculature <ul><li>Below C-Spine </li></ul><ul><ul><li>Continuous anastomoses with the radicular art...
Spinal Cord Anatomy: Vasculature  <ul><li>Thoracic/Lumbar Spine </li></ul><ul><ul><li>Anterior Segmental Arteries Alternat...
Initial Class III Study of BP Management in SCI <ul><li>Prospective assessment of 117 Acute Cervical SCI patients at Swiss...
Frankel Grade Function        A               complete paralysis     B               sensory function only below the injur...
Outcome <ul><li>62% of Cervical SCI patients improved </li></ul><ul><ul><li>Including 8 of 18 Frankel Grade A patients </l...
<ul><li>Treated 50 Acute Cervical SCI  </li></ul><ul><ul><li>ICU setting  </li></ul></ul><ul><ul><li>Hemodynamic monitorin...
<ul><li>8 patients had shock at time of admission (SBP ≤ 90 mm Hg) </li></ul><ul><li>82% had volume-resistant hypotension ...
<ul><li>Treated 77 Consecutive Acute Cervical/Thoracic SCI  </li></ul><ul><ul><li>ICU setting  </li></ul></ul><ul><ul><li>...
Outcomes <ul><li>They concluded that the enhanced neurological outcome identified in their series after ASCI was optimized...
Oxygenation <ul><li>Measured pulmonary function in 16 cervical level complete ASCI patients and compared  initial values w...
 
 
Stomach <ul><li>NG Tube to Suction:  </li></ul><ul><ul><li>Prevents vomiting and aspiration </li></ul></ul><ul><ul><li>Dec...
Bladder <ul><li>Place indwelling urinary catheter: </li></ul><ul><ul><li>I’s & O’s </li></ul></ul><ul><ul><li>Prevent dist...
DVT Prophylaxis <ul><li>Overall mortality from DVT is 9% in SCI patients. </li></ul>Greenberg, M.  Handbook of Neurosurger...
Temperature Regulation <ul><li>Vasomotor paralysis may produce poikilothermy (loss of temperature control) </li></ul><ul><...
 
 
 
Electrolytes <ul><li>Hypovolemia and hypotension cause increased plasma aldosterone which may lead to hypokalemia </li></u...
Detailed Neurological Examination <ul><li>Focused history: key questions should center on </li></ul><ul><ul><li>Mechanism ...
<ul><li>B. Palpation of the spine for point tenderness, a “step off”, or widened interspinous space </li></ul>Detailed Neu...
<ul><li>Motor level assessment </li></ul><ul><ul><li>Skeletal muscle exam (can localize dermatome) </li></ul></ul><ul><ul>...
Motor impairment related to Spinal Cord Injury
<ul><li>Sensory level assessment </li></ul><ul><ul><li>Sensation to pinprick (tests spinothalamic tract, can localize derm...
Dermatomes
Detailed Neurological Examination <ul><li>E. Evaluation of reflexes </li></ul><ul><ul><li>Muscle stretch reflexes: usually...
Detailed Neurological Examination <ul><li>F. Examine for signs of autonomic dysfunction </li></ul><ul><ul><li>Altered patt...
Radiographic Assessment of the Cervical Spine in the Asymptomatic Trauma Patient <ul><li>Asymptomatic Patients Include: </...
<ul><li>Largest Class I study addressing this issue encompassed 34,069 patients evaluated at 21 emergency room in the Unit...
<ul><li>Clinical investigations that provide Class I evidence involving nearly 40,000 patients, plus Class II and III evid...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>The reported incidence of cervical sp...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Flexion/Extension </li></ul><ul><ul><...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>MRI </li></ul><ul><ul><li>A negative ...
Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>A prospective comparison should be ma...
Medical Management Specific to Spinal Cord Injury <ul><li>Treatment with methylprednisolone for 24 or 48 hours after SCI i...
<ul><li>Exclusion criteria: </li></ul><ul><li>Cauda equina syndrome </li></ul><ul><li>Gunshot wounds </li></ul><ul><li>Lif...
