Michael, Daniel

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Michael, Daniel

  1. 1. Spine Trauma: Surgical Management Professor of Neurological Surgery Oakland University William Beaumont School of Medicine Chief of Neurotrauma and Critical Care Beaumont Health System; Royal Oak, MI Director of Michigan Head and Spine Institute, PC Daniel B. Michael M.D., Ph.D. [email_address]
  2. 4. Spinal Cord Injury: Demographics 2-5/100,000 M:F 1-5/1 2nd-3rd decade
  3. 5. Mechanisms of SCI secondary injury <ul><li>Excitatory amino acid receptor binding </li></ul><ul><li>Endogenous opioid receptor binding </li></ul><ul><li>Increased cholinergic activity </li></ul><ul><li>Increased monoamine activity </li></ul><ul><li>Platelet activating factor; ischemia & edema </li></ul><ul><li>Cytokines & inflammation </li></ul><ul><li>Ion flux </li></ul><ul><li>Free radical production </li></ul><ul><li>Genomic alterations </li></ul><ul><li>Gliosis & scar formation </li></ul>
  4. 6. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries Neurosurgery (Supplement) March 2002 50:3 Hadley MN Walters BC Grabb PA Oyesiku NM Przybylski GJ Resnick DK Ryken TC
  5. 7. Methods <ul><li>Medline review – http://www.ncbi.nlm.nih.gov/PubMed/ </li></ul><ul><li>Degrees of certainty </li></ul><ul><ul><li>Standards , Guidelines , Options </li></ul></ul><ul><ul><li>High , Moderate , Low Quality evidence </li></ul></ul><ul><li>Classification of evidence </li></ul><ul><ul><li>Class I : prospective, randomized, controlled trials </li></ul></ul><ul><ul><li>Class II : prospective data collection, retrospective analysis </li></ul></ul><ul><ul><li>Class III : retrospective data analysis </li></ul></ul>
  6. 8. Cervical Spine Immobilization Before Admission to the Hospital Standard : none Guideline : none Option : all potential patients should be immobilized at scene with rigid collar & backboard with straps
  7. 9. Transportation of Patients with Acute Cervical Spine Injuries Standard : none Guideline : none Option : “Expeditious and careful” transport to “nearest capable definitive care medical facility”
  8. 10. Clinical Assessment After Acute Cervical Spine Injuries Standard Neuro & Functional  none Guideline Neuro  none Functional  use Functional Independence Measure (FIM) Option Neuro  American Spinal Injury Association (ASIA) standards Functional  Modified Barthel Index
  9. 11. History & Physical <ul><li>ETOH, drugs, allergies </li></ul><ul><li>Look for associated injuries (20%) </li></ul><ul><li>Use American Spinal Injury Association (ASIA) terms </li></ul><ul><ul><li>Motor grades 0-5 </li></ul></ul><ul><ul><li>Level=lowest myotome with grade 3 (anti-gravity) function </li></ul></ul><ul><ul><li>Impairment Scale A-E (complete-normal) </li></ul></ul>
  10. 12. ASIA Myotomes <ul><li>C5-elbow flexors (biceps) </li></ul><ul><li>C6-wrist extensors </li></ul><ul><li>C7-elbow extensors (triceps) </li></ul><ul><li>C8-finger flexors </li></ul><ul><li>T1-small finger abductors </li></ul><ul><li>L2-hip flexors (iliopsosas) </li></ul><ul><li>L3-knee extensors </li></ul><ul><li>L4-ankle dorsiflexors </li></ul><ul><li>L5-long toe extensors (EHL) </li></ul><ul><li>S1-ankle plantar flexors </li></ul>
  11. 13. Dermatomes
  12. 14. <ul><li>Traumatic Spinal Cord Syndromes </li></ul>
  13. 15. Coincidence of Head and Cervical Spine Injury <ul><li>Coincident injuries occur because of similar mechanisms </li></ul><ul><li>A primary injury (most obvious) is identified </li></ul><ul><li>Incidence of primary HI with CSI is 6% </li></ul><ul><li>Incidence of primary CSI with HI is 24% </li></ul><ul><li>Mortality of coincident HI & CSI is 13.6% </li></ul><ul><li>2.4% of comatose patients harbor CSI </li></ul><ul><li>Patients with coincident injuries have unique rehab needs </li></ul>Michael DB et al. J Neurotrauma 1989;6(3):177-189
  14. 16. Radiographic Assessment of the Cervical Spine in Asymptomatic Trauma Patients <ul><li>Standard : studies not required in awake, alert, patients without neck pain if not intoxicated or distracted by associated injuries </li></ul>
