COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF MEDCINE
DEPARTMENT OF ANESTHESIA &CRITICAL CARE
SPINAL
CORD
INJURY

2
SPINAL CORD INJURY (SCI)

o Spinal cord injury (SCI):

 Insult to spinal cord resulting in a change, in the normal

motor, sensory or autonomic function.

 This change is either temporary or permanent.

06/25/2023 3
SPINAL CORD INJURY …

o Annually 15,000 permanent spinal cord injuries

o Commonly men 16-30 years old

o Male 4x more common than women

06/25/2023 4
SPINAL CORD INJURY …

o 25% of all spinal cord injuries occur from improper

handling of the spine and patient after injury.
 ASSUME that patient’s have a spinal injury.

 Manage ALL spinal injuries with immediate and

continued care.

06/25/2023 5
TYPES OF INJURIES

06/25/2023 6
SPINAL CORD ANATOMY

06/25/2023 7
SPINAL NERVE PLEXUSES

06/25/2023 8
SPINAL CORD INJURIES

o Concussion
 Similar to cerebral concussion
 Temporary and transient disruption of cord function
o Contusion
 Bruising of the cord
 Tissue damage, vascular leakage and swelling
o Compression
 Secondary to:
 Displacement of the vertebrae
 Herniation of intervertebral disk
 Displacement of vertebral bone fragment
 Swelling from adjacent tissue

06/25/2023 9
SPINAL CORD INJURIES …

o Laceration

o Causes

 Bony fragments driven into the vertebral foramen

 Cord may be stretched to the point of tearing

 Hemorrhage into cord tissue, swelling and disruption of

impulses
 Hemorrhage associated with contusion, laceration, or
stretching
06/25/2023 10
MECHANISM OF SCI

06/25/2023 11
TERMINOLOGY

o Plegia = complete lesion

o Paresis = some muscle strength is preserved
o Tetraplegia (or Quadriplegia)
 Injury of the cervical spinal cord
 Can move arms using the segments above the injury
o Paraplegia
 Injury of the thoracic/ lumbo-sacral/or cauda
equine
o Hemiplegia
 Paralysis of one half of the body
 Usually in brain injuries (e.g., stroke)
06/25/2023 12
DEGREE OF INJURY

o Complete transection

 Total paralysis and loss of sensory and motor function

although arms or rarely completely paralyzed

o Incomplete (partial transection)

 Mixed loss of voluntary motor activity and sensation

06/25/2023 13
COMPLETE

06/25/2023 14
INCOMPLETE

06/25/2023 15
SIGN AND SYMPTOM OF SCI

o Extremity paralysis
o Pain with & without movement
o Tenderness along spine
o Impaired breathing
o Spinal deformity
o Posturing
o Loss of bowel or bladder control
o Nerve impairment to extremities
o Neurogenic shock

06/25/2023 16
SPINAL CORD PARALYSIS LEVELS

o C1-C4
 All daily functions must be totally assisted
 Breathing is dependant on a ventilator
 Motorized wheelchair controlled by sip and puff or chin
movements is required
o C5
 Good head, neck, shoulder movements, elbow flexion
 Electric wheelchair, or manual for short distances

06/25/2023 17
SPINAL CORD PARALYSIS LEVELS …

o C6
 Wrist extension movements are good
 Assistance needed for dressing, and transitions from bed
to chair and car may also need assistance
o C7-C8
 All hand movements
 Able to dress, eat, drive, do transfers, & upper body
washes
o T1-T4 (paraplegia)
 Normal communication skills
 Help may only be needed for heavy household work or
loading wheelchair into car.

06/25/2023 18
SPINAL CORD PARALYSIS LEVELS …

o T5-T9
 Manual wheelchair for everyday living
 Independent for personal care
o T10-L1
 Partial paralysis of lower body
o L2-S5
 Some knee, hip and foot movements with possible slow
difficult walking with assistance or aids
 Only heavy home maintenance and hard cleaning will
need assistance

06/25/2023 19
SPINAL VS NEUROGENIC SHOCK

o Spinal Shock :
 Transient reflex depression of cord function below level of
injury

 Initially hypertension due to release of catecholamines

 Followed by hypotension

 Flaccid paralysis

 Bowel and bladder involved (Bladder overflow incontinence

and Paralysis of the bowel wall)