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Initial Management Of Sci

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Initial Management Of Sci

  1. 1. Initial Management of Spine Cord Injury Leslie Hutchins, MD Intern Conference November 11, 2008
  2. 2. The frog instantly dies when the spinal cord is pierced; and before this it lived without head, without heart or any bones or intestines or skin, and here therefore it would seem lies the foundation of movement and life. All the nerves of the animals derive from here: when this is pricked they instantly die. -Leonardo da Vinci. Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  3. 3. Edwin Smith Surgical Papyrus (2500 BC) <ul><li>Case Thirty-One </li></ul><ul><li>Title: </li></ul><ul><li>Instructions concerning a dislocation in a vertebra of [his] neck. </li></ul><ul><li>Examination: </li></ul><ul><li>If thou examinest a man having a dislocation in a vertebra of his neck, shouldst thou find him unconscious of his two arms (and) his two legs on account of it, while his phallus is erected on account of it, (and) urine drops from his member without his knowing it; his flesh has received wind; his two eyes are bloodshot; it is a dislocation of a vertebra of his neck extending to his backbone which causes him to be unconscious of his two arms (and) his two legs... </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Thou shouldst say concerning him: &quot;One having a dislocation in a vertebra of his neck, while he is unconscious of his two legs and his two arms, and his urine dribbles. An ailment not to be treated .&quot; </li></ul>Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  4. 4. Hippocrates (5 th -4 th Century BC) <ul><li>Described chronic paralysis with </li></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Bladder difficulty </li></ul></ul><ul><ul><li>Bed sores </li></ul></ul><ul><ul><li>Venous stasis of the lower extremities </li></ul></ul>Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  5. 5. Galen (150 BC) <ul><li>“… it is obvious that the upper sections of the spinal marrow are more important than the lower.” </li></ul><ul><li>Credited with the observations of functional differences between longitudinal and transverse lesions of the spinal cord. </li></ul>Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  6. 6. World War I <ul><li>80% of individuals with spinal cord injury died within the first 2 weeks. </li></ul><ul><li>“ The conditions were such owing to pressure of work, as to make it almost impossible to give these unfortunate men the care their conditions require. No water beds were available, and each case demands undivided attention of a nurse trained in the care of paraplegics….” –Dr. Cushing </li></ul>Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  7. 7. 14,000 Spinal Cord Injuries in North America per year Lifshutz J. Colohan A. A brief history of therapy for traumatic spinal cord injury. Neurosurg Focus. 2004 Jan 15;16(1):E5.
  8. 8. Level of Injury <ul><li>Some use the lowest level of completely normal function. </li></ul><ul><li>Most sources define the “level” as the most caudal segment with motor function that is at least 3/5 and if pain and temperature sensation is present </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  9. 9. Spinal Cord Anatomy <ul><li>31 pairs of spinal nerves (Each formed by 2 roots) </li></ul><ul><li>The spinal nerves exit through the intervebral foramen </li></ul><ul><ul><li>8 cervical </li></ul></ul><ul><ul><ul><li>1 st exits through the Occipital Bone and C 1 </li></ul></ul></ul><ul><ul><ul><li>8 th exits between C7 & T 1 </li></ul></ul></ul><ul><ul><li>1 2 thoracic </li></ul></ul><ul><ul><ul><li>Distal to T 1 each spinal nerve exits below its corresponding vertebra </li></ul></ul></ul><ul><ul><li>5 lumbar </li></ul></ul><ul><ul><li>5 sacral </li></ul></ul><ul><ul><li>1 coccygeal </li></ul></ul>
  10. 10. Spinal Cord Anatomy <ul><li>Begins </li></ul><ul><ul><li>Foramen Magnum as a continuation of the Medulla Oblongata </li></ul></ul><ul><li>Terminates </li></ul><ul><ul><li>Conus Medullaris </li></ul></ul><ul><ul><ul><li>Adult: Lower Border of L1/L2 </li></ul></ul></ul><ul><ul><ul><li>Young Child: Upper Border of L3 </li></ul></ul></ul>
