Initial Management of Spine Trauma PDF

INITIAL MANAGEMENT OF THE SPINE TRAUMA PATIENT DR DEAN WRIGHT APRIL 2008 importance Spinal column injury ± spinal cord injury must be sought in all multitrauma patients 2.6% all admitted trauma The real challenges are the ‘unstable’ patient, the ‘obtunded’ patient, the occult injury. Accurate clinic...

INITIAL MANAGEMENT OF THE SPINE TRAUMA PATIENT DR DEAN WRIGHT APRIL 2008 importance Spinal column injury ± spinal cord injury must be sought in all multitrauma patients 2.6% all admitted trauma The real challenges are the ‘unstable’ patient, the ‘obtunded’ patient, the occult injury. Accurate clinical and radiological assessment precedes classification Edwin Smith papyrus “…. When examing a man suffering from dislocation of the cervical vertebrae, you will find that he is unaware of his arms, hands and legs, his penis is erect, that his urine escapes without his knowing, he is flatulent and his eyes are red, it is obvious that a dislocation of the cervical vertebrae has affected his spine and caused him to be unaware of his hands and legs and you will be forced to say that the man has suffered a dislocation of the vertebrae in his neck. This is a disease that cannot be treated ….” Imhotep – physician to Pharaoh Zoser III, Circa 5000 BC HISTORY Hippocrates accredited with treatment of spinal injuries including vertebral reduction and alignment by applying axial distraction. HISTORY2 British Medical Council – 1924 – “ the paraplegic may live a few years in a state of more or less ill health” 1929 – Cervical traction by Halter device – A.S.Taylor 1940 – Skull tongs in 43 patients with minimal morbidity – W. G. Crutchfield 1940 – Current concept of spinal cord rehabilitation including reduction of cervical spine fractures ,stabilization, nursing care and comprehensive rehabilitation. – Sir Ludwig Guttman. 1973 – Spring loaded points on skull tongs – W.J. Gardner History3 1942 – Interspinous wiring techniques for fracture dislocation – W.A. Rogers 1955 – Anterior disc removal and fusion – R.A. Robinson and G.W. Smith 1958 – Circular graft anterior cervical fusion – R.B Cloward 1992 – Development of lateral mass plates – R, Roy – Camille Importance2 Assessments are #accurate #serial #intra and interobserver # legibly and carefully recorded Injuries Epidemiology Anatomy review Pathophysiology Clinical evaluation and classification Prehospital Care A/E Department Care Radiographic evaluation Management principles Special situations Epidemiology: Demography Modal age =30 years Median = 25 years M:F =4:1 MVAs/ Falls/Violence/ Sports = 50/ 20/ 15/ 15% Epid. 2 SCI in multisystem trauma =45% in head/ facial injuries =15% Tetraplegic (quadriplegic) or paraplegic patients 80% have multisystem trauma 40% have head injuries At least mild head injury in 25% spine injured patients Epid3: Spinal levels Multilevel spinal cord/column trauma =10-15% Incidence at spinal levels OC /C /CT /T /TL /LS, = 55% /15/15 /15% Spine …vol 26 # 24S,p S3 Epid.4 Affects quality of life With SCI mortality at 1st presentation = 17% * High incidence of early even immediate mortality from high C spine injury with tetra(quadri)plegia 1200 plegics/yr 4000 die in field 1000 during hospital Anatomy review Spinal column 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, coccyx Vertebral body (weight bearing) Neural arch Pedicles/ lamina (pillars & roof) Anatomy2 Facet joints Interspinous ligaments Paraspinal muscles All contribute to spinal stability Interspinous ligaments ALL PLL Interspinous Supraspinous Ligamentum flavae (interlaminar) Intervertebral disc Anatomy3 C spine most vulnerable, most mobile, lordosis Occipitocervical junction and upper C spine Lower C spine C3-7 Cervicothoracic junction Upper C spine C1-C2 Facet Joints – Horizontal plane – Facilitates axial rotation Tectorial Membrane – Continuation of PLL – Major occip- cervical stabilizer – Secondary restraint for extension of occiput on atlas Alar Ligaments Upper C spine ‘Wide’ cervical canal foramen magnum to C2 Approx. 