  15. 17. Radiographic Assessment of the Cervical Spine in Symptomatic Trauma Patients <ul><li>Standard </li></ul><ul><ul><li>AP, Lateral, odontoid x-rays </li></ul></ul><ul><ul><li>supplement w/ CT as needed </li></ul></ul><ul><li>Guideline </li></ul><ul><ul><li>none </li></ul></ul><ul><li>Option </li></ul><ul><ul><li>d/c collar in awake pts w/ pain after flex-ex or MRI </li></ul></ul><ul><ul><li>d/c collar in obtunded pts after flouro flex-ex, MRI </li></ul></ul><ul><ul><li>“ discretion of treating physician” </li></ul></ul>
  16. 18. Initial closed reduction of Cervical Spine Fracture-Dislocation Injuries <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>-Use early closed reduction in awake patients </li></ul><ul><li>-Avoid in patients with associated rostral injuries </li></ul><ul><li>-MRI 1st if patient cannot be examined during reduction (rupt disc relative indication for ventral decompression) </li></ul><ul><li>-MRI if reduction failed </li></ul><ul><li>-½ to 1/3 patients with fx dislocation have disc rupture; pre reduction MRI usefulness in awake patients unclear </li></ul>
  17. 19. Management of Acute Spinal Cord Injuries in an Intensive Care Unit or Other Monitored Setting Standard : none Guideline : none Option : Management in ICU with cardiac, hemodynamic & respiratory monitoring
  18. 20. Blood Pressure Management after Acute Spinal Cord Injuries Standard : none Guideline : none Option : avoid SBP<90mm Hg; maintain MAP 85- 90 mm Hg for 1st 7 days post injury
  19. 21. Pharmacological Therapy after Acute Spinal Cord Injuries Standard : none Guideline : none Option : 24 or 48 hour methylprednisolone protocol per NASCIS II & III or GM-1 ganglioside treatment “ ...most controversial of the Guidelines.”- M.L.J. Apuzzo
  20. 22. NASCIS 3 <ul><li>All pts received methylprednisolone bolus:20mg/kg </li></ul><ul><li>Randomized to 24 or 48 hour methylprednisolone drip: 5.4mg/kg/hour or q6 hour tirilazad bolus for 48 hours </li></ul><ul><li>Outcome at 6 months: neuro grade, FIM, complications </li></ul><ul><li>Conclusion: pts starting Rx 0-3 hours post injury should receive 24 hour infusion of methylprednisolone; 3-8 hours: 48 hour infusion </li></ul>Bracken et al. JAMA 1997; 277:1597-1604
  21. 23. Deep Venous Thrombosis and Thromboembolism in Patients with Cervical Spinal Cord Injuries Standard : use prophylaxis with LMW heparin, roto beds, adjusted dose heparin, or low dose heparin with compression stockings Guideline : low dose heparin alone or oral anticoagulation not recommended Option : monitor with Doppler u/s, impedance plesmethography or venogram, Prophylax for 3 months post injury, consider cava filters in non responders or non anticoagulation candidates
  22. 24. Nutritional Support after Spinal Cord Injury Standard : none Guideline : none Option : provide support based on indirect calorimetry
  23. 25. Management of Pediatric Cervical Spine and Spinal Cord Injuries Diagnostic Standard : none Guideline -If child conversant, use adult radiographic criteria -If not, obtain AP & Lateral x-rays Option - <9y obtain x-rays - >9y use adult criteria - Supplement with CT, flex-ex, or MRI
  24. 26. Management of Pediatric Cervical Spine and Spinal Cord Injuries Standard : none Guideline : none Option : -Account for head-spine size difference in children < 8y when immobilizing -Closed reduction and halo immobilization for C2 injuries < 7y -Consider surgery for ligamentous injuries Treatment
  25. 27. Spinal Cord Injury without Radiographic Abnormality SCIWORA <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>Diagnosis may be aided by entire spine x-rays, CT, &/or MRI; angiography & myelography not recommended </li></ul><ul><li>Consider external mobilization (12 wks) and avoidance of high risk activities (6 mo) </li></ul><ul><li>MRI may provide prognostic info </li></ul>
  26. 28. Diagnosis and Management of Traumatic Atlanto-occipital Dislocation Injuries <ul><li>Standard : none </li></ul><ul><li>Guideline :none </li></ul><ul><li>Option : </li></ul><ul><li>Diagnosis: use lateral x-ray supplemented (upper STS) by CT &/or MRI </li></ul><ul><li>Traction risks neuro deterioration (10%) </li></ul><ul><li>Surgical fixation and arthrodesis recommended </li></ul>
  27. 29. Occipital Condyle Fractures Standard : none Guideline : CT for dx Option : Diagnosis may be aided by &/or MRI external mobilization