  11. 11. Incomplete Lesion <ul><li>Any residual motor or sensory function more than 3 segments below level of injury. </li></ul><ul><li>Look for signs of preserved long-track function. </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  12. 15. Signs of Incomplete Lesion <ul><li>Sensation (including position sense) or voluntary movements in the lower extremities. </li></ul><ul><li>“ Sacral Sparing” sensation around anus, voluntary rectal sphincter contraction, or voluntary toe flexion. </li></ul><ul><li>An injury doesn’t qualify as incomplete with preserved sacral reflexes alone. </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  13. 16. Types of Incomplete Lesions: <ul><li>Central Cord Syndrome </li></ul><ul><li>Brown-Séquard Syndrome </li></ul><ul><li>Anterior Cord Syndrome </li></ul><ul><li>Posterior Cord Syndrome </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  14. 17. Complete Lesion <ul><li>No preservation of any motor and/or sensory function more than 3 segments below the level of injury. </li></ul><ul><li>Almost 3% of patients with complete injuries on initial exam will develop some recovery within 24 hours. </li></ul><ul><li>The persistence of complete spinal cord injury beyond 24 hours indicates no distal function recovery </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  15. 18. Spinal Shock <ul><li>Hypotension: </li></ul><ul><ul><li>Interruption of sympathetics </li></ul></ul><ul><ul><ul><li>Loss of vascular tone below level of injury </li></ul></ul></ul><ul><ul><ul><li>Leaves parasympathetics relatively unopposed causing bradycardia. </li></ul></ul></ul><ul><ul><li>Loss of muscle tone due to skeletal muscle paralysis below the level of injury results in venous pooling and thus a relative hypovolemia. </li></ul></ul><ul><ul><li>Blood loss from associated wounds -> true hypovolemia. </li></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  16. 19. Spinal Shock <ul><li>Transient loss of neurologic function </li></ul><ul><ul><li>(including segmental and polysynaptic reflex activity and autonomic function) below the level of spinal cord injury -> flaccid paralysis & areflexia lasting various periods (usually 1-2 weeks, occasionally several months and sometimes permanently), the resolution of which yields the anticipated spasticity below the level of the lesion. </li></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  17. 20. Treated for SCI until proven otherwise: <ul><li>All victims of significant trauma </li></ul><ul><li>Trauma patients with LOC </li></ul><ul><li>Minor trauma victims with complaints referable to the spine (neck or back pain or tenderness) or spinal cord (numbness or tingling in an extremity or weakness). </li></ul><ul><li>Associated findings associated with SCI include: </li></ul><ul><ul><li>Abdominal breathing </li></ul></ul><ul><ul><li>Priapism (autonomic dysfunction) </li></ul></ul>
  18. 21. Initial Management of Spine Cord Injury <ul><li>The major causes of death in spinal cord injury are aspiration and shock. </li></ul><ul><li>ATLS Protocol </li></ul><ul><ul><li>Assessment of airway takes precedence </li></ul></ul><ul><ul><li>Then breathing </li></ul></ul><ul><ul><li>Then circulation & control of hemorrhage </li></ul></ul><ul><ul><li>Followed by brief neurological exam </li></ul></ul><ul><ul><ul><li>Other injuries may be masked below the level of SCI. </li></ul></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  19. 22. Stabilization & Initial Evaluation <ul><li>Stabilization (medical & spinal) </li></ul><ul><ul><ul><li>Preliminary evaluation & treatment </li></ul></ul></ul><ul><li>Evaluation of spinal stability </li></ul><ul><li>Subsequent (definitive) treatment </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  20. 23. Immobilization Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713. http://www.itim.nsw.gov.au/go/clinical-resources/spinal-injuries/guidelines-on-spinal-injuries/spinal-log-roll-guide
  21. 24. Hypotension <ul><li>Maintain SBP ≥ 90mm Hg. </li></ul><ul><li>Pressors if necessary: </li></ul><ul><ul><li>Dopamine is agent of choice </li></ul></ul><ul><ul><li>Avoid phenylephrine: non-inotropic and possible increase in vagal tone with bradycardia. </li></ul></ul><ul><li>Careful hydration: propensity to pulmonary edema </li></ul><ul><li>Atropine for bradycardia with hypotension </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  22. 25. Maintenance <ul><li>MAP at 85 to 90 mm Hg for the first 7 days after acute spinal cord injury to improve spinal cord perfusion is recommended. </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  23. 26. Spinal Cord Anatomy: Vasculature <ul><li>Upper Cervical Spine </li></ul><ul><ul><li>Vertebral Artery: </li></ul></ul><ul><ul><ul><li>One Anterior Spinal Artery </li></ul></ul></ul><ul><ul><ul><li>Two Posterior Spinal Arteries </li></ul></ul></ul>