1/3 of those injured die on scene from high cervical tetraplegia Most survivors neurologically intact on arrival Lower C spine Lateral mass: – Consists of ipsilateral sup/inf. facets – Upward inclination of ~ 400 – Facet joint complex resists anterior translation and rotation Vertebral artery – Traverses foramen in TP – Does not traverse C7 T spine 12 vertebrae kyphosis T spine Ribs and sternum limit thoracic spine movement; increase stability Spinal cord takes up the majority of the canal space Facet joints in coronal plane L spine Lordotic sagittal alignment (20-600) Significant (F/E) motion at each level Biplanar facet joints L2 -L5: Cauda Equina Anatomy4 Spinal cord begins at medulla oblongata Ends at L1/ L2 Conus medullaris at L1 Cauda equina L2-5 Spinal Cord Many tracts 3 assessed clinically The corticospinal tract The spinothalamic tract The posterior columns Spinal Cord FG Fasc. Gracilis (Sensory, lower part of cord, Proprioceptive, Deep pain, Vibration, Ipsilateral) FC Fasc. Cuneatus (Sensory, Upper part of cord, Proprioceptive, Deep pain, Vibration Ipsilateral) PH Posterior Horn (Sensory cell bodies) AH Anterior Horn (Motor Cell Bodies) Spinal Cord LCS Lateral Corticospinal Tract (Crossed Pyramidal Upper Motor Neurons to ipsi AH) ACST Anterior Corticospinal Tract (Direct Pyramidal go to contra AH) PSCT ASCT Spinocerebellar Tracts LST Lateral Spinothalamic Tract (Sensory, Pain and Temp: cell bodies in contra PH) AST Anterior Spinothalamic Tract. (Sensory, Touch: cell bodies in contra PH) Spinal Nerves Union of dorsal (sensory) and ventral (motor) roots Exits through intervertebral foramen – – – – C1 exits between skull and atlas C2 to C7 exit above corresponding vertebrae C8 exits below C7, above T1 Below T1; all nerves exit below corresponding numbered vertebral pedicle Cauda Equina Spinal nerves that have exited from the cord L1-L5: Nerve cell bodies lie in the cord behind T11-T12 S1-S5: Nerve cell bodies line within the region of the conus medullaris Cauda equina nerves are more like peripheral nerves 🡺 withstand trauma better than CNS Damage to this region causes LMN signs Dermatomes Area of skin supplied by a single spinal nerve(or spinal cord segment) 31 pairs of spinal nerves spinal nerve consists of a motor and a sensory rootlet Autonomic fibres(unmyelinated & hence are grey) also hitch hike along each spinal nerve eg sympathetic to blood vessels, piloerector and sudomotor sweat glands Cervical spinal nerves C1 C1 - No cutaneous distribution 50% of the times there is no sensory or dorsal rootlet from C1 segment of the spinal cord C2 to C8 C2 - Occipital region,/ ANGLE OF MANDIBLE. C3 - Neck C4 _ Infraclavicular region (manubriosternal jn C5 Lateral arm and elbow C6 Lateral forearm and thumb C7- Middle finger C8 Little finger & distal medial forearm T1-4 T1 Medial arm and elbow T2 Medial arm , axilla & thorax T3 Thorax & occasional extension to axilla T4 nipple T7-T12 T7 Subcostal angle T8 Rib margin T10 Umbilicus T12 Lower abdomen, upper buttock suprapubic & suprainguinal L1-5 L1 - Suprapubic and inguinal regions, penis, anterior scrotum(labia), upper buttock L2 Anterior thigh, upper buttock L3 anterior and medial thigh & knee L4 medial leg, medial ankle and side of foot L5 Lateral leg , dorsum of foot , medial sole S1 - S5 & Coccygeal S1 Lateral ankle , lateral side of dorsum and sole of foot S2 Posterior leg & knee, Dorsum of foot S3 Sitting area of buttock (ischial tuberosity) , posterior scrotum(labia) S4 Perianal skin S5 Anal canal Co over coccyx MYOTOMES Myotomes refer to muscles developed from the lateral epithelial plate Each muscle is supplied by two adjacent spinal cord segments/ adjacent spinal nerves complete paralysis of a muscle requires interruption of the two adjacent segments or spinal nerves Motor unit refers to the muscle fibres supplied by a single motor neuron in the anterior horn of the spinal cord Upper Limb Shoulder- Abduct& Lat Rotn- C5 Adduct & Medial Rotn- C6,7,8 Elbow- Flex- C5,6 Extend - C7,8 Forearm _ Pronate C7,8 Supinate C6 Wrist _ Flex C6,7 Extend C6/7 Fingers and thumb- Flex- C7,8 Extend - C7,8 Hand (intrinsic) - T1 Lower limb Hip - Flex - L2/3 Knee Exten_L3/4 Ankle Exten/dorisflex- L4/5 Hip Exten- L4/5 Knee Flex_ L5/S1 AnkleFlexion/Plantar Flexion _ S1/2 Denis et al Clin Orthop.1984; 189:65-76 the three-column concept initially evolved from a retrospective review of 412 thoracolumbar spine injuries and observation of spinal instability, it has also been applied to the cervical spine. The posterior column consists of what Holdsworth described as the posterior ligamentous complex. The middle column includes the posterior longitudinal ligament, posterior annulus fibrosus, and posterior