06/25/2023 20
 SPINAL VS NEUROGENIC SHOCK …

06/25/2023 21
 SPINAL VS NEUROGENIC SHOCK …

06/25/2023 22
 SPINAL VS NEUROGENIC SHOCK …

o Neurogenic shock:
 Seen in cervical injuries
 Due to interruption of the sympathetic input from
hypothalamus to the cardiovascular centers
 Hallmark (triads):
 hypotension (vasodilation, due to loss of sympathetic
tonic input)
 bradycardia (due to inability to convey the
information to the vasomotor centers in the spinal
cord)
 Hypothermia

06/25/2023 23
AUTONOMIC DYSREFLEXIA

o Commonly seen in clients with upper spinal cord injury.

o Occurs after spinal shock.

o Cause is some noxious stimuli

o s/s include:
o severe hypertension, bradycardia, severe

headache, nasal stuffiness, flushing above site of SCI.

06/25/2023 24
AUTONOMIC DYSREFLEXIA …

o Emergency:
– Severe, pounding headache
– Paroxysmal hypertension, flushing
– Profuse diaphoresis, bradycardia

o Interventions:
– Remove stimulus – e.g., empty bladder…
– Sit patient up to decrease BP
– Apresoline may be given IV.

06/25/2023 25
SURGICAL MANAGEMENT

o Preoperative (Initial) evaluation and care

o Diskectomy

o Laminotomy

o Laminectomy

o Spinal fusion (arthrodesis)

06/25/2023 26
INITIAL ASST & IMMOBILIZATION

o History
 Pain/paresthesia
 Transient or persistent motor or sensory symptoms
o Physical Examination
 Abrasions/hematoma, tenderness
 Interspinous process widening
 Babinski, holdup tests and dermatomes.
o Investigations
 CT, MRI, X-Ray

06/25/2023 27
 ANESTHESIA
CONSIDERATIONS FOR
SCI

28
ANESTHESIA CONSIDERATIONS

1. Secure the airway, support respiratory status, and consider postoperative

ventilatory support.

 All surgery for acute SCI requires GA with ETT.

 Secure the airway safely without exacerbating SCI.

 Technique used depends on: amount of time elapsed since injury, the NPO status,
the anticipated DAW, ± C spine injury, & anesthetist experience.

 Succinylcholine – safe in the 1st 48 hours.

06/25/2023 29
CONT …

 Blood loss & prone positioning may compromise RS.

 Lung compliance may be reduced.

 Transfusion-related ALI may develop.

 Surgical intervention may exacerbate neurological deficit with increased

diaphragm weakness (Lesions of C5 & above - at risk for respiratory failure)

 Have a low threshold for transfer patient to the ICU.

06/25/2023 30
CONT …

SCI Respiratory Sequale:

 Atelectasis

 Ventilatory failure (PaCO2 > 50mmHg and pH < 7.30)

 Increased secretions

 Pneumonia

 Pulmonary emboli

 Pulmonary edema

06/25/2023 31
CONT …

2. Maintain MAP and perfusion.

 As a result of autonomic instability, injuries ± T4 are associated with hypotension.

 Responds poorly to IV fluid

 Choice of drug depends on the level of the SCI.

 A high thoracic or cervical SCI – Chronotropic, inotropics & vasoconstrictor

(Dopamine & norepinephrine)

 Low thoracic lesions - Pure vasoconstrictor, (Phenylephrine)

06/25/2023 32
CONT …

3. Anticipate bradycardia & hypotension during intubation of tetraplegic

patient.

 Hypoxia or manipulation airway may cause profound bradycardia

 Atropine pretreatment may be appropriate.

 PPV can cause profound hypotension

 IV fluid administration prior to intubation with vasopressor support is frequently

required

06/25/2023 33
CONT …

4. Avoid use of succinylcholine after the 1st 48 hours post-SCI.

 Upregulation of acetylcholine receptors on denervated muscle  fatal

hyperkalemia response to succinylcholine.

 Safe time is variable, but the first 48 hours.

 In SCI patients, it is uncertain whether the risk of hyperkalemia ever resolves,

and many clinicians avoid using succinylcholine indefinitely in this setting.

