Spinal Cord Injuries

Bradley J. Phillips, MD
Burn-Trauma-ICU Adults & Pediatrics

Incidence

8,000-10,000 per year Mechanisms

MVC 48% Falls 21% Assaults 15% Sport-related 14% (majority diving)

Incidence

50% involve cervical spine (C5-6)

40% lead to quadriplegia

Limb fractures - 67% Intrathoracic - 53% Head injury - 33%

Co-morbidity

Cervical Spine Fractures

C5 C6

Anatomy & Biomechanics

Spine stability dependents

bone ligaments joints applied force

axial extension rotation

Biomechanics

Upper cervical spine

C1 - vulnerable to axial load (Jeffersons fx) C2 - vulnerable to hyperextension (Hangmans fx) C5-C7 - most common fx and dislocation
highly mobile vulnerable to hyperextension significant neurologic injury

Lower cervical spine

Biomechanics

Rotation + Flexion

unilateral locked facet severe - bilateral locked facet usually stable and no sig ligamentous disruption or neurologic injury
direct blows or extreme hyperflexion axial loading - compression or burst fx T12- L1 vulnerable to hyperflexion/axial force severe ligamentous injury, retropulsion of fragments

Thoracic spine

Pathophysiology

Actual mechanical transection rare Neural action potentials will not cross Immediate vascular disruption Leads to necrosis Rapid swelling of cord tissue Histologic changes max at 72 hours May extend for two segments proximally and distally !!!

Diagnosis

History

mechanism associated injuries

head and spine injury 6-15% of patients

Physical exam

MUST BE
conscious and alert non-intoxicated no distracting injury

Risk Factors for Cervical Injury

Blunt

potentially any blunt mechanism of injury

low risk

Penetrating

Diagnosis

Physical

palpate entire spine thorough neuro exam including

sensory (pinpoint, position) sacral function (rectal,bulbocavernosus reflex)

Complete or incomplete Clinical level is lowest nerve root providing good sensation/motor function

Markers of Nerve Root Function

C4-sensation to nipple motor to trapezius C5-sensory lat arm motor deltoid/biceps C6-sensory thumb/index motor wrist extension C7-sensory ring finger motor wrist flex/triceps C8- sensory little finger motor finger flexors T1-sensory medial arm motor hand intrinsic L1 - sensory pubis/lower abdomen

L2 - sensory ant thigh motor flexion at hip L3 - sensory knee and motor knee extension L4 - sensory medical calf motor dorsiflex ankle L5 - sensory lat calf and motor dorsiflex toes S1 - sensory fifth toe/heel motor plantar flex toes S2/3 -sensory back thigh/buttock motor anal spinchter contraction S4 - sensory perineum S5 - sensory perianal

Incomplete Syndromes

Pitfall
Unwise to predict neurologic outcome within 48 hours of apparently complete spinal cord injury

Xrays needed?

Cervical

neck tenderness, intoxication, abnormal neuro exam, distracting injury, difficult clinical exam
spine tenderness, MVC ejections, MCC, falls > 10 ft, neurologic deficit, difficult clinical exam

Thoracolumbar

Radiology Exam

Radiography bony deformation full bony excursion and damage at time of injury Films

Cervical spine
lateral odontoid AP Flexion/extension ? obliques

Lateral View

Adequate film C1-T1 top Column alignments

Anterior line of vertebral body Posterior line of vertebral body Junction of laminae with spinous process Tips of spinous process

Curvature overall

Lateral View - Helpful Measurements

2. 1.

3.

4.

5.

1. prevertebral space < 5 mm 2. atlantodental interval 2.5-3 mm 3. sup-inf vertebral align < 2.7 mm 4. ant-post body height < 3 mm 5. spinal canal width > 13 mm

Test - Whats Abnormal

Whats abnormal ?

Cervical Views

Odontoid

AP

Pitfalls
Absence of typical signs of spinal fracture on plain radiograph does not guarantee the absence of a fracture or predict stability

Focused CT

CT better than plain Xray?

Superior for Occiput - C3 in altered mental status patients

(Schenarts, J Trauma, 2001)

recommend obtain at time of CT Head Helical CT + plain films increased accuracy of detecting cervical spine injury from 54% to 100% (Barba, J Trauma,

2001)

recommend full Cervical CT at time of CT Head Conclusion: CT with plain films better in altered mental status and should be obtained with CT Head

Spine Instability

Indicators of instability on plain radiographs

> 5 mm subluxation bilateral jumped facets burst fractures with bone fragments in canal widening of interspinous space fractures of posterior element

Columns - 2 of 3 damaged Flexion/extension

plain radiographs - no pain & active full motion

Cervical Spine Clearance

Intubated and Difficult Exam
No
Clear Clinically

Yes
Abnormal Plain Films

Yes Yes

Meets Clinical Criteria (A)

