resuscitation of spinal cord injury

1. DR. DAVIS KURIAN

2. Normal spine – 3 columns
Anterior – ant 2/3 of vertebral body,
anterior longitudinal ligament.
Middle – post 1/3 of the body, post
longitudinal ligament, post component of
annulus fibrosis
Posterior – laminae, facets, spinous
process and interspinous ligament.
Two or more columns disturbed – spinal
injury results

3. Careful assessment required.
Failure to immobilise, investgiate and
manage – leads to worsening of the
existing cord injury or creating a new one.

4. Blunt trauma accounts for the majority of
cord trauma: 40% from motor vehicle
collisions, 20% from falls, and the
remainder due to physical violence.
Usual sites include C5-C6 and T12-L1
Spinal cord injury at midthoracic levels is
less common -rotational stabilization
provided by the rib cage and intercostal
musculature.

5. PATHOPHYSIOLOGY:
Primary neural damage- due to initial
insult.
Secondary neural injury – d/t:
 mechanical disruption
 hypoxia
 hypotension
 edema
 haemorrhage into cord
 hyper/hypoglycemia

6. Includes – sensory or motor deficits or
both.
Incomplete deficits – may be worse on
one side, improve rapdily in the first
minutes and hours following injury
Complete deficits – more obvious, little
improvement seen.

7. Cervical spine injury -> quadriplegia and
significant hypotension seen (vasodilatation
and loss of cardiac inotropy).
Lower cord – normalises gradually –
normal vascular tone returns.
Autonomic hyperreflexia in 85% with
complete injury above T5 (excess
sympathetic stimulus, absence of damping
effect of brain).

8. MECHANISMS:
Distraction
Compression
Torsion
Penetration.

9. Distraction – in hyperextension (eg.
Hanging), significant impact on the head or
face
Compression of the bony spine – directly
compromise the spinal canal and spinal
cord.
Torsion – falls, high energy vehicle
collisions – can tear the spinal cord tissue
Penetration – in gun shot or stab injury

10. Usually radiographically visible injury to
the bony spine and concomitant disruption
of the muscles, ligaments, and soft tissues
that support it are seen.
SCIWORA (spinal cord injury without
radiographic abnormality) is more common
in children and is presumably the result of
temporary hyperdistraction or torsion of the
neck insufficient to disrupt the bony
skeleton

11. TYPES OF INJURY:
1. Complete cord lesion: - motor, sensory
and autonomic functions are lost below
the level of lesion.
2. Incomplete cord lesion – includes 4
syndromes

12. Anterior cord syndrome :-
Due to ischemia (eg. aortic injury) – blood
supply from anterior spinal artery is
distrupted.
Damage to cortico-spinal and
spinothalamic tracts – paralysis, abnormal
touch, pain and temperature sensation.
Posterior columns unaffected – vibration
and joint position senses preserved.

13. Central cord syndrome :-
Central gray matter is damaged.
Paralysis with variable sensory loss –
UL>LL (upper limb fibres – close to
centre).
Bladder dysfunction – present as urinary
retention.

14. Brown – Sequard syndrome: -
Hemisection of the cord
Usually in penetrating trauma
Ipsilateral paralysis and loss of vibration
and joint position sense, with contralateral
loss of pain and temperature sensation.

15. Cauda equina syndrome:
Presents with loss of bowel and baldder
function with LMN signs on lower limbs.
Sensory signs – unpredictable.

16. Assessing sensory level:-
Cervical : C5 – deltoid
C6 – thumb
C7 – middle finger
C8 – little finger
Thoracic : T4 – nipple
T8 – xiphoid
T10 – umbilicus
T12 – symphysis

17. Lumbosacral:
L4 – medial leg
L5 – first/second toes
S1 – lateral foot
S4-5 – perianal.

18. Assessing motor level:
Cervical/thoracic: C5 – biceps flexion
C6 – wrist extension
C7 – elbow extension
C8 – middle finger extn
T1 – little finger abduction
Lumbosacral: L2 – hip flexion
L3 – Knee extension
L4 - ankle dorsiflexion
L5 – big toe extension
S1 – big toe/ankle plantar
flexion

19. PROBLEMS:
AIRWAY:
Airway reflexes are lost and gastric stasis
– can have aspiration.

20. BREATHING:
Above C4 – diaphragm is paralysed –
apnea.
T2-T12 – innervates intercostal muscles –
fractures above – diaphragmatic breathing
– limited expansion, decreased TV and
FRC, impaired cough, inc RV. Dec muscle
power – pneumonia is common.
ARDS and pulmonary emboli also occur

21. CIRCULATION:
Damage above T2 – sympathteic
innervation of heart lost – loss of reflex
tachycardia, impaired LV function and risk of
severe bradycardia and asystole following
unopposed vagal stimulation.

22. NEUROLOGICAL:
Spinal shock – ms flaccidity and areflexia
– duration is variable.
Following a/c phase of spinal shock –
majority of patients with lesion above T7 –
autonomic dysreflexia (mass spinal reflex
when area below the lesion is stimulated)
develops severe bradycardia, hypertension,
flushing and sweating above the lesion –
triggered by distended bladder or bowel,
pressure sores etc

23. TEMPERATURE:
Hypothermia due to peripheral
vasodialatation.
BIOCHEMICAL AND ENDOCRINE:
Increased ADH – water retention
Glucose intolerance
NG tube – hypokalemic metabolic
alkalosis
Hypoventilation – respiratory acidosis
Osteoporosis and hypercalcemia

24. SKIN – pressure sores
THROMBOELASTOGRAM – DVT and
embolism.
MUSCULOSKELETAL – muscle spasms
and contractures.
PSYCHOLOGICAL – reactive depression

25. MANAGEMENT:
PRIMARY SURVEY & RESUSCITATION:
Look for other injuries
Immobilise, minimise secondary causes of
injury like hypoxia and hyperperfusion before
transferring the patient.