wall of the vertebral body The Anterior column consists of the anterior vertebral body, anterior annulus fibrosus, and the Anterior longitudinal ligament Pathophysiology of SCI PRIMARY INJURY mechanical insult – Rapid compression due to bone displacement from burst or dislocation – Distraction *** – Shear *** – Penetration Primary injury leads to cascade of secondary injury mechanisms *** Portends poor prognosis !!! Pathophysiology of SCI Secondary Injury Vascular changes – – – – Diminished blood flow Hemorrhage Vasospasm Thrombosis Electrolyte shifts Free radical production Inflammatory cascade Secondary Injury Final pathway is neuron death by: – Cell necrosis with structural dissolution – Apoptosis: chemical trigger initiates process that removes non-functioning neurons but also kills normal neurons in zone of injury (May be a role for pharmacologic agent that can block apoptosis) Reducing 2° injury Aggressive field resuscitation – Maintain systemic BP – Maintain optimal oxygenation Steroids – NASCIS-2 – NASCIS-3 8 hour window < 3 hrs---24 hrs; 3-8 hrs---48 hrs. Surgical decompression? Timing Safe Assumptions Every patient with a head injury or is unconscious has a spinal cord injury (SCI) Every patient with multiple trauma has a SCI Every MVA victim has a SCI Every sports injury has a SCI Every victim of a fall has a SCI Every severely injured worker has SCI Every SCI has an unstable spinal column and any movement of the spinal column will cause further damage to the spinal cord SCI presentations Complete – Cervical tetraplegia – Thoracic and lumbar paraplegia Incomplete syndromes – – – – – – – Anterior cord Central cord Brown-Sequard Posterior cord Conus medullaris Cauda equina Sacral sparing Complete SCI Definition – No motor or sensory function more than three segments below the neurological level of injury – There is absence of sacral sparing C1 - 4 Tetraparesis Absent limb function Ventilator dependence C4 level may be vent independent tetraplegia C5 - 8 Tetraplegia C5 deltoids, biceps C6 biceps, wrist extension C7 wrist extension, triceps C8 functional grasp T1 intrinsic hand fct 4 5 Thoracic Paraplegia Better respiratory and trunk control with injury at more caudal levels Thoracolumbar most common Lumbar Paraplegia L2hip flexion L3/4 knee extension L4foot dorsiflexion L5EHL S1 gastrocsoleus Lumbar Paraplegia L2 Incomplete SCI: Sacral Sparing Indicates some continuity of long tract fibers Sacral structures are most peripheral in both posterior columns and lateral corticospinal tracts Continued function of sacral LMNs in conus Sacral Sparing Perianal sensation (S4-S5) dermatome Voluntary external anal contraction Great toe flexor activity Incomplete SCI: Anterior Cord Affects the anterior 2/3 of cord Preserves the posterior column: proprioception, vibratory sensation May be due to persistent retropulsed bone or disc material/ mechanical insult Vascular component Anterior Cord Loss of all motor and sensory below injured level Deep pressure sensation only Poor prognosis for motor recovery Incomplete SCI: Central Cord Older patients with preexisting spondylosis MOI: Hyperextension injury: fall, whiplash Spinal cord pinched by osteophytes anteriorly and the underlying hypertrophic ligamentum flavum posteriorly; leads to significant injury to the “central portion” of the cord Incomplete SCI: Central Cord Best prognosis among common patterns Upper extremity > lower extremity involvement Distal > proximal Earliest and greatest recovery in legs followed by bladder Hand dexterity often slow to return, full recovery variable Incomplete SCI: Brown-Sequard Results from functional hemisection of cord, projectile or penetrating wound Loss of ipsilateral motor Loss of contralateral pain, temperature, and light touch sensation 75% regain independent ambulation 80% recover bowel and bladder function Brown-Sequard Posterior Cord Rare Loss of proprioception Maintain ambulation but rely on visual input Incomplete SCI: Conus Medullaris Syndrome region (L1-L2) Presents as mixed lesion of cord and nerve root damage Bowel, bladder, and sexual dysfunction Injury to CM can disrupt the bulbocavernosus reflex arc – Therefore, the absence of a bulbocavernosus reflex unreliable indicator of spinal shock in this clinical setting Distal spinal cord injury Cauda Equina Syndrome Lower motor neuron lesion (not cord) Sacral segments