  28. 30. Isolated Fracture of the Atlas in Adults <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>If transverse ligament intact (Spence excursion < 6.9 mm) immobilize </li></ul><ul><li>If transverse ligament ruptured consider surgery </li></ul>Jefferson Fracture
  29. 31. Isolated Fracture of the Axis in Adults Standard : none Guideline : consider surgery in Type II, >50 y Option : Initial treatment of Type I, II, III with external immobilization; Consider surgery if >5mm displacement, comminution or inability to stabilize in external device Odontoid
  30. 32. Odontoid Fracture Due to GSW
  31. 33. Traumatic spondylolisthesis of the axis (Hangman’s Fracture) Standard : none Guideline : none Option : Initial treatment with external immobilization in most cases; Consider surgery if severe angulation, c2-3 disc disruption or inability to stabilize in external device Isolated Fracture of the Axis in Adults
  32. 34. Isolated Fracture of the Axis in Adults Standard : none Guideline : none Option : external immobilization Miscellaneous Fractures of the Axis Body
  33. 35. Management of Combination Fractures of the Atlas and Axis in Adults <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>External immobilization for most </li></ul><ul><li>Consider surgery if odontoid >5mm displacement, or C2 angulation >11 degrees </li></ul>
  34. 36. Os Odontoideum <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>Image with x-ray, flex-ex, CT &/or MRI </li></ul><ul><li>Asymptomatic: surveillance </li></ul><ul><li>C1-C2 unstable or neuro symptoms: C1-C2 surgery </li></ul><ul><li>Use post op halo unless transarticular screws placed </li></ul><ul><li>Occipital cervical fusion if cervico-medullary compression </li></ul><ul><li>Consider transoral decompression </li></ul>
  35. 37. Treatment of Subaxial Cervical Spine Injuries Subaxial cervical facet dislocation injuries <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>Closed or open reduction </li></ul><ul><li>External immobilization, internal anterior or posterior fixation and fusion </li></ul><ul><li>Prolonged bed rest in traction </li></ul>
  36. 38. Cervical Spine Stability White & Punjabi
  37. 39. Cervical Spine Stability White & Punjabi
  38. 40. Unilateral Facet Fracture
  39. 41. Cervical Flexion-Distraction Injuries
  40. 42. Cervical Flexion-Distraction Injuries
  41. 43. Treatment of Subaxial Cervical Spine Injuries Sub axial cervical injuries excluding facet dislocation injuries <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><li>Closed or open reduction </li></ul><ul><li>External immobilization, internal anterior or posterior fixation and fusion </li></ul>
  42. 44. Cervical Axial Loading Injuries
  43. 45. Management of Acute Central Cervical Spinal Cord Injuries <ul><li>Standard : none </li></ul><ul><li>Guideline : none </li></ul><ul><li>Option : </li></ul><ul><ul><li>ICU care </li></ul></ul><ul><ul><li>Maintain MAP 85-90 mm Hg for 1st 7d post injury </li></ul></ul><ul><ul><li>Early reduction of fracture dislocation injuries </li></ul></ul><ul><ul><li>Surgical decompression for focal or anterior lesions </li></ul></ul>
  44. 46. Management of Vertebral Artery Injury after Non-penetrating Cervical Trauma Standard : none Guideline : none Option : -Angiography or MRI in complete cord injuries, fx thru f. transversarium, facet dislocation or vertebral sublux -IV anticoagulation if evidence of posterior circulation stroke -Observe or anticoagulate if evidence of ischemia -Observe if no evidence of stroke or ischemia
  45. 47. Thoracic Spine Stability White & Punjabi
  46. 48. A 40 y/o unlimited hydroplane driver injured at the 2003 Detroit Gold Cup race. Injuries: concussion, thoracic compression fxs and left ankle fx.
  47. 49. T2-3 Fracture, Complete paraplegia
  48. 50. T2-3 Fracture, Complete paraplegia
  49. 51. Unstable T4-5 complete - MVA
  50. 52. Motorcycle Accident T3-4 100% Sublux (complete)
  51. 53. T3-4 100% Sublux (complete) Nine days post injury
  52. 54. Snowmobile Injury
  53. 55. L2-3 complete-assault rifle injury (AK-47) 2000
  54. 56. L2-3 complete-assault rifle injury (AK-47) 2003
  55. 57. Sacral Injuries
  56. 58. Prevention: ThinkFirst

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