Principles of management of spinal cord injuriesDr. Rajendra Prasad FRCS FRCS(SN) : Principles of management of spinal cord injuriesDr. Rajendra Prasad FRCS FRCS(SN) Indraprastha Apollo Hospitals
New Delhi SCI : Incidence : SCI : Incidence Most of the spinal cord injuries (SCI) in India occur as a result of road traffic accidents or fall from heights.
India: 30 SCI per million per year or 26,000 per year.
M:F 3:1. Age : 18 to 30 yrs At risk: treat as SCI : At risk: treat as SCI All patients who have sustained polytrauma
Any unconscious trauma patient
Patient with minor trauma with complaints referable to the spine Management in the field : Management in the field Immobilization before and during extrication from a vehicle or removal of the helmet and immobilization during transport to hospital.
Patients should then be transported in a cervical hard collar and side head supports on a hard spine board with straps. Slide 5: Spinal immobilisation is a priority in multiple trauma,
spinal clearance is not. Clinical examination: : Clinical examination: The primary survey focuses on life-threatening conditions: ABC
D: Brain and spinal cord injuries must be considered concurrently. Glasgow Coma Scale.
When the ABC has been attended to, the patient is log-rolled and the whole spine palpated for injury. Slide 8: Attention is given to the respiratory rate, chest wall expansion, abdominal wall movement and pulmonary injuries.
The degree of respiratory dysfunction is ultimately dependent on pre-existing pulmonary co-morbidity, the level of SCI, and any associated chest wall or lung injury, head injury or effect of drugs or alcohol. Slide 9: Haemorrhagic shock may be difficult to diagnose because the clinical findings may be affected as autonomic dysfunction prevents tachycardia and peripheral vasoconstriction
Neurogenic shock occurs only in the presence of acute SCI above T6. Hypotension and/or shock with acute SCI at or below T6 is caused by hemorrhage. Frankel’s grades : Frankel’s grades After a careful neurological examination the SCI is most commonly graded using Frankel’s grades (A to E).
A; Complete motor and sensory
B: Sensory only below lesion
C: Sensory plus motor (useless)
D: Motor useful but not normal below the lesion
E: No neurological defecit. Slide 11: The neurological level of injury is the lowest (most caudal) level with normal sensory and motor function. For example, a patient with C5 quadriplegia has, by definition, abnormal motor and sensory function from C6 down. Slide 12: The cervical spine may be cleared clinically:
Fully alert and orientated
No head injury
No drugs or alcohol
No neck pain
No abnormal neurology Imaging Studies: : Imaging Studies: Plain X-rays: The standard 3 views of the cervical spine (AP, lat and odontoid) and AP and lat views of the thoracic and lumbar spine are recommended.
The cervical spine radiographs must include the C7-T1 junction to be considered adequate. Slide 14: Imaging the spine does not take precedence over life-saving diagnostic and therapeutic procedures. Slide 16: Some studies of spinal trauma have recorded a missed injury rate as high as 33%.
Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology Role of CT Scan : Role of CT Scan CT scan: CT cervical spine in all cases of head injuries or intoxication at the same time as the brain CT.
CT : when plain X-Ray is inadequate.
X-Ray depicts fracture or displacement whereas CT scanning provides better visualization of the extent and displacement of the fracture. Cervical spine : Cervical spine Role of MRI : Role of MRI MRI : for evaluating injury to the soft tissues and ligaments, discs, intrinsic cord damage (oedema, hematoma, or contusion) and Para vertebral soft tissues.
MRI is helpful in the assessment of brachial plexus injury Slide 22: Drawbacks of MRI :
-length of the imaging time
-susceptibility to movement artifacts,
-need for MRI-compatible monitoring and traction equipment.
The timing of the MRI in cervical spine injuries is debatable. If possible done before the halo traction is applied. Slide 25: Dynamic flexion/extension X-Ray -Ligamentous injury.
Patients with posttraumatic neck pain who are neurologically intact, and who have normal X-Ray should be placed in a rigid cervical collar and reevaluated 1 to 2 weeks later.
CT or MRI in limited flexion and extension is possible. Emergency Department Care: : Emergency Department Care: ABC
May need ventilatory assistance.
Lesions above T5 may be accompanied by loss of sympathetic tone : hypotension.
paralytic ileus : insert nasogastric tube.
Urinary retention : insert foley’s catheter
Vasomotor paralysis may cause poikilothermia (uncontrolled temperature regulation. Airway management : : Airway management : Clearing of oral secretions
Modified jaw thrust and insertion of an oral airway
Intubation may be required in high SCI. The ideal technique is fiberoptic intubation with cervical spine control.
Blind nasotracheal or oral intubation with in-line immobilization is acceptable. ICU care: Pulmonary function: : ICU care: Pulmonary function: Monitoring: pulse oximetry, frequent examination and ABG (6hrly).
