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Assessment Of Spinal Cord Injury

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Assessment Of Spinal Cord Injury by Dr Zaheer ahmed Nishtar Hospital Multan and compiled by Dr Taha Bashir

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Assessment Of Spinal Cord Injury

  1. 1. U I N N D L S Y S W I T H F F O C Y O R M O B I L E K P H O E
  2. 2. U I N NDL SY S WIT HFF O C YO R MOBILE K P H O E
  3. 3. Welcome
  4. 4. Assessment of Spinal Cord Injury Incidence Pathophysiology and Mechanics Classification Assessment Cases The ASIA/ISCoS Exam Management Complications
  5. 5. Assessment of Spinal Cord InjuryIncidence
  6. 6. Assessment of Spinal Cord Injury • Approximately 55% of spinal injuries occur in the cervical region • 15% in the thoracic region • 15% at the thoracolumbar junction • and 15% in the lumbosacral area. Approximately 10% of patients with a cervical spine fracture have a second, noncontiguous vertebral column fracture. ( Advanced Trauma Life Support.ATLS.9th.Edition) Incidence
  7. 7. Assessment of Spinal Cord InjuryIncidence • Approximately one-third of patients with upper cervical spine injuries die at the injury scene from apnea caused by loss of central innervation of the phrenic nerves caused by spinal cord injury at C1. • When a fracture-dislocation in the thoracic spine does occur, it almost always results in a complete spinal cord injury because of the relatively narrow thoracic canal. ( Advanced Trauma Life Support.ATLS.9th.Edition)
  8. 8. Assessment of Spinal Cord Injury Pathophysiology and Mechanics
  9. 9. Assessment of Spinal Cord InjuryPathophysiology and Mechanics The Secondary Injury Hemorrhage, oedema, ischemia results in biochemical cascade that causes the secondary injury, accentuated by hypotension, hypoxia, spinal instability and persistent compression of the neural elements. The Primary Injury This is the direct insult to the neural elements and occurs at the time of initial injury. (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  10. 10. Assessment of Spinal Cord InjuryPathophysiology and Mechanics Trauma causes a wide variety of injury patterns in the spine. • Flexion/extension: Flexion loads the spine anteriorly (the vertebral bodies) and distracts the spine posteriorly (the spinous process and interspinous ligaments). • Compression/Distraction: Force applied along the spinal axis (axial loading) compresses the spine. • Rotation:Force applied tangential to the spinal axis rotates the spine. (Schwartzs Principles of Surgery, 10th Ed)
  11. 11. Assessment of Spinal Cord Injury Classification
  12. 12. • It can be classified According to 1.Level 2.Severity of Neurologic Deficit 3.Spinal cord Syndromes 4.Morphology Assessment of Spinal Cord InjuryClassification ( Advanced Trauma Life Support.ATLS.9th.Edition)
  13. 13. Assessment of Spinal Cord Injury Assessment
  14. 14. Assessment of Spinal Cord Injury Assessment Patient Assessment Relevant history Physical Examination
  15. 15. Assessment of Spinal Cord InjuryAssessment Patient Assessment • The spine should initially be immobilized on the assumption that every trauma patient has a spinal injury until proven otherwise. • In unconcious patient, definitive clearance of the spine may not be possible in the initial stages and spinal immobliziation should be maintained, until MRI or equivalent can be used to rule out unstable spinal injury. (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  16. 16. Assessment of Spinal Cord InjuryAssessment Patient Assessment • Patients who have no findings on examination, demonstrate no decreased level of consciousness, and have no distracting injuries can undergo clearance of the spine by clinical means alone. • Although plain radiographs of the spine are acceptable, the high-quality images and rapid availability associated with CT have made this the modality of choice in most emergency departments. (Sabiston Textbook of Surgery)
  17. 17. Assessment of Spinal Cord InjuryAssessment • The mechanism and velocity of injury • Presence of spinal pain • Onset of neurological sypmtoms • Duration of neurological sypmtoms Relevant history (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  18. 18. Assessment of Spinal Cord InjuryAssessment Physical Examination • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock • Spinal Examination: • The entire spine must be palpated and the overlying skin is inspected and formal log roll should be performed to achieve this. (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  19. 19. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord InjuryAssessment • Neurogenic shock results from impairment of the descending sympathetic pathways in the cervical or upper thoracic spinal cord. This condition results in the loss of vasomotor tone and in sympathetic innervation to the heart. Neurogenic shock Loss of sympathetic Loss of vasomotor tone innervation of heart Vasodilation of blood vessels Hypotension Bradycardia or normal heart rate Beacause of cervical cord injury above the level of sympathetic outflow(C7/T1) .….. Warm peripheries …. Physical Examination ( Advanced Trauma Life Support.ATLS.9th.Edition)
  20. 20. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord InjuryAssessment Physical Examination • The classic presentation of neurogenic shock is hypotension in the setting of warm, well-perfused extremities in the paralyzed patient. (Sabiston Textbook of Surgery)
