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Questions and Answers
What type of spinal cord injury is characterized by anterior subluxation or fracture dislocations of the vertebral bodies?
Which spinal cord injury mechanism is associated with disruption of the anterior longitudinal ligaments?
What is the likely physiological effect of a spinal cord injury at the C1-C3 level?
Why is initial assessment critical in spinal cord injuries?
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What treatment approach is aimed at ensuring spinal alignment and stabilization?
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What physiological response occurs below the level of a spinal cord injury?
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Which symptom is a common manifestation of a spinal cord injury?
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What is the primary treatment strategy for managing symptoms related to spinal cord injuries?
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Which of the following conditions can also lead to symptoms similar to those seen in spinal cord injury?
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What results from the loss of supraspinal control over sympathetic preganglionic neurons in spinal cord injury?
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What are common triggers for muscle spasms in patients with chronic spinal cord injury?
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Which medical treatments are appropriate for managing muscle spasms associated with spinal cord injuries?
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Which condition is characterized by widespread nerve discharges and violent muscle spasms due to spinal cord transection?
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What should be avoided when administering succinylcholine to patients with chronic spinal cord injury?
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In postoperative care for patients with chronic spinal cord injury, what is a key consideration for extubation?
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Which medication is classified as a direct acting vasodilator for treating blood pressure?
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What is an essential consideration for anesthetic management in patients with spinal cord injuries?
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Which drug is notably cardiac stable and should be avoided in trauma cases due to potential adrenocortical suppression?
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Which scenario would justify continued intubation after surgery?
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What is one of the emergency drugs used in anesthetic management of spinal cord injuries?
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Which type of monitoring is essential for patients with spinal cord injuries during surgery?
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In the context of cervical spine surgery, what is the primary focus of the procedure?
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What is a critical piece of equipment needed in the room setup for anesthetic management?
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What is the first action to take when managing a venous air embolism (VAE)?
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Which of the following is a consequence of untreated VAE?
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What is a potential risk factor for paradoxical air embolism (PAE)?
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In which patient position is the incidence of venous air embolism notably higher?
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What is an important consideration when performing lumbar disc surgery?
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Which technique is essential for spinal cord monitoring during thoracolumbar spine surgery?
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What should be done if the initial measures to manage a VAE fail?
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Which factor significantly influences blood loss considerations during spine surgeries?
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Study Notes
Spinal Cord Injury Types
- Flexion injuries involve anterior subluxation or fracture dislocations of the vertebral bodies.
- Hyperextension injuries result in transverse fractures of the vertebra and disruption of the anterior longitudinal ligaments, often leading to posterior dislocations.
- Vertical compression causes burst fractures and ligamentous rupture.
- Rotational injuries lead to fractures of the vertebral peduncles and facets.
System Effects of Spinal Cord Injury (SCI)
- Depend on the level of injury and phase, emphasizing the importance of initial assessment.
- C1-C3 complete injuries result in respiratory failure due to diaphragmatic paralysis.
- Hypotension, bradycardia, hypothermia are potential complications, particularly with C7 or higher injuries.
- Bladder and bowel dysfunction, alteration in sweating, and respiratory dysfunction are common.
Treatment Goals for SCI
- Immobilization to stabilize the spine.
- Medical stabilization to address physiological complications.
- Spinal alignment to maintain proper vertebral positioning.
- Operative decompression to relieve pressure on the spinal cord.
- Spinal stabilization to prevent further injury.
Autonomic Dysreflexia
- Afferent impulses are transmitted to the isolated spinal cord.
- Afferent stimulation is tolerated in healthy individuals, but in SCI patients, it elicits a massive sympathetic response leading to the release of adrenaline and activation of the sympathetic nervous system (SNS).
- The brainstem and hypothalamus are unable to inhibit this response due to the SCI.
- Neural plasticity allows the nervous system to re-organize in response to stimuli.
Physiological Changes in Autonomic Dysreflexia
- Loss of supraspinal control over sympathetic preganglionic neurons.
- Vasoconstriction occurs below the lesion.
- Vasodilation occurs above the lesion.
- Carotid and aortic arch baroreceptor activation leading to decreased heart rate, ventricular dysrhythmias, and complete heart block.
Common Symptoms of Autonomic Dysreflexia
- Severe hypertension, bradycardia, tachycardia, hyperreflexia, muscle rigidity and spasticity.
- Profuse diaphoresis (sweating) and changes in skin color including pallor, redness, blue-grey skin color, and flushing above the lesion.
- Intense headache.
- Untreated autonomic dysreflexia can lead to seizures.
Less Common Symptoms of Autonomic Dysreflexia
- Horner's syndrome (oculosympathetic palsy) characterized by pupillary constriction, ptosis, and decreased sweating.
Other Causes of Autonomic Dysreflexia
- Medication side effects (e.g., cocaine or amphetamines).
- Guillain-Barre syndrome.
- Subarachnoid hemorrhage.
- Severe head trauma and other brain injuries.
- Full bladder (ensure Foley catheter is draining) or stool impaction.
Treatment of Autonomic Dysreflexia
- Stop the stimulus.
- Place the patient in an upright position.
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Treat blood pressure.
- Administer medications with rapid onset and short duration.
- Direct-acting vasodilators such as sodium nitroprusside.
- Beta blockers.
- Combined alpha and beta blockers like labetalol.
- Calcium channel blockers such as nifedipine.
- Ganglionic blockers.
- Prophylaxis and acute episodic treatment are important.
Anesthesia Considerations for Spinal Cord Injury
- Thorough preoperative assessment is crucial to evaluate level of consciousness (LOC), motor system, cranial nerves, reflexes, and deficits.
- Hemodynamic status must be assessed.