26. AIRWAY WITH CERVICAL SPINE
CONTROL
MILS
Low GCS- intubate at the earliest –
maintaining MILS
Sch – can be safely used.
FOB – requires experienced hands.

27. BREATHING :
Sufficient oxygen and ventilation.
CIRCULATION:
Maintain adequate BP – fluids alone/ fluids
with pressors – r/o haemorrhage.
MAP >85mm Hg for 7 days after injury.
Hypotension with bradycardia is seen

28. SECONDARY SURVEY AND DIAGNOSIS
HISTORY
Mechanism of injury
Patient usually unconscious- so reliable
history not always possible.
EXAMINATION
Log roll – tenderness and “step off”
deformity

29. Other signs :
Flaccid anal sphincter
Areflexia
Diaphragmatic breathing
Hypotension without tachycardia
Priapism
Surgical decompression and stabilisation
of spinal fractures – indicated when vertebral
body loses >50% of normal height or spinal
canal – narrowed >30% original diameter

30. INVESTIGATIONS/CLEARING THE SPINE
IN TRAUMA PATIENTS:
X ray of cervical spine – lateral – occiput
to T1, AP-C2-T1, open mouth view- lateral
masses of C1 and odontoid process.
Axial CT – if radiological visibility is
limited.

31. Life threatening injuries – first priority.
Flexion and extension views in patients
with normal radiographs – but has neck
pain.
Patient with neurological deficit
attributable to cervical spine injury –
surgical subspeciality consult, MRI – limited
use in acute phase, but gives definitive
indication of severity of cord injury.

32. DEFINITIVE CARE:
Early referral to a spinal injuries unit for
early fixation.
AIRWAY:
Tracheostomy after cervical spine fixation
for prolonged ventilation.

33. BREATHING :
Insiduous worseing can occur – hence
close monitoring of ventilation.
Early intubation – to avoid late
complications.
Suxamethonium – avoided after the first 24
hrs for a year following injury – to avoid
hyperkalemia.

34. CIRCULATION:
IBP & CVP usually sufficient.
MINIMISING SECONDARY INJURY :
Avoid hypotension, hypoxia,
hyper/hypothermia
Steroids – methylprednisolone – 30mg/kg
over 15 min followed 45 min later by cont
infusion @ 5.4mg/kg/hr within 3 hrs of injury for
23 hrs and for 48 hrs if started 3-8 hrs after
injury

35. AUTONOMIC DYSREFLEXIA
Good bowel and bladder care.
GIT
Early enteral feeding- maintains gut
mucosa integrity. PEG- for long term – if
swallowing inadequate.
SKIN
Prevent bed sores

36. THROMBOEMBOLISM:
Compression stockings, calf compression
devices, s/c LMW heparin for a minimum of 8
weeks.
PSYCHOLOGICAL
Important for good outcome, to avoid
reactive depression.

37. INTRAOPERATIVE MANAGEMENT:
Challenge for anaesthesiologist :
intubation for a known C spine injury
most commonly by FOB – nasal –
sinusitis later on, oral route preferred.
Other methods : blind nasal, use of an
illuminated stylet, intubating LMA or bullard
laryngoscope.

38. The clinician is advised to use the
instrument and method which he/she is
familiar.
Whatever the method used – the goal must
be definitive tracheal intubation with minimal
cervical spine movement.

39. Quadriplegic and paraplegic patients –
hemodynamic instability due to spinal shock.
Bleeding is minimal in spine surgeries – but
occur during iliac crest bone harvesting.
Pressors should be continued, ABP
monitored. Increased dose of pressors – to
be assessed based on response to fluid
therapy.

40. Thoracic and lumbar # bleed more.
Cases of other injuries with known spine
injury – management guidelines are the
same.
Remember that like a patient with
traumatic brain injury, spinal cord injured
patient will also have impaired autoregulation
– hence close monitoring of perfusion in the
involved area is essential.

41. SPINAL CORD INJURIES IN CHILDREN
Low incidence – due to mobility of spine in
children that can dissipate force over larger
area.
Management same as that in adults.
Infants and children less than 8 yrs- may
need padding under back for neutral position
for immobilisation of spine.

42. SCIWORA:
Spinal cord injury without radiological
abnormality.
Almost exclusively in children <8 yrs of
age.
Upper cervical cord is usually affected

43. GUIDELINES:
Eastern association for Srugery of Trauma
1. Trauma patients – alert, awake, without
mental changes or pain that might
distract them– considered to have stable
cervical spine if there are no neurological
signs or neck pain. No radiological
studies needed.
2. Patients with neurological deficit –
immediate surgical subspecialty consult
and MRI done

44. 3. All other patients should have the cervical
spine screened and cleared.
4. Patients with normal studies, but severe
neck pain – flexion and extension views.
In any doubtful patient, better to immobilise
the C spine till it is cleared of injuries.