  24. 27. Spinal Cord Anatomy: Vasculature <ul><li>Lower Third of C-Spine: </li></ul><ul><ul><li>Anterior Segmental Medullary (Radicular) Arteries </li></ul></ul><ul><ul><ul><li>Vertebral Artery </li></ul></ul></ul><ul><ul><ul><li>Ascending Cervical Artery </li></ul></ul></ul><ul><ul><ul><li>Deep Cervical Artery </li></ul></ul></ul>
  25. 28. <ul><li>1: posterior spinal vein 2: anterior spinal vein 3: posterolateral spinal vein 4: radicular (or segmental medullary) vein 5: posterior spinal arteries 6: anterior spinal artery 7: radicular (or segmental medullary) artery </li></ul>Spinal Cord Anatomy: Vasculature
  26. 29. Spinal Cord Anatomy: Vasculature <ul><li>Below C-Spine </li></ul><ul><ul><li>Continuous anastomoses with the radicular arteries. </li></ul></ul><ul><ul><ul><li>Aorta </li></ul></ul></ul><ul><ul><ul><li>Intercostal Arteries </li></ul></ul></ul><ul><ul><ul><li>Spinal Arteries </li></ul></ul></ul><ul><ul><ul><li>Anterior & Posterior Radicular Arteries </li></ul></ul></ul>
  27. 30. Spinal Cord Anatomy: Vasculature <ul><li>Thoracic/Lumbar Spine </li></ul><ul><ul><li>Anterior Segmental Arteries Alternate Sides of Cord </li></ul></ul><ul><ul><li>Artery of Adamkiewicz </li></ul></ul><ul><ul><ul><li>Major Blood Supply to Lower Thoracic & Lumbar Spine </li></ul></ul></ul><ul><ul><ul><li>Arises on the Left ~78% </li></ul></ul></ul><ul><ul><ul><li>Enters single intervertebral foramen between T8 & L3 </li></ul></ul></ul>
  28. 31. Initial Class III Study of BP Management in SCI <ul><li>Prospective assessment of 117 Acute Cervical SCI patients at Swiss center, ICU setting with hemodynamic monitoring. </li></ul><ul><li>Dexamethasone (40) x 10 days </li></ul><ul><li>Volume Expansion 500 ml/day x 7 days </li></ul><ul><li>Patients were stratified by injury level, degree of deficit (Frankel grade) </li></ul>Zach GA, Seiler W, Dollfus P: Treatment results of spinal cord injuries in the Swiss Paraplegic Centre of Basel. Paraplegia 14: 58-65, 1976.
  29. 32. Frankel Grade Function     A               complete paralysis     B               sensory function only below the injury level     C               incomplete motor function below injury level     D               fair to good motor function below injury level     E               normal function
  30. 33. Outcome <ul><li>62% of Cervical SCI patients improved </li></ul><ul><ul><li>Including 8 of 18 Frankel Grade A patients </li></ul></ul><ul><ul><ul><li>2 patients improved 2 grades </li></ul></ul></ul><ul><ul><ul><li>1 patient improved 3 grades </li></ul></ul></ul><ul><li>67% improved if they were admitted within 12 hours </li></ul><ul><li>59% improved if they were admitted within 12-48 hours </li></ul><ul><li>50% improved if they were admitted after 48 hours </li></ul>Zach GA, Seiler W, Dollfus P: Treatment results of spinal cord injuries in the Swiss Paraplegic Centre of Basel. Paraplegia 14: 58-65, 1976.
  31. 34. <ul><li>Treated 50 Acute Cervical SCI </li></ul><ul><ul><li>ICU setting </li></ul></ul><ul><ul><li>Hemodynamic monitoring </li></ul></ul><ul><li>Goal: Maintain a hemodynamic profile with adequate cardiac output and MAP ≥ 90mm Hg </li></ul>Class III Study of BP Management in SCI Levi L, Wolf A, Belzberg H: Hemodynamic parameters in patients with acute cervical cord trauma: Description, intervention, and prediction of outcome. Neurosurgery 33:1007-1017, 1993.
  32. 35. <ul><li>8 patients had shock at time of admission (SBP ≤ 90 mm Hg) </li></ul><ul><li>82% had volume-resistant hypotension requiring pressors within the first 7 days of treatment </li></ul><ul><ul><li>Volume-resistant hypotension was 5.5x more common in patients with complete motor injuries. </li></ul></ul><ul><li>40% improved </li></ul><ul><li>42% unchanged </li></ul><ul><li>18% died </li></ul>Levi L, Wolf A, Belzberg H: Hemodynamic parameters in patients with acute cervical cord trauma: Description, intervention, and prediction of outcome. Neurosurgery 33:1007-1017, 1993. Outcomes
  33. 36. <ul><li>Treated 77 Consecutive Acute Cervical/Thoracic SCI </li></ul><ul><ul><li>ICU setting </li></ul></ul><ul><ul><li>Hemodynamic monitoring </li></ul></ul><ul><li>Goal: Maintain a hemodynamic profile with adequate cardiac output and MAP ≥ 85 mm Hg for 7 days after injury. </li></ul>Class III Study of BP Management in SCI Vale FL, Burns J, Jackson AB, Hadley MN: Combined medical and surgical treatment after acute spinal cord injury: Results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 87: 239-246, 1997.