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Room setup should include:
- Airway equipment: laryngoscope blades and handles, oral airways, tongue depressors, and Yankauer suction.
- Monitors: routine monitors, transducers for central venous pressure (CVP) and arterial line, precordial Doppler for sitting patients.
- Emergency drugs: phenylephrine, ephedrine, atropine, glycopyrrolate.
- Eye tape and pads.
- Induction and intubation should be performed with careful consideration.
- Monitoring should be continuous and comprehensive.
- Positioning must be carefully planned to avoid pressure on the spinal cord.
- Maintenance of anesthesia should be individualized based on the patient's condition.
- Emergence from anesthesia should be carefully monitored.
Extubation Criteria
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Extubation can be considered in patients with:
- Normal LOC preoperatively.
- No respiratory problems or surgical complications.
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Continued intubation may be required in patients with:
- Decreased LOC preoperatively.
- Increased intracranial pressure (ICP).
- Additional severe injuries.
Cervical Spine Surgery
- Performed for cervical disc problems related to diseases, injuries, and cervical instability.
- Potentially associated with hypotension and tachycardia.
- Hypoxemia can occur due to partially occluded pulmonary vasculature and local release of vasoactive substances.
- Untreated hypoxemia can lead to decreased carbon monoxide (CO) levels due to right heart failure and/or reduced left ventricular (LV) filling.
Management of Venous Air Embolism (VAE) During Cervical Spine Surgery
- Alert the surgeon to irrigate the surgical field with saline.
- The CRNA should aspirate from the CVP catheter simultaneously.
- Discontinue nitrous oxide (N2O) if in use and increase fraction of inspired oxygen (FiO2) to 100%.
- Provide cardiovascular support if needed.
- Compress both jugular veins lightly to minimize air entrainment.
- Change patient position if the above measures fail to prevent ongoing VAE.
Paradoxical Air Embolism
- VAE can lead to paradoxical air embolism (PAE).
- Air can pass to the arterial side through a pulmonary vascular bed or patent foramen ovale (PFO).
- Embolization of a coronary or cerebral vessel can occur.
- The risk of PAE is increased with posterior fossa surgery and in the sitting position.
Anesthesia Considerations for Cervical Spine Surgery
- Prone positioning is often required.
- Two large bore IVs, a Bair Hugger, fluid warmer, Foley catheter, and nerve monitoring (e.g., somatosensory evoked potentials (SSEPs) may be needed.
Considerations for Lumbar and Thoracolumbar Spine Surgery
- Lumbar disc surgery (e.g., lumbar laminectomy/fusion) is performed for trauma injury, disease, or herniated nucleus pulposus (HNP).
- Prone positioning is recommended.
- Two large-bore IVs, routine monitors, upper body Bair Hugger, fluid warmer, Foley catheter, and nerve monitoring (e.g., train of four (TOF)) may be utilized.
- Thoracolumbar spine surgery corrects deformity, stabilizes fractures, and resect tumors.
- Positioning, spinal cord monitoring, minimizing blood loss, and postoperative respiratory care are crucial aspects.
- Anterior and posterior procedures may be staged or performed at one time.
- An anterior approach through a thoracotomy incision requires an endobronchial or double-lumen endotracheal tube (ETT).
- Positioning for thoracolumbar spine surgery necessitates careful attention to prevent head and neck compression.
Additional Considerations for Thoracolumbar Spine Surgery
- Spinal cord monitoring (SSEPs and MEPs).
- Wake-up tests.
- Blood loss considerations (e.g., autologous donation, cell saver, induced hypotension).
- TOF monitoring during the surgery.
- Pain management postoperatively.
- Fluid and blood management due to fluid shifts and hemodynamic instability.
Chronic Spinal Cord Injury
- Many of the same issues and problems as acute SCI.
- Respiratory issues can be present.
- Autonomic hyperreflexia is a significant concern.
- Muscle spasms and hyperactive spinal reflexes are common.
- Mass reflex is an abnormal condition in spinal cord transection leading to widespread nerve discharge, violent muscle spasms, and incontinence.
- Stimulation below the lesion can trigger flexor muscle spasms, incontinence, hypertension, and profuse sweating.
- Triggers for autonomic hyperreflexia include scratching, painful skin stimuli, bladder or bowel distention, cold weather, prolonged sitting, and emotional stress.
- Treatment for autonomic hyperreflexia involves diazepam, dantrolene, and surgical approaches including chordotomy, rhizotomy, peripheral nerve transection, or tenotomy.
- Prevention of decubiti and bladder infections is essential.
Anesthesia Considerations for Chronic Spinal Cord Injury
- Regional versus general anesthesia considerations.
- Hemodynamic control is vital, and medications such as direct-acting vasodilators, alpha blockers, antihypertensives, antiarrhythmics, and atropine may be needed.
Hyperkalemia and Chronic Spinal Cord Injury
- Increased risk of hyperkalemia with depolarizing muscle relaxants (e.g., succinylcholine).
- Avoid succinylcholine in patients with chronic SCI.
- Up-regulation of receptors at the neuromuscular junction.
- Dosing of muscle relaxants must be individualized according to twitch response in a denervated limb.
Extubation Considerations for Chronic Spinal Cord Injury
- Extubation should be based on the patient's underlying medical condition, surgical procedure, emergence response, and pre-operative status.
Additional Considerations for Chronic Spinal Cord Injury
- Airway management and positioning should be extremely cautious.
- Foley catheter placement is essential to prevent urinary retention.
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Description
This quiz covers the various types of spinal cord injuries, including flexion, hyperextension, vertical compression, and rotational injuries. It also addresses the systemic effects of these injuries based on their level and initial assessment, as well as the treatment goals aimed at stabilization and recovery.
