spinal cord injuries
TRANSCRIPT
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FADHIL M. KALOKOLADAVID B. MBANYE PHILEMON RAHAEL
(MD5)
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Outlines
IntroductionAetiology & EpidemiologyMechanism of injuryclassificationNeurological evaluationWork upManagementComplications
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31 pairs of spinal nerves:8 cervical12 thoracic5 lumbar5 sacral1 coccygeal
Spinal cord:Extends from medulla oblongata – L1
Lower part tapered to form conus medullaris
Enclosed within 33 vertebrae
Anatomy :
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On the surface :Deep anterior median fissure Shallower posterior median sulcus
Spinal cord segment :Section of the cord from which a pair of
spinal nerves are given off
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Dorsal root – sensory fibres
Ventral root – motor fibres
Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve
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Physiology and functionGrey matter – sensory and motor nerve cells
White matter – spinal tracts - Ascending, descending and intersegmental
tracts
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Tracts :
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Posterior column and lateral corticospinal tract crosses over at medulla oblongata
Spinothalamic tract crosses in the spinal cord and ascends on the opposite side
NB Understanding this helps to reveal the
clinical features of injury patterns and the neurological deficit
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Dermatomes Area of skin innervated by sensory axons
within a particular segmental nerve root
Knowledge is essential in determining level of injury
Useful in assessing improvement or deterioration
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Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
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Myotomes : Segmental nerve root innervating a muscleAgain important in determining level of injury
Upper limbs:C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
Lower Limbs : L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Kneeflexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
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Definition
Insult to spinal cord resulting in a change, in the normal motor, sensory or autonomic function.
This change is either temporary or permanent.
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Terminologies Plegia = complete lesionParesis = some muscle strength is preservedTetraplegia (or quadriplegia)
Injury of the cervical spinal cordPatient can usually still move his arms using the segments
above the injury (e.g., in a C7 injury, the patient can still flex his forearms, using the C5 segment)
Paraplegia – paralysis of both LL Injury of the thoracic or lumbo-sacral cord, or cauda equina
HemiplegiaParalysis of one half of the bodyUsually in brain injuries (e.g., stroke)
Monoplegia is a paralysis of one limb only.Diplegia is a paralysis of two corresponding limbs (i.e.,
arms or legs).
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Causes of SCI
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CAUSES
MVAFalls Violence Sports injuries Gunshot InjuriesDiving accidents Blunt Assault Stab Wounds Sport Injuries
55% cases occur in 16 – 30yrs of age> 80% are male!
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Other causes:
Vascular disordersTumoursInfectious conditionsSpondylosisIatrogenicVertebral fractures secondary to
osteoporosis Development disorders
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Mechanisms:
i) Direct traumaii) Compression by bone fragments /
haematoma / disc materialiii) Ischemia from damage / impingement on
the spinal arteries
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Patterns of injury
Fracture
Dislocation
Fracture dislocation
SCIWORA
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SCI - Classification
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ASIA – American Spinal Injury Association
Based on neurological responses, touch & pinprick sensation (dermatome), +muscle strength.
A – Complete: no sensory or motor function preserved in sacral segments S4 – S5
B – Incomplete: sensory, but no motor function in sacral segments
C – Incomplete: motor function preserved below level and power graded < 3
D – Incomplete: motor function preserved below level and power graded 3 or more
E – Normal: sensory and motor function normal
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Can be1) Complete 2) Incomplete
Complete: i) Loss of voluntary movement of parts
innervated by segment, this is irreversibleii) Loss of sensationiii) Spinal shock
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Incomplete:
i) Some function is present below site of injury
ii) More favourable prognosis overalliii) Are recognisable patterns of injury,
although they are rarely pure and variations occur
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Incomplete injury syndromes
i) Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome
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i) Central Cord Syndrome : Typically in older patients Hyperextension injury Compression of the cord anteriorly by
osteophytes and posteriorly by ligamentum flavum
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Also associated with fracture dislocation and compression fractures
More centrally situated cervical tracts tend to be more involved hence flaccid weakness of arms > legs
Perianal sensation & some lower extremity movement and sensation may be preserved
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ii) Anterior cord Syndrome: Due to flexion / rotationAnterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal
Corticospinal and spinothalamic tracts are damaged either by direct trauma or ischemia of blood supply (anterior spinal arteries)
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Clinically: Loss of powerDecrease in pain and sensation below lesionDorsal columns remain intact
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ii) Posterior Cord Syndrome: Hyperextension injuries with fractures of
the posterior elements of the vertebrae
Clinically: Proprioception affected – ataxia and
faltering gait Usually good power and sensation
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Brown-Sequard syndrome
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v) Cauda Equina Syndrome: Due to bony compression or disc
protrusions in lumbar or sacral region
Clinically Non specific symptoms – back pain
- bowel and bladder dysfunction- leg numbness and weakness
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Spinal Shock
Transient reflex depression of cord function
below level of injuryInitially hypertension due to release of
catecholaminesFollowed by hypotensionFlaccid paralysis Bowel and bladder involvedSometimes priaprism develops Symptoms last several hours to days
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AsessmentSpinal shock
Bulbocavernosus reflex
Complete VS incomplete cord injury spinal shock Sacral sparing
Voluntary anal sphincter control Toe flexor Perianal sensation Anal wink reflex
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Neurogenic shock:
Triad of - i) hypotensionii) bradycardia iii) hypothermia
More commonly in injuries above T6
Secondary to disruption of sympathetic outflow from T1 – L2
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Loss of vasomotor tone – pooling of bloodLoss of cardiac sympathetic tone –
bradycardia Blood pressure will not be restored by
fluid infusion aloneMassive fluid administration may lead to
overload and pulmonary edema Vasopressors may be indicated
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Autonomic dysreflexia (AD)
A syndrome of massive imbalanced reflex sympathetic discharge
Occurring in patients with spinal cord injury (SCI) 48-90% in patients with SCI above T6 Above the splanchnic sympathetic outflow (T5-T6).
Primarily a male phenomenon; M:F=4:1
About 66% in females in labour
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Pathophysiology
Occurs after the phase of spinal shock in which reflexes return.
Below the injury, intact peripheral sensory nerves transmit impulses
That ascend in the spinothalamic and posterior columns
Stimulate sympathetic neurons located in the intermediolateral gray matter of the spinal cord.
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Inhibitory outflow above the SCI from vasomotor centres is increased,
Unable to pass below the block of the SCI.
Release of various neurotransmitters (dopamine-b-hydroxylase, norepinephrine, dopamine),
Causing piloerection, skin pallor, and severe vasoconstriction in arterial vasculature.
Sudden elevation in blood pressure + vasodilatation above the level of injury.
Headache caused by vasodilation of pain sensitive intracranial vessels.
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Increase in parasympathetic vagal tone by Vassomotor centers compensatory bradycardia.
Parasympathetic nerves prevail above the level of injury sweating and vasodilatation with skin flushing.
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Clinically
Headaches, and a sense of anxiety
sudden rise in both systolic and diastolic blood pressures, usually with bradycardia
profuse sweating above the level of lesion,
flushing of the skin
nasal congestion is common.
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Neurological evaluationMotor: how to test each segment?
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Sensory: how to determine the level?
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Spinal assessment
Palpate entire spine
DeformityGrating / crepitus
TendernessGapping interspinous spaces
BogginessLacerations
DRE, perineal sensation + tone
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Imaging modalitiesCT scanMRIX-ray - standard trauma series is composed of 5 x-ray
views: cross-table lateral, swimmer's, oblique, odontoid, Anteroposterior
Radiographic level = the level of fracture on plain XRays / CT scan / MRINB: spine level does not correspond to spinal cord
level below the cervical region
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Radiolographic evaluation X-ray Guidelines (cervical)
AABBCDS
Adequacy, Alignment Bone abnormality, Base of skull Cartilage Disc space Soft tissue
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Alignment• The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities
• Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation
• A step-off of >3.5mm issignificant anywhere
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Bones
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Disc
Disc SpacesShould be
uniform Assess spaces
between the spinous processes
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AP C-spine Films
Spinous processes should line up
Disc space should be uniform
Vertebral body height should be uniform. Check for oblique fractures.
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Swimmer’s view
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Open mouth view
Adequacy: all of : all of the dens and the dens and lateral borders of lateral borders of C1 & C2C1 & C2
Alignment: lateral : lateral masses of C1 and masses of C1 and C2C2
Bone: Inspect dens for lucent fracture lines
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Management
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Management….
Advance Trauma Life Support (ATLS) guidelines
Primary survey; ABCDE -Adequate airway and ventilation are the most
important factorsSupplemental oxygenationEarly intubation is critical to limit secondary
injury from hypoxia
Secondary surveys (e.g. Hx)
Initial Management
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Immobilization
Entire spine until when the x-ray are available
Supine, no rotation no bending
It protect further damage -Beware of decubitus ulcers
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Methods of immobilization
Rigid collar (Philadelphia hard collar)>>>
Sandbags and straps
Spine board
Braces
Log-roll to turn
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LogrollingAt least 4 people
1 Maintain inline manual immobilization 1 For the torso (trunk) 1 For the pelvis and legs 1 To direct the move
Move the pt towards the attendants as a unit
Maintain neutral position of the spine
Children have proportionally large heads
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IV fluidsPersistent hypotension after 2 liters neurogenic
shockUse of vasopressors Dopamine / AdrenalinInvasive monitoring; CVP and urethral catheters
SteroidsMethylprednisolone - 30mg/kg in the first 15minThen 5.4mg/kg/hr for 24-48hrs
Exclusion criteria Cauda equina syndrome Pregnancy Age <13 years Patient on maintenance steroids
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Mnx … cont
NGT Prevents aspirationDecompresses the abdomen (paralytic ileus is common
in the first days)
Foley catheterUrinary retention is common andFor monitoring
- Spinal assessment
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Care of paraplegics
Skin careBowel and bladderPsychological supportWheelchair rehabilitation
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Surgical Mnx
Indications for surgeryInstability
maintaining alignment to allow development of solid bone fusion;
preventing progression of deformity;
alleviating pain
progressive neurological deficit???? For early rehabilitation????
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complications HypotensionNeurogenic painSpinal shockhypothermiaparaplegiaSexually dysfunction Bladder + bowel
dysfunction -Incontinence -paralytic ileus -urinary problems
(UTI)
Weight loss or gainDepressionAutonomic dysreflexiaPressure sores (bed
sores)Pneumonia and
asthmaCVS diseasesSpasmsyringomyeliaDeep vein thrombosis -pulmonary embolism
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References:
1. ATLS, et al. Student Course Manual. 7th Edition 2004;7:177-204
2. Keith L Moore et al. Clinically Orientated Anatomy. 3rd Edition1992;4:359
3. Snell.Clinical.Neuroanatomy.7th.20094. Essential of Orthopedics
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