CME ONSpinal InjuryAnd It’s Management Prepared by - Dr. Md Nazrul Islam, MBBS, M.sc. Supervised by - Dr. Sk. Abbas Uddin Ahmed MS (Ortho), AO(Basic), AO(Spine). Presenting by - Dr. Abdul Hannan From - Department Of Orthopaedic & Traumatology, Shaheed Suhrawardy Medical College Hospital. Dhaka. 1
Spinal Injury & its Management Over view Functions of spine Definition of spinal injury Anatomy of human spine Classification of spinal injury Epidemiology Pathophysiology of spinal injury Clinical features of spinal injury Investigations Diagnosis Management Prognosis Rehabilitations Conclusions
Spinal Injury & its Management The spine has many functions, the main ones are listed below- 1.To provide protection of the spinal cord and associated nerves 2.To allow for movement 3.To support our body frame in an upright position 4. To allow for flexibility 5. To provide a structural foundation for the shoulder girdle and the pelvic girdles 6. To act as shock absorbers from load- bearing 7. To provide a structural base for rib attachments which protect the heart and lungs.
Spinal Injury & its Management Spinal Injuries Definition Of Spinal Injury: “ Spinal injury” may be defined as- Injury to the Spinal column (Bony Column)/Spinal Cord, or both of them. Spinal injury can be divided into- Spinal Column(Bony)Injury. Spinal Cord injury. Combined (Both Column & Cord) Injury.
Spinal Injury & its Management Bony spinal injuries may or may not Spinal Column be associated with spinal cord injury Injury These bony injuries include: Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae Other injuries may include: Sprains- over-stretching or tearing of ligaments Strains- over-stretching or tearing of the muscles.
Spinal Injury & its Management Spinal Cord Injury Cutting, compression, or stretching of the spinal cord Causing loss of distal function, sensation, or motion Caused by: Unstable or sharp bony fragments pushing on the cord, or Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia.
Spinal Injury & its Management Epidemiology 50% of SCI’s are complete 50-60% of SCI’s are cervical Immediate mortality for complete cervical SCI ~ 50% Risk factors: Occurs primarily in young males (> 75%Alcohol intoxication of cases)Drug abuse Half of these injuries result from MVAsParticipation in high- risk activities: 2/3 of patients are < 30 years old Diving Other sources of SCI: Falls, sporting Contact sports and industrial accidents, gunshot wounds.Osteoporosis Most common vertebrae involved are C5, C6, C7, T12, and L1 because they have the greatest ROM. 9
Spinal Injury & its ManagementEpidemiology Incidence 10 - 15 per million 18 - 35 years Male - 3:1 RTA 51% - cars Domestic 16% Industrial 11% Sports 16% - diving incidents Self harm 5%
Spinal Injury & its Management Incomplete injury: Some motor or sensory functions is spared distal to the cord injury. Voluntary sphincter contraction, toe flexor contraction –present. Prognosis-Good’ Complete injury: Total motor & sensory loss distal to the injury after Spinal shock (usually lasts for 24-48 hrs) is over. When the bulbo cavernosus reflex is positive & no sacral sensation or motor function has returned, paralysis will be permanent & complete in most patients. 11
PATTERNS OF MULTIPLE SPINALINJURY :Pattern: A. Primary lesion occur between C5 & C7 with secondary injuries at T12 or the lumber spine.Pattern : B. Primary injury at T2-T4 with secondary injury in cervical spine.Pattern : C.. Primary injury occur between T12 & L2 with secondary injuries from L4-L5.
CLINICAL INSTABILITYAcute: Caused by bone or ligament disruption that places the normal elements in danger of injury with any subsequent loading deformity.Chronic: Result of progressive deformity that may cause neurological deterioration.
Spinal Injury & its Management Predisposing factors Degenerative Disease Of Spine Spinal Canal Stenosis Ankylosing Spondylitis Downs Syndrome Klippel-feil Syndrome Arnold-chiari Malformation Metastatic CA Osteomyelitis Rheumatoid Arthritis. 14
Spinal Injury & its Management Spine consists of alternating Bony vertebrae Fibrocartilaginous disc Supported by musculature. Motion segment – Two adjacent vertebrae with intervening disc.
Spinal Injury & its Management Anatomy of the spine is usually described by dividing up the spine (Bony vertebrae) into 3 major bony sections: The cervical, The thoracic, and The lumbar spine in which the spinal cord is embedded. (Below the lumbar spine is a bone called the sacrum, which is part of the pelvis). Each section is made up of individual bones called vertebrae. There are 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae.