  34. 37. Outcomes <ul><li>They concluded that the enhanced neurological outcome identified in their series after ASCI was optimized by early and aggressive volume resuscitation and blood pressure augmentation and was in addition to and/or distinct from any potential benefit provided by surgery at one year follow-up. </li></ul>Vale FL, Burns J, Jackson AB, Hadley MN: Combined medical and surgical treatment after acute spinal cord injury: Results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 87: 239-246, 1997.
  35. 38. Oxygenation <ul><li>Measured pulmonary function in 16 cervical level complete ASCI patients and compared initial values with those obtained in the same patients at 1, 3, and 5 weeks and 3 and 5 months after injury. </li></ul><ul><ul><li>Patients with FVC less than 25% of expected had a high incidence of respiratory failure requiring ventilator support. </li></ul></ul><ul><ul><ul><li>This was especially true of patients with injuries at C4 or above </li></ul></ul></ul><ul><ul><ul><li>The authors found a significant increase in FVC at 5 weeks post injury and an approximate doubling of FVC at 3 months, irrespective to level of injury. </li></ul></ul></ul><ul><ul><li>Identified hypoxemia (PO2 < 80 mm Hg) in most of the patients (74% of those who did not require ventilator support) despite adequate alveolar ventilation (PCO2 normal despite low FVC). </li></ul></ul>Ledsome JR, Sharp JM: Pulmonary function in acute cervical cord injury. Am Rev Respir Dis 124: 41-44, 1981.
  36. 41. Stomach <ul><li>NG Tube to Suction: </li></ul><ul><ul><li>Prevents vomiting and aspiration </li></ul></ul><ul><ul><li>Decompresses abdomen which can interfere with aspirations if distended </li></ul></ul><ul><ul><ul><li>Paralytic ileus is common and, and usually lasts several days </li></ul></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  37. 42. Bladder <ul><li>Place indwelling urinary catheter: </li></ul><ul><ul><li>I’s & O’s </li></ul></ul><ul><ul><li>Prevent distension from urinary retention </li></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  38. 43. DVT Prophylaxis <ul><li>Overall mortality from DVT is 9% in SCI patients. </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  39. 44. Temperature Regulation <ul><li>Vasomotor paralysis may produce poikilothermy (loss of temperature control) </li></ul><ul><ul><li>This should be treated as needed with cooling blankets </li></ul></ul>
  40. 48. Electrolytes <ul><li>Hypovolemia and hypotension cause increased plasma aldosterone which may lead to hypokalemia </li></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  41. 49. Detailed Neurological Examination <ul><li>Focused history: key questions should center on </li></ul><ul><ul><li>Mechanism of injury (hyperflexion, extension, axial loading…) </li></ul></ul><ul><ul><li>History suggestive of loss of consciousness </li></ul></ul><ul><ul><li>History of weakness in the arms or legs following trauma </li></ul></ul><ul><ul><li>Occurrence of numbness or tingling at any time following the injury </li></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  42. 50. <ul><li>B. Palpation of the spine for point tenderness, a “step off”, or widened interspinous space </li></ul>Detailed Neurological Examination Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713. http://www.itim.nsw.gov.au/go/clinical-resources/spinal-injuries/guidelines-on-spinal-injuries/spinal-log-roll-guide
  43. 51. <ul><li>Motor level assessment </li></ul><ul><ul><li>Skeletal muscle exam (can localize dermatome) </li></ul></ul><ul><ul><li>Rectal exam for voluntary anal sphincter contraction </li></ul></ul>Detailed Neurological Examination Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  44. 52. Motor impairment related to Spinal Cord Injury
  45. 53. <ul><li>Sensory level assessment </li></ul><ul><ul><li>Sensation to pinprick (tests spinothalamic tract, can localize dermatome) </li></ul></ul><ul><ul><ul><li>Also test sensation in face because spinal trigeminal tract can sometimes descent as low as ~C4 </li></ul></ul></ul><ul><ul><li>Light (crude) touch: tests anterior cord (anterior spinothalamic tract) </li></ul></ul><ul><ul><li>Proprioception/joint position sense (tests posterior columns) </li></ul></ul>Detailed Neurological Examination Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  46. 54. Dermatomes