  21. 21. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord InjuryAssessment Physical Examination • Spinal shock. There is initial loss of all neurological function below the level of the injury Paralysis Hypotonia Areflexia Usually lasts 24 hours following spinal cord injury. Once it has resolved the bulbocavernosus reflex returns. (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  22. 22. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord InjuryAssessment Physical Examination (Bailey and Love’s Short Practice Of Surgery 26th Edition) Spinal Examination: The entire spine must be palpated and the overlying skin is inspected and formal log roll should be performed to achieve this.
  23. 23. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord Injury Assessment (Bailey and Love’s Short Practice Of Surgery 26th Edition)
  24. 24. • Initial Assessment The primary survey followed by carefull systems examination. • Identification of shock Three categories of shock may occur in spinal trauma: 1. Hypovolaemic shock 2. Neurogenic shock 3. Spinal shock Assessment of Spinal Cord InjuryAssessment Patient Assessment Relevant History Physical Examination
  25. 25. Assessment of Spinal Cord Injury Cases ( Advanced Trauma Life Support.ATLS.9th.Edition)
  26. 26. Assessment of Spinal Cord InjuryCases The presence of paraplegia or quadriplegia is is presumptive evidence of spinal instability.
  27. 27. Assessment of Spinal Cord InjuryCases 1 Patients who are awake, alert, sober, and neurologically normal, and have no neck pain or midline tenderness, or a distracting injury • Remove the c-collar and palpate the spine. If there is no significant tenderness, ask the patient to voluntarily move his or her neck from side to side then flex and extend • If no pain, c-spine films are not necessary.
  28. 28. Assessment of Spinal Cord InjuryCases 1 2 • Patients who are awake and alert, neurologically normal, cooperative, and do not have a distracting injury and are able to concentrate on their spine, but do have neck pain or midline tenderness • Where available, all such patients should undergo multi-detector axial CT from the occiput to T1 with sagittal and coronal reconstructions. • Lateral, AP, and openmouth odontoid x-ray examinations of the c-spine • If these films are normal, remove the c-collar. • if any of these films are suspicious, obtain consultation from a spine specialist.
  29. 29. Assessment of Spinal Cord InjuryCases 1 2 3 • Patients who have an altered level of consciousness or are too young to describe their symptoms • Where available, all such patients should undergo multi-detector axial CT from the occiput to T1 with sagittal and coronal reconstructions. • Where not available, all such patients should undergo lateral, AP, and open-mouth odontoid films with CT supplementation through suspicious areas. • If the entire c-spine can be visualized and is found to be normal, the collar can be removed after appropriate evaluation
  30. 30. Assessment of Spinal Cord InjuryCases 123 4 When in doubt leave the collar on. • Backboards: Patients who have neurologic deficits (e.g., quadriplegia or paraplegia) should be evaluated quickly and removed from the backboard as soon as possible. A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for pressure ulcers.
  31. 31. Assessment of Spinal Cord Injury Cases 1 2 3 4 5
  32. 32. Assessment of Spinal Cord Injury Neurological Examination • The American Spinal Injury Association (ASIA) neurological evaluation system is an internationally accepted method of neurological evaluation. • This is a system of tests used to define and describe: • Extent • Severity • Future Rehabilitation • Recovery needs
  33. 33. Assessment of Spinal Cord Injury The ASIA/ISCoS Exam
  34. 34. Assessment of Spinal Cord InjuryThe ASIA/ISCoS Exam Steps in Classification 1. Determine sensory levels for right and left sides. 2. Determine motor levels for right and left sides. 3. Determine the neurological level of injury (NLI) 4. Determine whether the injury is Complete or Incomplete. 5. Determine ASIA Impairment Scale (AIS) Grade:
  35. 35. The ASIA/ISCoS Exam Assessment of Spinal Cord Injury
  36. 36. The ASIA/ISCoS Exam Assessment of Spinal Cord Injury Level of neurological impairment The ASIA neurological impairment scale is based on the Frankel classification of spinal cord injury: • A, complete; • B, sensation present motor absent; • C, sensation present, motor present but not useful (MRC grade <3/5); • D, sensation present, motor useful (MRC grade 3/5); • E, normal function
  37. 37. Assessment of Spinal Cord Injury Management ( Advanced Trauma Life Support.ATLS.9th.Edition)
  38. 38. Assessment of Spinal Cord InjuryManagement Primary Survey and Resuscitation—Assessing Spine Injuries
  39. 39. Assessment of Spinal Cord Injury Management Secondary Survey--Neurologic Assessment
  40. 40. Assessment of Spinal Cord InjuryManagement Treatment Principles for Patients with Spinal Cord Injuries
  41. 41. Assessment of Spinal Cord Injury Complications
  42. 42. Assessment of Spinal Cord Injury Complications • Pain and spasticity • Autonomic dysreflexia • Neurological deterioration • Thromboembolic events • Osteoporosis, heterotopic ossification • Contractures
  43. 43. Assessment of Spinal Cord Injury
  44. 44. Thankyou
  45. 45. Thankyou

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