more affected than lumbar Saddle anesthesia with incontinence Lumbar sparing Cauda Equina Syndrome Nerve Root Injuries More favorable prognosis than cord injuries In c-spine injuries: frequently see complete cord injury with varying levels of root injury – Good chance of recovery of one level – Recovery dependent on level of injury Caveat As long as the spine is protected, evaluation of the spine and exclusion of an injury may be deferred especially in the face of systemic instability* Prognostic factors Age Level of injury Neurologic grade Initial management ATLS guidelines: A-B-C’s Examine for head, neck, or back trauma –need to logroll LOOK FOR SPINAL CLUES Paradoxical diaphragmatic breathing Priapism Neurogenic shock: hypotension and bradycardia – Loss of sympathetic tone Initial Evaluation Log roll !!!!! Inspect -bruising -neurodeficit Palpate – Tenderness – Gap/ Step-off – Crepitus -swelling Spinal Clues Movement then none?? No movement then some? Sensory and motor complaints? Paralysis of limb(s)-flaccid,(a)symmetrical Lack of response to pain--or level Painful stimuli ---grimace/head motion Spinal Clues2 Urinary retention or incontinence Hypotension, bradycardia and warm extremities- HYPOVOLEMIC SHOCK OR SPINAL SHOCK Paradoxical resp. low body temp.+ high skin temp Priapism, Horner’s Neurological Examination Motor: MRC grades 0-5 Sensory: MRC grades 0-2 Rectal exam: sacral sparing? DTRs: LMN function Spinal reflexes: UMN function ASIA Worksheet Deep Tendon Reflexes Biceps C5 Brachioradialis C6 Triceps C7 Quadriceps L4 Gastroc-soleus S1 Spinal reflexes Hoffman reflex Babinski reflex Bulbocavernosus reflexes Sacral Sparing Perianal/perineal sensation Rectal tone Big toe flexion Implies partial structural continuity of white matter long tracts May be only evidence of incomplete injury🡺higher chance of recovery DOCUMENT Bulbocavernosus reflex: – Pull glans or press clitoris 🡺 anal contraction (int. sphincter) around gloved finger – Absence is indicator of spinal shock Bulbocavernosus reflex: spinal shock loss of somatic motor, sensory and sympathetic autonomic function due to spinal cord injury. Temporary loss of all or most spinal reflex activity below level of injury More severe in the upper cord Lasts around 24 hours (max 48 hrs) Ends when bulbocavernosus reflex and/or anal wink returns An injury cannot be considered complete until resolution of spinal shock Classification 1992 American Spinal Injury Assoc. (ASIA) and the International Medical Society of Paraplegia (IMSOP) developed the standardsfor neurological and functional classification of spinal cord injury Neurological Classification Neurologic level of injury (NLI) – Most caudal level with bilateral normal motor and sensory function Vertebral level is the level of greatest vertebral damage on radiological examination. Complete/incomplete Zone of partial preservation dermatomes and myotomes caudal to the neurological level that remain partially innervated. Neurological Classification Motor level Sensory level Classification2 ASIA impairment scale Functional independence measure (FIM) Ambulation Other (psychosocial, etc) ASIA Impairment Scale A Complete: No motor or sensory below lesion B C Incomplete: Incomplete: D Incomplete: E Normal: Sensory only below lesion to S4-5 Preserved motor below lesion, key muscle strength < 3 Preserved motor below lesion, key muscle strength > 3 Normal motor and sensory below lesion -ASIA 1992 ASIA Impairment Scale A B C D E Complete: Incomplete: Incomplete: Incomplete: NORMAL 45% 15% 10% 30% Functional Independence Measure (FIM) Functional assessment scale Measures disability and rehabilitation outcomes 18 item scale rated 1 - 7 based on independence categories (18 - 126) FIM Motor (13) Self care Sphincter control Mobility Cognition (5) Communication Psychosocial adjustment Cognitive function Imaging X-rays CT MRI MRA X rays Lateral C-spine in trauma room – Must include down to C7-T1 – Swimmer’s view or pull-down if necessary – Single most important radiographic examination C-spine series – AP, Open mouth (dens) T-L-S spine films as indicated (one spine fracture mandates full spine radiographic evaluation) – T-L junction: 50% of injuries occur at T11-L1 Lateral C-spine Lordosis – Unreliable sign of injury Prevertebral soft tissues – – – – Unreliable No agreed upon measure 6 mm at C3 22 mm at C6 Lateral C-spine