Dr Arun L Naik is a Spine Surgeon practicing in India Bangalore for 14 years. He was trained at AIIMS New Delhi in 2000. He is well known for his surgery for ''failed back surgery syndrome'' where previous surgery was gone wrong. He has expertise in 'minimal invasive key hole spine surgery'' . He operates on complex spinal cord tumors which are challenges to any surgeon. Dr Naik is one of the few neurosurgeons in India to operate on cranio vertebral junction with excellent surgical results. Spinal cord injuries are special areas of interest to him. He has successfully treated hundreds of spinal injured patients many of whom are walking today. He has trained many surgeons in developing spine surgery technique.

1. Dr. Arun L Naik
Senior Consultant Neurosurgeon
Apollo Hospital
Bannerghatta Road
Bangalore

2. Annual cases: 20000
55 cases per day
2 persons per minutes
Cost per year : INR 5400 cr

3.  MVA 56%
 Falls 16%
 Gunshot Injuries 11%
 Blunt Assault 6%
 Diving Accidents 5%
 Stab Wounds 4%
 Sport Injuries 2%

4.  Flexion: bilateral facet dislocations
 wedge fractures of anterior vertebrae,
 Disruption of the disc with forward
bilateral facet dislocations, and fracture
of the pedicle.
 Flexion with rotation:
 Causes unilateral facet dislocation
 fracture of the vertebra,
 rupture of supporting ligaments.
 Vertical compression/axial loading
 These usually stable injuries
 "burst" fracture

5. Trauma to the cord itself
Vertebral column
Distractional forces associated with flexion, extension,
dislocation, or rotation
Stretching or shearing of the neural elements
Compression and contusion from bone fragments,
ligaments, and hematoma within the spinal canal

6. Edema
Intramedullary hemorrhage
Axonal degeneration
Demyelination
Ischemia

9. Paramedics
Intubation?
Immobilization
Prolonged time spent in
transport
Respiratory compromise
Pain and discomfort in
conscious patient
Pressure sore in
prolonged use

10. Airway with attention to spinal protection
Breathing
Circulation
Disability: Neurological
Exposure of the entire patient for signs of injury

11. Nasotracheal intubation (ATLS ): Fallen out of
practice
Cricothyroidotomy has also become less common
Intubating laryngeal mask airway
Lighted stylet
Elastic bougie devices

12. • Diminished or absent airway protective mechanisms:
intracranial injury or other pathology
• Evidence of airway obstruction in the multiple trauma
• Acute respiratory failure in patients with injuries at
C4
• Thoracoabdominal trauma
• Inability to cough, clear secretions

13. The ideal MAP: 80 to 100 mmHg
Hypertension: Risk of intramedullary hemorrhage
and edema
Adequate volume resuscitation
Vasopressor therapy

14. Spinal Shock
• Temporary suppression of
all or most reflex activity
below the level of injury
• Occurs immediately after
injury
• Intensity & duration vary
with the level & degree of
injury
Neurogenic Shock
• The body’s response to the
sudden loss of sympathetic
control
• Distributive shock
• Occurs in people who have
SCI above T6 (> 50% loss of
sympathetic innervation)
• Paralyzed, hypotensive
patient with warm, dry,
hyperemic extremities, and
bradycardia

15. Rapid neurological
assessment: prior to the
administration of paralytic
agents
Pupils for size and reactivity
GCS
Extremities power
Rectal tone

16. Head-to-toe
Complete neurological examination
Spinal injury: tenderness, step-off deformities,
edema, and ecchymoses
Long bone fractures
Severe soft tissue injuries

17. Head Injury
Chest injury
Chest wall
Rib fractures
Pulmonary contusions
Hemothorax
Pneumothorax
Abdominal injury
Pelvic injury
Bony injury

18. Plain X rays
C spine
CXR
DL / LS Spine
Long bones
Pelvis
CT scan
MRI

19. Inadequate plain films
Suspicious plain film findings
Any fracture / displacement on plain films
High clinical suspicion of injury despite normal plain
films

23. Anterior cord syndrome
Central cord syndrome
Posterior cord syndrome
Brown–Séquard syndrome
Conus medullaris syndrome
Cauda equina syndrome

24. • Flexion-rotation force to the
spine producing an anterior
dislocation or by a compression
fracture of the vertebral body
• There is often anterior spinal
artery compression so that the
corticospinal and spinothalamic
tracts are damaged
• Loss of power as well as
reduced pain and temperature
sensation below the lesion

25.  Older patients with cervical
spondylosis
 Hyperextension injury
 Flaccid (lower motor
neuron) weakness of the
arms and relatively strong
but spastic (upper motor
neuron) leg function
 Sacral sensation and
bladder and bowel function
are often partially spared

26. • Hyperextension injuries with
fractures of the posterior
elements of the vertebrae
• Good power and pain and
temperature sensation but there
is sometimes profound ataxia
due to the loss of
proprioception, which can make
walking very difficult

27.  Stab injuries, lateral mass
fractures of the vertebrae
 Power is reduced or absent
 Pain and temperature
sensation are relatively normal
on the side of the injury
 The uninjured side therefore
has good power but reduced or
absent sensation to pin prick
and temperature

28. Loss of bladder, bowel and lower
limb reflexes
Injury to the lumbosacral nerve
roots results in areflexia of the
bladder, bowel, and lower limbs

29. Primary Injury
Secondary Injury

30. Hypotension should be avoided
Optimal blood pressure in the first week after SCI
through aggressive volume expansion and the use of
pressor agents may improve outcome
SBP in adults should be kept 90 mmHg

31. Skin care
Foley catheter
Respiration
Low molecular Weight Heparin
Adequate analgesia
Spinal braces
Management of associated injuries

32. 30 mg /kg bolus
5.4 mg/kg/h x 23
hours
MPSS
8 hours : Better neurologic recovery at 6w / 6 m / 1 yr˂
8 hours : Worse neurologic function than the placebo group.˃
3- 8 hours
MPSS
> 8 hours
30 mg /kg bolus
5.4 mg/kg/h x 48
hours

34. Maximize neurologic recovery
Restore normal alignment and correct deformity
Promote spinal stability, fusion, or both
Minimize pain
Facilitate early mobilization and rehabilitation
Minimize hospitalization and cost
Prevent secondary complications

35. Irreducible anatomic compressive lesion with
neurological deficits (spl incomplete or progressive)
Complete injury except MR showing transection of
cord
Instability
Need for multiple surgical procedures or associated
multiple trauma

36. Neurologically complete injury of thoracic cord with
compression but stable fracture
Incomplete neurological injury with modest compression
( for example 25%)
Central cord syndrome with associated spondylotic
compression of cord

37. Hemodynamic instability
Inadequate resuscitation
Severe TBI
Insufficient radiological imaging
MRI showing complete transaction

38. Decompressive
Stabilization
Both the above

42. Quick decision of screw dimensions

43. Decreased deviation between plan and results