REHABILITATION OF SPINAL

CORD INJURY
Spinal Cord Injury (SCI)
• “an ailment not to be treated” – earliest reference to SCI in Edwin
Smith Surgical Papyrus, 2,500-3,000 BC
• SCI is damage to the spinal cord due to trauma. It usually results from
a sudden traumatic blow to the spine that fractures or dislocates
vertebrae, causing bruising or tearing of the spinal cord tissue.
EPIDEMIOLOGY OF TRAUMATIC SCI
• Incidence – 40 new cases/million
• Prevalence – 250,000 persons (US)
• Age – young adults, 16 & 30
• Average – 39.5 y/o
• Gender – Men > women, 4:1 ratio
• Etiology
• Motor vehicle crashes (MVC) (42%)
• Falls (27.1%)
• Acts of violence (15.3%) (gunshot wounds [GSW])
• Recreational sporting activities (7.4%)
• Associated injuries – most common are:
• broken bones (head, chest, ribs, long bones)
• loss of consciousness
• traumatic pneumothorax (more in GSW)
• Neurological Level & Extent of Lesion
• most common – cervical lesions (50%) > thoracic > lumbosacral lesions
• most common lesion level – C5 segment > C4, C6, T12, L1
• most frequent neurologic category at discharge from rehabilitation:
• incomplete tetraplegia (34%)
• complete paraplegia (23%)
• incomplete paraplegia (18.5%)
• complete tetraplegia (18.3%)
• Life Expectancy
• Mortality rates – higher during 1stt year after injury
• Predictors of mortality:
• Male gender
• Advanced age
• Ventilator dependence
• Injury by act of violence
• High injury level (C4 or above)
• Neurologically complete injury
• Poor self-related adjustment to disability
• Poor community integration
• Poor economic status indicators
 • Mortality rates in complete injuries:
• higher in high tetraplegia (C1-3) > mid/low tetraplegia > paraplegia
• Causes of Death
• Diseases of respiratory system - pneumonia (most common)
• Tetraplegia
• Heart disease
• Paraplegia
• Injured for >30 years
• Patients >60 y/o
• Septicemia (assoc. w/ pressure ulcers, urinary tract or respiratory infections)
• Paraplegia
• Cancer (most common in lung > bladder > prostate > colon/ rectum)
• Suicide – highest in younger patients
• Paraplegia
ACUTE MEDICAL & SURGICAL MANAGEMENT
• Treatment – begins at the scene
• All trauma victims – spine immobilized
• w/ a rigid cervical collar
• w/ supportive blocks on a backboard
• w/ straps to secure entire spine
• transferred onto a firm padded surface
• maintaining spinal alignment to prevent skin breakdown
• via logrolling until spinal injury has been ruled out
• Traditional CPR methods  jaw-thrust maneuver to access airway
• Important after injury:
• prompt resuscitation
• stabilization of spine
• avoidance of additional neurologic injury & medical complications
• 1st seconds after SCI  catecholamines  initial hypertensive phase
 state of spinal shock (flaccid paralysis & extinction of muscle
stretch reflexes below the injury level) w/ 4 phases from initial loss of
reflex activity to hyperreflexia
• Neurogenic shock
• part of the spinal shock syndrome
• direct result of reduction in sympathetic activity below level of injury
• hypotension
• bradycardia
• hypothermia
• Treatment of hypotension – fluid resuscitation (1-2 L) – adequate urine
output of >30 cc/h
• neurogenic shock, further fluid administration
• proceed cautiously
• risk for neurogenic pulmonary edema
• vasopressors
• MAP at 85 mmHg during 1st week post-injury
• Bradycardia – in acute period in cervical spinal level injury
• treated: <40/min or symptomatic w/ IV atropine (0.1-1 mg)
• prevented by: atropine prior to any vagal stimulation maneuvers
(nasotracheal suctioning)
• significant bradycardia  resolves w/in 6 weeks
• cardiac pacemaker implant to facilitate safe mobilization
• Respiratory assessment is critical
• ABG & FVC – assessment of respiratory muscle strength
• VC <1 L – ventilatory compromise, requires assisted ventilation
• NGT – to prevent emesis & aspiration
• Foley catheter – for urinary drainage & accurate assessment of UO
until hemodynamically stable
• Emergency department
• baseline neurological examination, maintaining spinal precautions
• Imaging studies
• assess spinal fracture, instability, &/or spinal cord pathology
• X-rays
• CT scan  C1 to C7
• MRI  neuronal structures
• Noncontiguous fractures – when 1 fracture is identified, careful inspection of
the rest of the spine
• Stiff spine & midline tenderness – suspect fracture (esp. in spondylosis,
ankylosing spondylitis, or diffuse interstitial skeletal hyperostosis [DISH])
• Objects embedded around spinal canal  left in place w/ removal in
the OR
• IV methylprednisolone – adults after acute SCI
• MOA:
• improve blood flow to spinal cord
• prevent lipid peroxidation
• free radical scavenger
• anti-inflammatory function
• Anesthesia – avoid use of succinylcholine after 1st 48 hours postinjury
– potentially fatal hyperkalemic response
Spinal Stability & Principles of Spinal
Stabilization
• Spinal instability
• “the loss of the ability of the spine, under physiologic loads, to maintain its
pattern of displacement so that there is no initial or additional neurological
deficit, no major deformity, & no incapacitating pain” (White & Panjabi)
• present if any 2 of the 3 columns are violated (“three-column theory” for
thoracolumbar fractures by Denis)
• primary goal of surgical intervention in acute SCI  decompress
neural elements either by anterior or posterior approach
• Postoperatively, or if surgery is not required – orthosis maintained for
3 months
Specific Injuries to the Spine
• Atlas fracture (“Jefferson” burst fractures)
• fracture of the vertebrae of C1
• stable injuries – Halo-vest orthosis
• unstable injuries – posterior surgical stabilization
• Odontoid fractures (Peg or Dens fractures)
• Type I
• very rare
• fracture of odontoid process tip
• Type II
• more common, in elderly
• fracture through base of the odontoid process, at its junction w/ C2 vertebral body
• internal stabilization
• Type III
• base of the odontoid into body of C2 vertebra proper
• external orthosis for 3 months
• Pedicles of C2 fractures (“Hangman’s” fractures)
• bilateral & stable injuries
• abrupt deceleration injury
• external orthoses
• Pure bony injuries in the subaxial spine (C3-7)
• w/o substantial neurologic compression – external orthosis alone
• ligamentous injuries – open surgical intervention to decompress &/or fuse the
cervical spine
• most common burst fracture in the cervical spine – C5 vertebra
• T12 vertebra fracture
• most common thoracic spinal injury
• Unstable injuries – stabilization & fusion
• Chance fracture
• horizontal splitting of vertebra extending from posterior to anterior through
spinous process, pedicles & vertebral body
• most common – thoracolumbar spine (T12, L1, or L2)
• acute hyperflexion of the back (“seat-belt” fractures)
• L1 burst fractures – most common in lumbar spine
• fall from a height
• conus medullaris &/or cauda equina
• Early spinal decompression w/in 8-24 hours
• may improve neurological recovery esp. in incomplete injuries
• Early surgery:
• reduces LOS in acute hospital
• facilitates rehabilitation
• decreases hospital costs
• reduces postoperative complications
• Current indication for emergent surgical treatment – progressive
neurologic deterioration