C SPINE IMAGING C SPINE IMAGING Lateral C-spine Lateral C-spine Lateral C-spine Anterior spinal line – Anterior aspect of vertebral body along ALL Posterior spinal line – Posterior aspect of vertebral body along PLL Spinolaminar line – Joins the anterior margins of the junction of the lamina and spinous processes Spinous process line – Joins tips of spinous processes Open Mouth (Dens) View Lateral masses of C1 should align over facet joints of C2 combined lateral mass displacement over 7 mm suggests transverse ligament tear (Spence’s Rule) Open Mouth (Dens) View Open Mouth (Dens) View Swimmers View Swimmers View FLEX/ EXT views CT scam Injury suspected on plain films Better visualize fracture (specificity and sensitivity) Unable to adequately assess on plain films Sagittal and/or coronal reconstructions can be helpful (particularly at Oc.-cervical and C-T jcts.) Fracture or soft tissue injury in the plane of the CT can be missed MRI for assessing cord and soft tissues R/O associated disc herniation ( facet dislocations) Hemorrhage vs edema in soft tissues ???? Ligamentous tears and facet capsule disruptions visualized with fat suppression MRI Distinguish recent vs ‘old’ bony and soft tissue injury Intrasubstance cord haematoma implies poor prognosis wrt motor function recovery MRI T1 T2 GRE Clearing the C-spine The Issues – Often difficult to diagnose – Missed or delayed diagnosis can lead to catastrophic neurologic disability – No agreed upon protocol in the intoxicated, multiply-injured, or head-injured patient Clearing the C spine The Problems – Unnecessary imaging? Should every patient with blunt trauma gets x-rays? – Overzealous consultation When and who should ‘clear the c-spine’ ?? – The Hard Collar Dilemma: Prolonged hard collar use leads to decubiti as well as neck pain C spine series Hoffman, Mower, et al., NEJM 2000 – – – – – Multicenter study 34,069 patients with blunt trauma AP/Lat/Open Mouth on all patients 810 with positive x-rays Only 8 with false-negative x-rays Only 2 clinically significant C spine series negative predictive value of this combination of studies is reported to be between 99 and 100% in several Class II and III evidence studies. Harris, Kronlage, et al. Spine 2000 – Polytrauma, intoxicated, CHI patients – IRB Protocol: Includes intra-op flex/ext with fluoro after all films read as normal – Goal: Identify ligamentous injuries – 3/ 153 (+) --- all required surgical stabilization Clearing the C-spine Criteria for clinical clearance – – – – – – No posterior midline tenderness Full pain-free active ROM No focal neurologic deficit Normal level of alertness No evidence of intoxication No ‘distracting injury’ C spine investigation NEXUS criteria Canadian C spine rules Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI: Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma: National Emergency X-Radiography Utilization Study Group. N Engl J Med 343:94– 99, 2000. Clearing the C-Spine: Conclusions – If x-rays negative, but patient c/o neck pain, active flexion/extension x-rays when able. Rarely helpful in acute setting – If neurologic deficit attributable to neck injury, immediate MRI – Controversy over the polytrauma or intoxicated patient remains EAST practice guidelines: trauma series and thin cut axial CT through C1-2 CT of cervical –thoracic junction if poor visualization on plain and swimmer’s Timing to Surgery Experimental evidence Clinical evidence – Non-operative – Operative Experimental Evidence Numerous studies – Classic: Tarlov 1954 – Delamarter 1995 – Dimar 1999 Experimental Evidence: Conclusions Severity of SCI dependent on: – Force of compression – Duration of compression – Displacement, canal narrowing Surgical decompression does attenuate the deleterious effects of acute SCI – Persistent compression is a potentially reversible form of secondary injury Injury prevention Legislative speed limits/ Drug and alcohol usage Protective headgear ; sportsgear Seat belts Airbags motor vehicle crumple zones Minimizing subsequent secondary CNS damage field and hospital Trauma Team Pre hospital Management –Extrication –Stabilization –Transport C spine stabilization C spine stabilization C spine stabilization A/E Dept – – – – Stabilization ABC’s 1° survey X–ray’s Trauma Series, CT scans 2° survey, Neurological Examination and documentation – MRI scan Priorities Adequate oxygenation Maintain Blood Pressure Admission ? ICU DVT prophylaxis – LMWH and pneumatic compression stocking Skin care Bladder care Gastric protection Nutrition Rehabilitation Adequate oxygenation Airway management Cervical stabilization INTUBATION oro and nasotracheal fibreoptic guide LMA in line jaw thrust Adequate ventilation O2 therapy / monitor ABGs Consider early interventions surgical airway tracheostomy (tetraplegics) Physiotherapy and tracheobronchial toilet ? Diaphragmmatic pacing Circulatory status Hypovolaemic Shock – Low BP – Tachycardia Neurogenic Shock – Low BP – Bradycardia hypotension Class III evidence from the literature suggests that maintenance of MAP at 85 to 90 mm Hg after ASCI for 7 days is safe and may improve spinal cord perfusion and, ultimately, neurological outcome. Hypovolemic shock Check for external and internal bleeding Resuscitate large bore ivs surgical intervention Neurogenic Shock Judicious fluid administration Monitors: CVP line Swan Ganz catheter Use of pressors Management principles suspected C spine injury NO neurodeficit “Normal’ X rays Immobilize Do obliques, CT scans No ## do Flex Ex views If unstable Fusion If ## seen Rx if stable with immobilization If unstable surgical fusion suspected C spine injury Normal neurology/ abnormal Xray Unstable traction/ halo then image CT/ MRI ligament disruption fusion bony disruption halo/ fusion Stable Hard collar then image CT/ Flex/Ex stable Hard collar (CERVICAL) CORD INJURY Trauma workup & immobilization Airway/ IV/ CVP/ FOLEY Steroids Image stable vs unstable Nonoperative vs operative Rx Dvt prophylaxis C spine injuries There is insufficient evidence to support treatment standards. Early closed reduction of cervical spine fracture-dislocation injuries with craniocervical traction is recommended to restore anatomic alignment of the cervical spine in awake patients. Closed reduction in patients with an additional rostral injury is not recommended. Patients with cervical spine fracture-dislocation injuries who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo magnetic resonance imaging (MRI) before attempted reduction. The presence of a significant disc herniation in this setting is a relative indication for a ventral decompression before reduction. MRI study of patients who fail attempts at closed reduction is recommended. Prereduction MRI performed in patients with cervical fracture dislocation injury will demonstrate disrupted or herniated intervertebral discs in one-third to one-half of patients with facet subluxation. These findings do not seem to significantly influence outcome after closed reduction in awake patient Steroids INCLUSION CRITERIA SCI ≤ 8 hrs Age ≥ 14 yrs. EXCLUSION CRITERIA Injury of nerve roots or cauda equina Gunshot wounds Life threatening morbidity Pregnancy Steroids Methylprednisolone Many RCTs >>men ,16-75 yrs NASCIS-1 : ‘84 no difference with MP NASCIS-2 : ’90 MP-- improved :1st 8 hrs. (30 mg/kg for 24hrs then 5.4mg/kg for 23 hrs) NASCIS-3 : ‘97 MP--improved(if started at 3-8 hrs continue to 48 hrs) Other drugs methylprednisolone tirilazad mesylate naloxone, GM-1 ganglioside DVT prophylaxis RECOMMENDATIONS low-molecular-weight heparins, rotating beds, adjusted dose heparin, or a combination Low-dose heparin in combination with pneumatic compression stockings or electrical stimulation DVT Duplex Doppler ultrasound, impedance plethysmography, and venography Vena cava filters are recommended for nonresponders Non-Operative Management Most studies uncontrolled and retrospective analyses Spontaneous recovery unpredictable, but generally occurs Timing to reduction is important Most dramatic benefit in bilateral jumped facets Surgical Decompression The only prospective randomized trial 62 patients with cervical SCI – 34 “Early” (< 72 hrs) surgery – 28 Late (> 5 days) surgery ASIA assessment No difference in neurological outcome Surgical Decompression Surgical benefit must be weighed against limited non-operative benefit Numerous studies, almost exclusively retrospective Strong experimental evidence for early decompression (animal data) Timing: early, late, and later no consensus Evidence inconclusive C-spine vs. T-L spine High energy vs. low energy Partial vs. complete – Spinal shock Definition of early surgery Role of steroids Type of decompression – traction vs. anterior vs. posterior Associated injuries