06/25/2023 34
CONT …

5. Monitor temperature, warm IV fluids, and use a patient warming device as

needed.

 The problem of unintended heat loss is common to all patients under GA and more so
in patients following SCI.

 Thermoregulation is impaired more severely in those with higher lesions due to

cutaneous vasodilation.

 IV fluid warmers, warm air blankets, and continuous temperature monitoring are
essential.

06/25/2023 35
 CONT …

6. Consider use of intraoperative spinal cord monitoring

• Intraoperative somatosensory-evoked potential (SSEP) or motor-evoked potential (MEP)

monitoring evaluates the integrity of the spinal cord during spinal surgery.

• SSEP signals are fairly tolerant of volatile anesthetics while MEP quality is severely
degraded.

• IV anesthesia with Propofol is commonly used.

• Availability of a monitoring ???.

• Use wake up test instead.

06/25/2023 36
WAKE UP TEST
o Lightening anesthesia at an appropriate point during the procedure and observing the
patient’s ability to move to command.

o It evaluates the gross functional integrity of the motor pathway.

Anesthesia requirements:
 As easy and as rapid to institute as possible

 Reliable but quickly antagonized

 Wakening should be smooth

 No pain during the test

 No recall

06/25/2023 37
WAKE UP TEST …

Advantage

o No special equipment is required

Disadvantage

o Intermittent monitor

o Patient discomfort and

o Increased blood loss

06/25/2023 38
MAINTENANCE OF ANESTHESIA

o Altered pharmacokinetics due to

1. Muscle wasting
2. Increased volume of distribution
3. Decreased serum albumin
4. Proliferation of extrajunctional receptors

o Nitrous oxide, narcotics, Propofol with or without inhalational agent can be used
safely and effectively.

06/25/2023 39
EXTUBATION

o Extubation is usually performed in the OR immediately following surgical procedures.

o Postoperative ventilation may be required for patients with:

1. Pre op pulmonary dysfunction

2. High cervical cord surgery
3. Hemodynamic instability
4. Prolonged procedure with massive fluid shift
5. Any case of expected difficult re-intubation

06/25/2023 40
POST –OP CARE
o Neurovascular checks
o Log rolling
o Muscle relaxants
o pain management
o Prevent infection, assess CSF leakage
o Prevent complications
Patient Teaching:
o Body mechanics, avoid strain, maintain alignment
o Maintain appropriate weight
o Exercise 15 min BID.
o Avoid standing long periods.
o Sleep on side with pillow between knees.

06/25/2023 41
PERIOPERATIVE COMPLICATIONS

Airway obstruction : edema, hematoma, recurrent laryngeal nerve palsy.

Respiratory: motor paralysis and infection (pneumonia).

Cardiovascular: hypotension, bradycardia, arrhythmias, hypertension ( spinal

cord injury, carotid sinus stimulation).

06/25/2023 42
PERIOPERATIVE COMPLICATIONS …

Neurological: Injury to nerve roots – as a result of direct surgical:

 Manipulation

 Injury to lower cranial nerves – VII, IX, X, XII

 Injury to peripheral nerves - as a result of positioning

 Injury to spinal cord .

06/25/2023 43
PERIOPERATIVE COMPLICATIONS …

Vessel injury – vertebral and carotid artery during dissection

Tracheal and oesophageal injury

CSF leaks - due to tear of dural and arachnoid membranes can lead to meningitis,
pseudomeningocoele, permanent CSF fistula

DVT – seen in 30% of neurosurgical patients, especially those who had been
paraplegic.

Pulmonary embolism

06/25/2023 44
RISK OF SPINAL CORD DAMAGE

Risk of damage depends upon:

 Length and type of surgical procedure – removal of intramedullary tumors

 Spinal cord perfusion pressure – vascular compromise

 Pressure on neural tissue during surgery - mechanical compression, direct injury

due to instrumentation

06/25/2023 45
RISK OF SPINAL CORD DAMAGE …

o Risk can be minimized by

 Careful positioning

 Maintenance of SCPP

 Drugs : Methylprednisolone within 8 hours after insult

06/25/2023 46
 READING ASSIGNMENT

• Trauma in pediatrics
• Trauma in pregnancy

06/25/2023 47
THANK
YOU!
48
49