Spinal Cord Injury PDF

spinal cord injury spinal cord spinal cord injuryinjury -Mai Ahmad AL-balawnah -Dana salameen Normal anatomy & physiology  spinal cord injury Spinal Cord Injury (SCI) is damage to the spinal cord that results in a loss of function such as mobility or feeling due to...

spinal cord injury spinal cord spinal cord injuryinjury -Mai Ahmad AL-balawnah -Dana salameen Normal anatomy & physiology  spinal cord injury Spinal Cord Injury (SCI) is damage to the spinal cord that results in a loss of function such as mobility or feeling due to traumatic or non- traumatic causes.  Epidemiology -450,000 people live with SCI in USA. -10,000 new case\year. -82% are males between 16-30 years. -45% are complete spinal damage. -50% involve the cervical spine c5-c6. ->50% result in quadriplegia. -Co-morbidity Limb fractures - 67% Intrathoracic - 53% Head injury - 33%  Signs and Symptoms.. 1-Weakness, numbness, tingling sensations or loss of feeling 2-Painful movements of arms and legs 3-Pain or tenderness along spine 4-Burning sensations along the spine or in an extremity 5-Deformity to patients head, neck or spine 6-Injuries to the head 7-Loss of bladder or bowel control 8-Labored breathing with little or no chest rise  Causes 1.Traumatic SCI (car accident, gunshot, falls, etc.) 2.Non-traumatic SCI (polio, spina bifida, Friedreich's Ataxia, etc)  Traumatic SCI Mechanisms 1-MVC 48% 2-Falls 21% 3-Assaults 15% 4-Sport-related 14% (majority diving)  Spinal And Spinal Cord Injury Spinal injury Spinal cord injury -With or without cord injury -With of without spinal injury -Fractures -Neuronal injury -Dislocation -SCIWORA -Facet lock -Tx: decompression, then waiting spinal cord repair ???!!! -Tx: reduction, fixation and fusion  Tracts vs Nu -When theres injury to a tracts it will effect all the levels below the injury level -When theres injury to a Nu in the horns it will effect only at the level of the injury Note: !The white matter increases in the spinal cord as you go higher because the tracts keep adding up till reaching the destination. Note: The spinal cord does not have to be severed in order for a loss of functioning to occur. -SCI is very different from back injuries such as ruptured disks, vertebral fractures or spinal stenosis. Spinal injury&Bony injury !!! stable vs unstable fractures -stable: not displaced by normal movements. -unstable: significant risk of displacement and neural damage Neurological injuries is not always immediate and may occur or be aggravated only if there is a movement or displacement of vertebral fracture or dislocation (primary vs. secondary)  con..... So generally, it requires damage to both the ligaments and the bony column to produce unstable spine  Principles of diagnosis and management: -inappropriate movements during examination can change the outcome to the worse. -immobilization is abandoned only after serious spinal injuries has been excluded by clinical and radiological assessment. History: -High index of suspicion-signs and symptoms may be minimum. -Every patient with blunt injury above the clavicle, head injury or loss of consc. -Fall from height, crushing accident or high speed deceleration accident. -lesser injuries if followed by pain in the neck, back or neurological symptoms in the limbs. Examination (look, feel but not move!) -Inspect the head and the face for bruises. -Exam the neck for deformity, bruising or penetrating injuries. -The bones and soft tissues of the neck are palpated. -Tenderness bogginess or abnormal space between adjacent spinous processes (suggest unstable spin). Back: -log-rolled. -inspect and palpate the back. Full neurological examination: -carried out and repeated several time during the first few days. -Test each dermatome, myotome and reflex. The unconscious patient: Features suggesting spinal cord lesion: -Hx of fall or rapid deceleration. -Head injury. -Diaphragmatic breathing. -Flaccid anal sphincter. -Hypotension with bradycardia. -Pain response above but not below the clavicles.  0 Imaging: 1-X-ray Cervical spine: AP, lateral (c1 to t1) and open mouth. 2-ct-scan. for difficult area (lower cervical and upper thoracic ), damage to individual vertebra and displacement of bone fragments. 3-MRI. Intervertebral disc, lig.flavum and neural structures  Cervical spine injuries -hx: fall from height, diving accident, MVA in which the neck is forcibly moved. Examination: abnormal position of the neck, tenderness, pain and parasthesia. -imaging: -AP view: the lateral outline should be intact, spinous process and tracheal shadow at the midline. -lateral view: from c1-to t1. - open mouth for odontoid fractures.  Fracture of C1. "jefferson's fracture". -Result From sudden severe load from on the top of the head. -No encroachment of the neural canal, usually no neurological damage. -Open mouth view: spreading of the lat.masses away from the odontoid peg. Treatment: -stable, undisplaced fractures: rigid collar until the fractures unites. -unstable, sideway spreading of the lat.masses skull-traction, halo body orhtosis followed by semi rigid collar.  Fractured pedicle of C2 "hangman's" -Fracture of c2 pedicle with torn c1\c2 disc. -Extension with distraction. MVA when the forehead strike the dashboard. -Treatment: Undisplaced fracture: semi rigid collar or halo-vast until united. Displaced fracture: reduction then halo-vast for 12- weeks.  