  47. 55. Detailed Neurological Examination <ul><li>E. Evaluation of reflexes </li></ul><ul><ul><li>Muscle stretch reflexes: usually absent initially in cord injury </li></ul></ul><ul><ul><li>Abdominal cutaneous reflexes </li></ul></ul><ul><ul><li>Cremasteric reflex </li></ul></ul><ul><ul><li>Sacral </li></ul></ul><ul><ul><ul><li>Bulbocavernosus </li></ul></ul></ul><ul><ul><ul><li>Anal-cutaneous reflex </li></ul></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  48. 56. Detailed Neurological Examination <ul><li>F. Examine for signs of autonomic dysfunction </li></ul><ul><ul><li>Altered patterns of perspiration (abdominal skin may have low coefficent of friction above lesion, and may seem rough below due to lack of perspiration) </li></ul></ul><ul><ul><li>Bowel or bladder incontinence </li></ul></ul><ul><ul><li>Priapism: persistent penile erection </li></ul></ul>Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  49. 57. Radiographic Assessment of the Cervical Spine in the Asymptomatic Trauma Patient <ul><li>Asymptomatic Patients Include: </li></ul><ul><li>Neurologically Intact </li></ul><ul><ul><li>GCS of 15 </li></ul></ul><ul><ul><li>Oriented to person, place, time </li></ul></ul><ul><ul><li>Able to recall 3 objects at 5 minutes. </li></ul></ul><ul><ul><li>Have no motor or sensory deficit. </li></ul></ul><ul><ul><li>Fail to have a delayed or inappropriate response to external stimuli </li></ul></ul><ul><li>No evidence of Intoxication </li></ul><ul><ul><li>Blood alcohol level of 0.08mg/dl or less </li></ul></ul><ul><li>Do not have a distracting injury </li></ul><ul><ul><li>Long bone fracture </li></ul></ul><ul><ul><li>Visceral injuries requiring surgical consult </li></ul></ul><ul><ul><li>Large lacerations, degloving or crush injuries </li></ul></ul><ul><ul><li>Large burns </li></ul></ul><ul><ul><li>Any other injury which may impair the patient’s inability to participate in a general, physical, mental & neurological examination. </li></ul></ul>Radiographic assessment of the cervical spine in asymptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  50. 58. <ul><li>Largest Class I study addressing this issue encompassed 34,069 patients evaluated at 21 emergency room in the United States. </li></ul><ul><ul><li>All patients were studied with standard three-view cervical radiography supplemented by CT, magnetic resonance imaging, or other studies as needed. </li></ul></ul><ul><ul><ul><li>Of 1818 patients found to have spinal injuries, 576 were considered to be clinically significant. </li></ul></ul></ul><ul><ul><ul><li>2 of the 576 were prospectively assigned to the “asymptomatic” group. </li></ul></ul></ul><ul><ul><ul><ul><li>One patient had a probable C2 injury that was not treated because the patient refused treatment. There was no sequelae on follow-up. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Second patient had a laminar fracture of C6, and subsequently developed paresthesias in the arm and underwent surgery. </li></ul></ul></ul></ul><ul><ul><li>Negative Predictive Value Asymptomatic Exam: 99.9% </li></ul></ul><ul><ul><li>Positive Predictive Value of a “Symptomatic” Exam: 1.9% </li></ul></ul>Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI: Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma: National Emergency X-Radiograph Utilizatio nStudy Group. N Engl J Med 343:94-99, 2000. Radiographic Assessment of the Cervical Spine in the Asymptomatic Trauma Patient
  51. 59. <ul><li>Clinical investigations that provide Class I evidence involving nearly 40,000 patients, plus Class II and III evidence studies involving more than 5000 patients, convincingly demonstrate that asymptomatic patients do not require radiographic assessment of the cervical spine after trauma. </li></ul><ul><ul><li>The combined negative predictive value of cervical spine x-ray assessment of asymptomatic patients for a significant cervical spine injury is virtually 100% </li></ul></ul>Radiographic Assessment of the Cervical Spine in the Asymptomatic Trauma Patient Radiographic assessment of the cervical spine in asymptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  52. 60. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>The reported incidence of cervical spine injuries in the symptomatic patient ranged from 1.9 to 6.2% in Class I evidence studies. </li></ul><ul><ul><li>Therefore, symptomatic patients require radiographic study to rule out the presence of a traumatic cervical spine injury before the cervical spine immobilization is discontinued. </li></ul></ul><ul><ul><li>Significant consequence of premature discontinuation of cervical spine immobilization in neurological injury. </li></ul></ul><ul><ul><ul><li>Prolonged immobilization is associated with: </li></ul></ul></ul><ul><ul><ul><ul><li>Decubitus ulcers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased cerebrospinal fluid pressure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pulmonary Complications </li></ul></ul></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  53. 61. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><ul><ul><li>With adequate visualization of the entire cervical spine (occiput to T1) the negative predictive value of a normal three-view cervical spine series has been reported to range from: </li></ul></ul><ul><ul><ul><li>93-98% in Class I studies </li></ul></ul></ul><ul><ul><ul><li>85-100% in Class II/III studies. </li></ul></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  54. 62. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><ul><li>2. Sensitivity is less impressive </li></ul><ul><ul><ul><li>The same Class I series showed a sensitivity rates for the three-view cervical spine series of 84, 62.5, & 83%. </li></ul></ul></ul><ul><ul><ul><li>The addition of oblique views does not seem to increase the overall sensitivity of the examination </li></ul></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  55. 63. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><ul><li>Best case scenario, assuming the highest values for negative predictive value and sensitivity: </li></ul><ul><ul><li>Approximately 98% of patients with a normal three-view cervical spine x-ray series will have a truly normal cervical spine. </li></ul></ul><ul><ul><li>Normal in 15-17 % of patients with cervical spine injuries. </li></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  56. 64. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Three-view cervical spine </li></ul><ul><li>Assume a 6% incidence of spinal injury in high-risk population </li></ul><ul><ul><li>Identify 5 of 6 spinal injuries in a group of 100 patients. </li></ul></ul><ul><ul><li>Correctly identify 94 of 94 patients without a spinal injury </li></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  57. 65. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Flexion/Extension </li></ul><ul><ul><li>Dynamic flexion/extension views with at least 30-degree excursion in each direction are safe and effective for detecting most “occult” cervical spine injuries not identified on plain x-rays. </li></ul></ul><ul><ul><li>Patients who are unable to cooperate with active flexion/extension radiographs because of pain or muscle spasm may be maintained in a cervical collar until they are able to cooperate, or they may be studied with MRI. </li></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  58. 66. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>MRI </li></ul><ul><ul><li>A negative MRI study within the first 48 hours of injury, in addition to normal radiographs and supplemental CT, seems to be sufficient for clearing the cervical spine. </li></ul></ul><ul><ul><li>The significance of a positive MRI study is currently unclear. It is suggested that cervical immobilization be continued in these patients until delayed flexion/extension views can be obtained. </li></ul></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  59. 67. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>A prospective comparison should be made between the three-view cervical spine series supplemented with selective CT through poorly visualized or suspicious areas and the CT of the entire cervical spine. </li></ul>Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review.
  60. 68. Medical Management Specific to Spinal Cord Injury <ul><li>Treatment with methylprednisolone for 24 or 48 hours after SCI is an option that should be undertaken only with the knowledge that the evidence suggesting harmful side effects is more consistent than any demonstrated clinical benefit. </li></ul><ul><ul><li>It has been asserted that beneficial (sensory and motor) effects at 6 weeks, 6 months, and 1 year are seen (for both complete and incomplete injuries) when methylprednisolone (MP) is administered within 8 hours of injury. </li></ul></ul>Pharmacological Therapy after Acute Cervical Spinal Cord Injury. Neurosurgery. 2002 Mar;50(3 Suppl):S30-5. Review. Greenberg, M. Handbook of Neurosurgery: Sixth Edition . 2006; 698-713.
  61. 69. <ul><li>Exclusion criteria: </li></ul><ul><li>Cauda equina syndrome </li></ul><ul><li>Gunshot wounds </li></ul><ul><li>Life-threatening mortality </li></ul><ul><li>Pregnancy </li></ul><ul><li>Narcotic addition </li></ul><ul><li>Age <13 years </li></ul><ul><li>Patient on maintenance steroids </li></ul>Medical Management Specific to Spinal Cord Injury
  62. 70. Questions?

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