Yes

No
Consult Spine Spine CT/MRI
Consult Spine: MRI Abnormal Plain Films

Consult Spine Spine CT/MRI

No
Clinical exam within 72 hours

No Yes
Abnormal Neurologic Exam

Yes

No
OR within 72 hours

Yes

Consult Spine Fluoroscopic Flex/Ex

No
Hard Collar F/U Spine Service

No
Meets High-Risk Criteria (B)

Yes

Posterior Cervical Midline Tenderness

Yes

Consult Spine: MRI

No
D/C Collar after Period of Observation

No
Consult Spine Spiral CT Occiput-C3

Criteria A

Criteria B High speed MVC (>35mph) MVC with death at scene Fall > 10 feet Significant closed head injury Referred cervical neurologic signs/symptoms Pelvic or multiple extremity fractures

No midline tenderness No focal neurologic deficit Normal alertness Negative toxicology screen No painful, distracting injury

Treatment

Immobilization Drug Therapies

Steroids GM-1 Gangliosides

Surgical management Rehabilitation

Steroids: blunt trauma

Standard of Care

National Acute Spinal Cord Study

within 8 hours of injury methylprednisolone 30mg/kg load, 5.4 mg/hr x23 hrs. result: slight but significant improvement in motor function and sensation at 6 months

NASCS 2nd trial

some benefit of 48hrs of steroids, but significant morbidity (severe sepsis and pneumonia)

Surgical Management

Subluxation/angulation

immobilization with traction not recommended with fractures

Halo brace Minerva jacket/vest

Braces

Surgical Management

C1 rotatory subluxation- after reduction treatment with Halo 3 months

C1 fx (Jefferson) - usually stable treat with hard collar (ligament injury- Halo) Odontoid fx - depend on type

Type I and III usually hard collar/halo 3 mos Type II - young (halo) and older (ORIF)

C2 fx (Hangmans) - Halo at least 3 months

Surgical Management

Lower cervical

fracture/dislocation - posterior ORIF with/without collar

compression/burst - anterior ORIF or halo

Thoracolumbar

compression without subluxation usually stable require brace only severe subluxation/retropulsion bone fragments require ORI

Timing of Surgery
Early

- Pro

Early - Con

provide

better restoration of bone alignment earlier decompression may improve neural function early stabilization prevents secondary cord injury early mobilization prevent pulm complications

adequate alignment by traction and closed manipulation early removal of bone fragments does not improve outcome benefits of early mobilization obtained by active PT Injury made worse

Timing of Surgery

Axiom - indications for early surgery

progressively worsening deficit persistent CSF leak failure to achieve spinal alignment by closed methods

Complications

*Cardiovascular

hemodynamics sinus bradycardia

*Venous Thromboembolism *Pulmonary problems Skin breakdown (most avoidable) Autonomic Hyperreflexia (usually above T6) Muscle spasiticity (trial of baclofen)

Complications

Gastrointestional

ileus (acutely need gastric decompression!!!) peritonitis

Malnutrition Hyperkalemia crisis (avoid succinylcholine) GU complications (infections) Heterotopic ossification

Cardiovascular Instability

Injury above T1-T2

disruption of descending sympathetic fibers

vasodilation myocardial dysfunction bradycardia

Effects = neurogenic shock (not spinal shock)

Cardiovascular Instability

Treatment

aggressive fluid resuscitation rule-out injury with continued blood loss vasopressors - alpha-agonists

Venous Thrombosis

Major risk factor ? Eventually all develop DVTs Significant PE in 10% Therapy

Mobilization/leg elevation Heparin (LMW vs Standard) Caval filters

Pulmonary Complications

Leading cause of death

pneumonia/atelectasis as high as 40% in quadriplegia (older study) aggressive pulmonary toilet (suctioning, quad cough, avoid NGT/FT if possible) positioning changes (manual, ROTO bed) check spontaneous TV frequently Ondines curse - ok awake, but lose respiratory drive asleep

Avoid intubation if possible

Rehabilitation

Begins immediately Objectives

maintain full range of motion of joints use of orthotics to prevent contractures muscle strenghtening patient education
self-range techniques activities of daily living

Prognosis

Depends

severity and location of injury age comprehensive rehab facilities

Early mortality

Mortality

< 50 = 11%

> 50 = 39%

Quadriplegia - 15-37% die within first year

Prognosis

Cause of death

pulmonary - 21%

20% who require vent assistance die within 3 mos

cardiovascular - 15% accidents, poisoning, or violence -10% infections - 9%

Prognosis

Up 7% have progressive decrease

neurologic function develop painful dysesthesias

syrinx - fluid in injured necrotic cavity compress surrounding tissue

Questions... ?