Physiotherapy for the chest, suctioning and incentive spirometry
Lower cervical injuries with preserved diaphragm function may fatique after a few days resulting in hypoventilation particularly if pneumonia sets in. Slide 32: Indications for intubation in SCI are
Acute respiratory failure
Decreased level of consciousness (Glasgow score <9)
Increased respiratory rate with hypoxia, PCO2 more than 50. Slide 33: CMV / SIMV +/- PEEP
Chest physio, postural chest drainage and occasionally brochoscopy may be required.
Tracheotomy can potentially infect the anterior cervical surgical wound.
Emergency tracheostomy is reserved for absolute life and death situations Cardiovascular stability: : Cardiovascular stability: Systolic BP : above 90-100 mm Hg.
Heart rate should be 60-100 beats per minute in normal sinus rhythm. ( atropine).
Ionotropic support with dopamine may be required: if decreased urinary output despite adequate fluid resuscitation.
Bradycardia may require trans-venous electrical pacing for a few days / permanent pacemaker. Pharmacologic Treatment : Pharmacologic Treatment Three multi-center, randomized, controlled clinical trials carried out in the United States evaluated Methylprednisolone for acute SCI: National Spinal Cord Injury Study (NASCIS) I, II, and III.
The use of high-dose methylprednisolone in non-penetrating acute SCI had become the standard of care in North America.
Several papers have cited flaws in the study designs, trial conduct, and final presentation of the data. Slide 36: The Congress of Neurological Surgeons has stated that steroid therapy "should only be undertaken with the knowledge that the evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit."
The American College of Surgeons has modified their Advanced Trauma Life Support guidelines to state that methylprednisolone is "a recommended treatment" rather than "the recommended treatment." Slide 37: The administration of steroids remains an institutional and physician preference in spinal cord injury.
If steroids are used they should be initiated within 8 hours of injury with the following protocol: methylprednisolone 30 mg/kg bolus over 15 minutes and an infusion of methylprednisolone at 5.4 mg/kg/h for 23 hours beginning 45 minutes after the bolus. Slide 38: Traction: The objectives of cranio-cervical traction are to reduce fracture-dislocations, to maintain normal alignment or immobility of the cervical spine, to prevent further injury, to decompress the spinal cord and roots, and to facilitate bone healing. A common technique is placement of Gardner-Wells tongs.
Alternatively, traction may be applied with the patient in a halo ring. Slide 41: Fractures of the cervical spine are usually treated initially with careful application of traction or halo traction. Use of Halo intra-op & post-op : Use of Halo intra-op & post-op Slide 44: Surgical Treatment: The primary goals of treatment are to decompress and protect underlying neural structures, to restore spinal stability and alignment, to facilitate early mobilization and rehabilitation, and to maximize neurologic recovery. Slide 45: Patients with irreducible fractures or continued compromise of the neural elements are taken to the OT promptly for urgent surgical decompression and fixation after MRI. Slide 46: The efficacy of early surgical decompression in patients with thoraco-lumbar fractures is not established, except in cases where the neurologic examination reveals deterioration.
Most surgeons advocate urgent decompression in patients who have canal compromise and an incomplete injury. DVT propylaxis : DVT propylaxis The peak incident occurs at 7-10 days but patients remain at high risk for DVT and PE
Prophylactic : elastic stockings and mechanical pneumatic compression devices, Low molecular weight heparin
Diagnosis is by non-invasive Doppler studies but venography remains the goal standard.
Early ambulation is therefore vital. P.E : P.E Suspicion for PE must be high.
Classic symptoms of chest pain, dyspnoea, tachypoena and tachycardia may be absent.
IVC filters especially in those patients of DVT who cannot be anti-coagulated. GI and Nutritional care : GI and Nutritional care Early insertion of a naso-gastric or oro-gastric tube relieves ileus and is used for feeding as soon as bowel sounds return. If NG feeding is delayed because of prolonged ileus TPN is recommended.
Regular evacuation of the bowels. Abdominal distension can further compromise breathing GU care : GU care Urinary catheter: monitoring of urine output is essential for fluid management.
When the condition is stable the catheter is removed and intermittent catheterisation is started.
Over distention of the bladder : autonomic dysreflexia = severe hypertension, piloerection, skin flushing, anxiety and bradycardia. Skin care starts early : Skin care starts early Special attention must be given to the type of bed and mattress for the SCI patient however the most important step in preventing pressure sores is 2 hourly posture change. Prognosis: : Prognosis: Patients with a complete cord injury have a less than 5% chance of recovery.
The prognosis is much better for the incomplete cord syndromes. If some sensory function is preserved, the chance that the patient will eventually be able walk is greater than 50%. Currently, the 5-year survival rate for patients with a traumatic quadriplegia exceeds 90%. Slide 59: THANK YOU