Spinal Injury & its Management Stability of Spine- • Anterior column = anterior 2/3 of the vertebral body, disc, and annulus, and the anterior longitudinal ligament) • Middle column = posterior 1/3 of the vertebral body, disc, annulus, and the posterior longitudinal ligament • Posterior column = pedicles, laminae, facets, capsule, and the interspinous and supraspinous ligament. injury is said to be stable if only one of the columns is involved. damage to two or more columns or risking neurological injury (ie damage to the middle column) - unstable. 5
Spinal Injury & its ManagementMost likely to occur at sites of Primary mechanism of cord injury canmaximum mobility•Adults C6 be due to four kinds of mechanical•Children <8 yrs old C2. forces. a. Impact with persisting compression e. g. fractures, dislocations, and disc herniations. b. Impact with no persisting compression e. g. hyperextersion injuries. c. Distraction e. g. hyperflexion injuries. d. Laceration/ Transection: Penetrating injuries, fracture dislocation. 8
Spinal Injury & its Management Pathophysiology of spinal cord injury: Secondary injury mechanisms that may be involved are: a. Systemic shock: Profound hypotension, and bradycardia (often lasting for days) follows cord injury and there may be a compromise of an already damaged cord. b. Local microcirculatory damage: may be due to mechanical disruption of capillaries, hemorrhage, thrombosis and loss of autoregulation. c. Biochemical damage: may occur due to excitotoxin release (glutamate), free radical production, arachidonic acid release, lipid peroxidation, eicosanoid production, cytokines and electrolyte shifts.
Spinal Injury & its Management Primary injury 25% of spinal cord injuries occur after primary injury. Primary injury results from focal injuries (eg avulsion, contusion, laceration and intra- parenchymal hemorrhage) and diffuse lesions (e.g. concussive and diffuse axonal injury). Further mechanical disruption can result from external compression or angulation and ischemic damage from occlusion of arterial supply.
Spinal Injury & its Management Secondary injury Results from: •Cellular hypoxia Immediately after an acute spinal cord •Oligaemia injury major reduction in blood flow occurs at the level of the lesion. Becomes progressively worse over the first few hours if left untreated. Pathophysiology underlying this ischaemia is unclear but involves both systemic and local effects. Putative local mechanisms include vasospasm, endothelial swelling or damage, haemorrhage causing obstruction of small blood vessels, loss of autoregulation and impaired venous drainage. 21
Spinal Injury & its Management Secondary injury- Secondary Injury Cascade Current understanding 22
Spinal Injury & its Management Primary Neurological damage Direct trauma, haematoma & SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis Secondary damage Hypoxia Hypoperfusion Neurogenic shock Spinal shock
Spinal Injury & its Management Factors affecting the severity of a spinal lesion- Loss of neural tissue - obvious Vertical level – Higher up, the greater the damage Transverse plane – What Diameter has a lesion
Spinal Injury & its Management Common features of spinal injuries are- Pain Breathing difficulty Sensitivity to stimuli Muscle spasms Loss of sensation Loss of reflex function Loss of autonomic activity Loss of bowel control Loss of bladder control Sexual dysfunction Loss of function, such as mobility or sensation Paralysis
Spinal Injury & its Management “Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function. Motor level = the last level with at least 3/5 (against gravity) function NB: this is the most important for clinical purposes Sensory level = the last level with preserved sensation Radiographic level = the level of fracture on plain XRays / CT scan / MRI NB: spine level does not correspond to spinal cord level below the cervical region.
Spinal Injury & its Management Spinal shock may mimic a complete cord lesion with total loss of motor and sensory function distal to injury. However if lesion is incomplete some function will return 99% of patients with a complete lesion over 24 h will not show functional recovery Patients with partial lesion may regain substantial or even normal neurological function even though the initial neurological deficit may be severe Presence of bulbocavernous reflex or anal- cutaneous reflex indicates sacral sparing and a more favorable prognosis.
Spinal Injury & its Management A. Clinical laboratory tests. Laboratory tests will be guided by clinical assessment of patient (history and physical examination). In addition to routine investigations diagnostic imaging is very important. B. Diagnostic imaging. 1. X-RAY 2. CT SCAN 3. MRI
Spinal Injury & its Management Indications for screening radiology. History of trauma and: Not fully conscious Drowsy or intoxicated Focal neurological deficit Midline cervical tenderness Other painful injury that may mask neck pain, particularly fractures Screening radiology of choice is CT of spine. Additional indications are- oExtremes of age oMechanism of injury highly suggestive of cervical spine injury oSignificant facial trauma Sensitivity approximately 98% and considerably higher than plain radiography. May miss soft tissue injury and spinal cord injury in the absence of bony injury.
Spinal Injury & its Management Although CT may miss soft tissue and spinal cord injury, MRI is a sensitive alternative method. Almost never an emergency Exception: cauda equina syndrome Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan. Risk of transfer to MRI ability of MRI to detect soft tissue injury may fall after 72 hour. 25
Spinal Injury & its Management SCIWORA (spinal cord injury without radiologic abnormality) The term SCIWORA (spinal cord injury without radiologic abnormality) originally referred to Incidence 3-5% (x-ray/CT) spinal cord injury without radiographic or CT Higher incidence in paediatric evidence of fracture or dislocation. population (34.8%)- However with the advent of MRI, the term has The relatively large size of the become ambiguous. Findings on MRI such as head. inherent skeletal mobility. intervertebral disk rupture, spinal epidural cord vulnerable to damage. hematoma, cord contusion, and hematomyelia Higher incidence above 60 yo- have all been recognized as causing primary orPosterior vertebral spurs due tospondylosis. Ligamentum flavum secondary spinal cord injury.bulging due to loss of disc height. SCIWORA should now be more correctlyRisk of central cord syndrome after renamed as "spinal cord injury without neuro-hyperextension injury. imaging abnormality" and recognize that its prognosis is actually better than patients with spinal cord injury and radiologic evidence of traumatic injury. 25
History-1. Mechanism of injury2. Misdiagnosis - head injury, acutealcoholic intoxication and multipleinjuries.3.Decreased level of consciousnessor comatose patients may notcomplain of neck pain.4. Profuse bleeding from face andscalp may divert attention fromcervical spine injury 20
General examination:a) Head and earb) Spinous process and interspinousligaments palpationc) Elbows may be flexed if a spinal cordinjury causes loss of function below bicepsand may be extended if the paralysis ishigher.d) Penile erection and incontinence of thebowel and bladder- significant spinalinjury.e) Flaccid paralysis of the extremities –Quadriplegiaf) Chest abdomen and extremities – Otherinjuries. 21
Accurate and detailed neurologicalevaluation – very important Level of consciousness- Pupillary size andreaction, epidural or subdural haematoma,depressed skull fracture. Evaluation of sensory (pinprick), motor andreflex function. Important dermatome landmarks are-• Nipple line –T4• Xiphoid process-T7• Umbilicus –T10• Inguinal region –T12,L1• Perineum and peri-anal region (S2,S3&S4) 22
Primary(Pre-hospital)management-Initial treatment of patients with cord injuryfocuses on two aspects - preventing furtherdamage and resuscitation. Immobilization with a hard cervical collar (in case ofcervical spine injuries) and care in transportation ofpatient is of paramount importance if the spine isunstable.Resuscitation is aimed at airwaymaintenance, adequate oxygen saturation ofperipheral blood, restoring blood pressureto acceptable limits, preventingbradycardia, done simultaneously to preventany ischemic damage to the alreadycompromised cord. 36
Spinal Injury & its Management Secondary (Hospital) Management: Medical Management Conservative (General)- Conservative (Medical)- Surgical Management Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation
Spinal Injury & its Management Conservative(General)- Immediate Management- Goals: Resuscitation according to ATLS guidelines . Determination of neurological injury Prevention of neurological deterioration Ongoing ID & Tx of assoc injuries Prevention of complications Initiation of definitive management for vertebral column injury or SCI 32
Spinal Injury & its Management Conservative(General)- Aim is to prevent extension of primary injury, to reduce secondary injury and to treat complications- Follow ATLS principles- A irway; protect Spine B reathing C irculation D isability, Dx and Rx shock E xpose patient And Treat Secondary survey. 32
Spinal Injury & its Management Conservative(Medical)- Conservative treatments of spinal disorders have improved significantly over the years. Of the many conservative non-surgical treatments that are currently available, a few of the most commonly practiced treatments are - •Epidural Steroid Injection •Intradiscal thermoplasty (IDET) •Nucleoplasty •Facet Injections, and/or Medial Branch Blockade •Radio Frequency Rhizotomy or Denervation. 40
Spinal Injury & its Management Surgical - Depending on the circumstances, when surgery is required. Surgery may be considered if the spinal cord is compressed and when the spine requires stabilization. The surgeon decides the procedure that will provide the greatest benefit for the patient. The common procedures which we perform are- Surgical Decompression Surgical Stabilization o Spinal fusion o Fixation of Vertebra o Fixation of Spine Discectomy, foramenotomy and laminectomy(Some times needed). Artificial disc implantation. 41
Surgical Decompression and/ or Fusion- Indications o Decompression of the neural elements (spinal cord/nerves) o Stabilization of the bony elements (spine) Timing o Emergent Incomplete lesions with progressive neurologic deficit o Elective Complete lesions (3-7 days post injury) Central cord syndrome (2-3 weeks post injury).
Spinal Injury & its Management There are many complications of spinal Injury, the followings are most common- Skin Breakdown Osteoporosis and Fractures: Pneumonia, Atelectasis, Aspiration: Heterotopic Ossification: Spasticity: Autonomic dysreflexia: Deep vein thrombosis: Cardiovascular disease: Syringomyelia- Neuropathic/Spinal Cord Pain- Respiratory Dysfunction- Miscellaneous pressure sores, Greatly increase cost and morbidity Pokilothermia in patients with lesion above T1 hyponatraemia common in first week.
Spinal Injury & its Management Rehabilitation after spinal injury (SI) focuses on the patient learning how to live life when faced with physical, occupational, and emotional challenges. After SI, everything can change, and you can face many issues including mobility, regular exercise and maintaining a level of fitness, communication challenges, and activities of daily living. Rehabilitation may be accomplished at a hospital, outpatient clinic, home, or a combination.
Spinal Injury & its Management Accredited rehabilitation centers provide SCI patients with a team of professionals and many resources. Some of the professionals include: oOccupational Therapist oPhysiatrist. oPhysical Therapist: oRehabilitation Nurse. oSpeech and Language Pathologist. oTherapeutic Recreational Specialist. oVocational Rehabilitation Therapist. oRehab Psychologist 36
Spinal Injury & its Management Prognosis The main determinant of outcome is the patients neurological grade at the time of admission with patients having complete motor and sensory myelopathy showing the worst prognosis. Other predictive factors include rectal tone status, admission blood pressure and pulse status, reflexes, and medical and surgical management since injury. The time course of recovery is also prolonged and recovery itself often incomplete. Taking all grades and locations into considerations a study concluded that while the majority of cases improved within a year, even at 3 years post injury 23.3% continue to improve whereas 7.1% deteriorated. The trend continued in the 5th year post injury also with 12.5% and 5.5% respectively showing further improvement and late deterioration. Hence prolonged rehabilitation at a comprehensive spinal rehabilitation center is the management of spinal cord injuries. 50
Spinal Injury & its Management “Neurological disorders are the most complicated problems known to medical science today, and we require the best scientific minds and technology in order to find cures.” W. Dalton Dietrich, Ph.D., scientific director, The Miami Project to Cure Paralysis 40
Spinal Injury & its Management Pre-hospital & hospital both phases are equally important for SI management. Surgical intervention improves recovery period, quality of life and Rehab, reduces morbidity/ mortality . SI is neglected and poorly managed. Research is sparse and data is missing. The demographics, epidemiological pattern of SC in the developing world is different from the developed world and this should be considered while formulating polices for the SI in future. Trauma evacuation protocols need to be developed and pre hospital care of suspected SI patient should be improved. Regional and national spinal injury centers providing comprehensive treatment and multidisciplinary rehabilitation should be established.
Spinal Injury & its Management From- Department Of Orthopedics’ & Traumatology Shaheed Suhrawardy Medical College Hospital.
Spinal Injury & its Management Associate Prof. Dr. P. C. Debenath Associate Prof. Dr. Sheikh Abbas Uddin. Associate Prof. Dr. Ziaul Haq Associate Prof. Dr. Shamimul Haq Associate Prof. Dr. Monowarul Islam Associate Surgeon Dr. Md. Aminur Rahman Assistant Prof. Dr. Kazi Shamimuzzaman Assistant Prof. Dr. A T M Bahar Uddin Dr. Abdul Hannan And Dr. Md Nazrul Islam Resident Surgeon, Department of Orthopedic & Traumatology. Shaheed Suhrawardy Medical College Hospital. 3/26/2011 54