Fracture of the odontoid process Flexion injury due to high velocity accident or falls. -1\4 neurological involvement. -Three types: 1.Evulsion of the tip. 2. Through the junction of the odontoid peg and body. 3. Through the body Wedge-compression fractures -Pure flexion injury causes compression of the anterior part of the vertebral body -Stable injury, comfortable collar for 6-8 weeks. Burst fracture -Axial compression of the cervical spine. (usually in diving or athletic accident). -persistent neurological injury is common. Treatment: Neurological deficit call for urgent ant. decompression.  Burst fracture, C7 -Lateral view of the cervical spine demonstrates a comminuted vertical fracture through the body of C7. The posterior surface of C7 is displaced posterior toward the spinal canal (red arrow)while there is slight soft tissue swelling anteriorly (white arrow)  Thoracic spine injuries. -hyperflexion injuries. -wedge compression fracture are relatively common, mechanically stable but may lead to progressive kyphosis. -t11-t12 carry high risk of cord damage.  Thoracolumbar and lumbar injuries. -transition zone between the relatively fixed thoracic spine and relatively mobile lumbar spine. -stable vs. unstable. 1.post.osteoligamentus complex (posterior column). 2.Middle column. 3.ant.column. All fracture involving the middle column and at least one other should be regarded as unstable. -wedge fractures. -burst fractures. -fracture dislocation injuries to the spine may be complicated with spinal cord damage (burst fracture and fracture dislocation). which result in: 1.complete transection (paraplegia or quadriplegia). 2.incomplete transection (partial motor or sensory loss).  Complete SCI -Loss of all function below the level of the lesion -Typically associated with spinal shock  Incomplete SCI -Central cord syndrome -Anterior cord syndrome -Brown- Squared syndrome -Spinal cord injury without objective radiologic abnormality (SCIWORA)  Anterior cord syndrome -flexion-compression injuries, damage the ant.spinal artery cutting off the blood supply to the ant 2\3 of the spinal cord. -herniated Intervertebral disc.  Central cord syndrome -hyperextension cause the cord to be pressed between the body anteriorly and the bulging lig.flavum posteriorly.  Brown-Sequard syndrome -fracture dislocation, bullet or stab wound or by expanding tumor.  Spinal cord injury without radiologic abnormality (SCIWORA) No bony abnormalities on plain film or CT MRI may show abnormalities Usually in children; symptoms may be transient at first Should probably lead to immobilization to prevent subsequent development of cord damage  Secondary injury - After the initial macroscopic injury, secondary injuries are an important cause of disability - Movement of unstable spine. - Vascular insufficiency - Free radical induced damage  Neural control of blood pressure & blood flow -Complete lesions above T1 will eliminate all sympathetic outflow. -Lesions between T1 and T6 will preserve sympathetic tone in the head and upper extremities but deny it to the adrenals and the lower extremities. -Lesions between T6 and the lumbar cord will preserve adrenal innervations but denervate the lower extremities  ‘Spinal’ shock’ -Actually refers to the acute loss of segmental tendon reflexes , muscle tone and sensation below the level of a spinal cord lesion. -in most patients it persist for 24-hours, in others it may persist for as long as 1-4 weeks. as the shock diminishes the neuron regain there excitability and the effect of upper motor neuron loss will make there appearance.  -Hypotension in spinal shock is typically accompanied by bradycardia, reflecting loss of cardiac sympathetic efferents and unopposed vagal tone. -Neurogenic pulmonary edema is common in patients with cervical spinal cord lesions, complicating their management  management Volume resuscitation cannot be guided solely by physical findings Hypotension and bradycardia will persist regardless of the volume of saline or colloid administered -Replace the missing adrenergic tone with - agonists (phenylephrine or norepinephrine depending on heart rate)  Spinal perfusion pressure management Developed by analogy to cerebral perfusion pressure management Attempt to prevent cord ischemia by raising blood pressure Assumes that the same secondary injury mechanisms (hypotension and hypoxia) worsen the outcome from spinal cord injury as in head injury  Management -ABCs If intubation needed, use in-line stabilization Direct laryngoscopy vs. fiberoptic Maintain blood pressure with volume, packed RBCs, vasopressors as needed - Prevent secondary injury Log-rolling - Consider concomitant head injury  Management Pharmacologic: Methylprednisolone 30 mg/kg bolus then 5.4 mg/kg/h for 23 – 47 hours depending on latency from the injury Although there is still debate about its efficacy, this is the ‘standard of care’  Blood pressure No standards or guidelines Options: Avoid or correct hypotension (systolic BP < 90 mmHg) Maintaining MAP between 85 and 90 mmHg for the first seven days is recommended  Acute non-traumatic spinal cord injuries. 1.Disc 2.Tumor 3.Infection 4.Hemorrhage 5.Iatrogenic.  Cervical Disc with Myelopathy Clinical Features: -Neck Pain -Hand Numbness. -Weakness -Unsteadiness -Hyperreflexia -Usually Not Emergent  Lumbar Disc Clinical Features: -Low back pain -Sphincter disturbance – retention, incontinence, rectal tone. -Saddle anesthesia -Radicular symptoms (multiple roots) – pain, weakness  Spinal Metastases Clinical Features: -Cancer patient with back pain -10% of cancer patients -Lung, breast, GI, Prostate, melanoma, lymphoma, kidney  Spinal Epidural Abscess Clinical Features: -Back Pain, Fever, Tenderness -DM, IVDA, CRF…. -WBC may be normal Iatrogenic: