Neck and Spinal Cord Injury

Alpesh A. Patel MD FACSAssociate Professor

Chief, Orthopaedic Spine SurgeryCo-Director, Northwestern Spine Center

Director, Fellowship in Spinal SurgeryDepartment of Orthopaedic Surgery

Northwestern University Feinberg School of Medicine

Disclosures

ConsultingAmedica, Biomet, DePuy, GE Healthcare, Stryker Spine, Zimmer

Product Design/RoyaltiesAmedica, Ulrich Medical

Stock options/Ownership (<1%)Amedica, Trinity, Nocimed, Cytonics

BoardCervical Spine Research Society, Lumbar Spine Research Society, Indo-American Spine Alliance

Editorial BoardContemporary Spine Surgery, Surgical Neurology International

NMH Spinal Cord Injury Center

• RIC – Midwest Regional Spinal Cord Injury Center

• One of 14 national sites• NIH

Traumatic Spinal Cord Injury

• Cervical spine most common• 12,000 new cases

per year in U.S• Dramatic Injuries• Young, Fearless Population

SCI Grouped Etiology

1973-79 1980-84 1985-89 1990-94 1995-99 2000-04 2005-09 2010-120%

10%

20%

30%

40%

50%

60%

14.4% 14.2%10.2%

7.6% 7.0% 8.8% 8.0% 9.2%

Vehicular Accidents Falls Violence Sports

Year

Perc

enta

ge

Age at Injury and Gender

1973–1979 1980–1984 1985–1989 1990–1994 1995–1999 2000–2004 2005–201220

25

30

35

40

45

Males: 23,442 (80.7%) Females: 5,610 (19.3%)

203080 million people

20% of US population

Mortality

• Long-term– 23-66% @

1 year

Fasset JN Spine 2007Harris JBJS 2010

Falls and SCI

• Fall Risk– Propioceptive dysfunction– Neuropathy– Medications– Medical co-morbidities

• Pre-existing canal stenosis– Spondylotic disease– Asymptomatic

• 25-90% > 60 years old

Boden JBJS 1990Teresi Radiology 1987

Economic Costs

• >170 days of hospitalization - 1st 2 yrs• Direct costs – 12-14 billion US $ per yr• Indirect costs

– Lost wages– Caregivers– Lost productivity

What are the challenges facing spinal cord recovery?

The Acutely Injured The Chronically Injured

Historical Perspective

• Traction• Bedrest• Benign neglect

“One having a crushed vertebrae in his neck; he is unconscious of his two arms (and) his two legs, (and) he is speechless.

- Translation of the Edwin Smith papyrus, 3000 B.C.

an ailment not to be treated.”

Pathophysiology of Spinal Cord Injury

• Primary mediators:– Direct injury to

spinal cord tissue– Hemorrhage– Ischemia

IntactCord

Acute Spinal Cord Injury

MechanicalForces

PRIMARYINJURY

Acute Pathophysiologic Processes

+

SECONDARYDAMAGE

PRIMARY DAMAGESECONDARY DAMAGE

Goals of Treatment

Neurological Preservation

Spinal Stabilization

Neurological Regeneration

Evaluation• Standardized• Spinal Immobilization• Exam

– Neurological exam– Concomitant injuries

Current Interventions

• Surgical decompression• Optimizing spinal cord circulation• Steroids

Neurologic Recovery

LaterNow

When do we operate?

Timing of Surgery

Past – Timing of Surgery

• No urgency in treatment– “Early treatment” 3-5 days

• Early treatment = risk !– Neurological decline– Cardiopulmonary– Polytrauma

Marshall 1985, Vaccaro 1997, Mirza 1999, McKinley 2004…

Benefits of Early Surgery

• Neurological protection• Early stabilization• Quicker and safer mobilization• Decreased morbidity

– ICU stay– Pulmonary complications– GI complications

Schlegel, J. Orth. Trauma, 1996

Animal Data

• Primate– Kobrine et al 1978, 1979

• Feline– Brodkey et al 1972– Croft et al 1972

• Canine– Bohlman et al 1979– Delamarter et al 1995– Carlson et al1997, 2003

• Rats– Guha et al 1987– Zhang et al 1993– Dimar et al 1999

Human ModelsWe operated right awayand by the next morning

she was moving her legs!

The plural of anecdote is not evidence

• Multicenter, Non-randomized• 2002 to 2009• Acute Cervical SCI – 313 patients

– 182 Early (<24 hours): mean 14.2 hr– 131 Late (>24 hours): mean 48.3 hr

STASCIS

• SAFETY : Equivalent• RECOVERY (p<0.05)

1 GradeImprovement

2 GradeImprovement

*

**

LaterNow ?SCIEvidence

Current Interventions

• Surgical decompression• Optimizing spinal cord perfusion• Steroids• Hypothermia

Spinal Cord Circulation

Tator CH. Review of experimental spinal cord injury with emphasis on the local and systemic circulatory effects. Neurochirurgie 1991; 37:291-301. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg 1991; 75:15-26.

• Decline in Blood Flow After Trauma– Autoregulation disrupted by

trauma– Systemic hypotension

• Post-Traumatic Ischemia and Infarction– Microcirculatory changes– Blood flow drops to < 20

cc/100g/min within 2 hrs– Vascular congestion & vasogenic

edema– Neurogenic shock

Spinal Cord Perfusion

• PRESERVE cord perfusion• PRESERVE neuro function• AVOID

– Hypotension– Anemia

• No strong published guidelines

Spinal Cord Perfusion

• Mean arterial pressure >80– Optimize Volume (CVP)– Pressure support

• Hematocrit >30• Duration

– 3-7 days– ICU care

Steroids – Wonder Drug?

NASCIS II and III High Dose Methylprednisolone

IV bolus: 30 mg/kg Continuous infusion: 5.4 mg/kg/hr

If steroids given: Duration0-3 hrs post injury 24 hrs3-8 hrs post injury 48 hrs

Bracken, et al. JAMA 1997Bracken, et al. N Engl J Med 1990

NASCIS Limitations

• Methodology– Post hoc analysis– Arbitrary time cut-offs

• Transparency– Private data

• Objectivity– Drug sponsored studies– COMPLICATIONS

High Dose Steroids

• AVOID steroids in:– Neurologically intact– Nerve root injuries– Patients > 3-8 hours from injury– Gun shot wounds– Penetrating trauma– Elderly– Multiply injured– Dose >24 hours

Why do we use steroids?

• Therapeutic Benefit – 17%• Litigation – 70 %

Hurlbert et al 2002 and 2009

Neuroprotectives and Regenerative Strategies

Future Studies• Drug interventions

– TWO at Northwestern• Multi-center trials• IV treatments in patients with Cervical/Thoracic Acute

Spinal Cord Injury

Future Studies• Early detection

– Advance MRI studies: find patients at risk BEFORE they are injured

Right Now:

• Early Diagnosis and Comprehensive Treatment

Thank You