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Acute Spinal Cord Injuries

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					Acute Spinal Cord Injuries

    Scott Paquette MD, FRCSC
           Neurosurgeon
            UBC, VGH
             CNOSP
                 Overview
•   ATSL
•   Radiology
•   Spinal Cord Injury
•   What happened to steroids?
•   The First 72 hours
•   Issues for transfer
   Treatment of Spinal Injuries
• No Current Effective Treatment

• Prevention is Key
  • all current medical and surgical treatments
    aimed to prevent further injury to the spinal
    cord.
Frida Kohlo de Rivera “The broken column”
                   1940
          ATLS principles
• A irway; protect Cspine
•   B reathing
•   C irculation
•   D isability, Dx and Rx shock
•   E xpose patient
•   Treat (IV, XR chest/Cspine)
•   Secondary survey
       Complex spinal trauma
 Radiological evaluation   Cervical spine


X-ray Guidelines (cervical)
 • Adequacy, Alignment
 • Bone abnormality, Base of
   skull
 • Cartilage, Contours
 • Disc space
 • Soft tissue
• Clinical exam
  • Neuro deficits
  • Pain
  • Step deformities
• Radiographic studies
  • Xray
     • Bones, alignment
  • CT
  • MRI
     Soft tissue, ligaments
           Late fracture diagnosis
• 10-15% of all neck fractures
•   Pain persists
•   Deformity progresses
•   Disability prolonged
•   Late reconstruction is complex
               Missed fracture risks
•fracture displacement
•pain
•paralysis
•litigation
… serious problems well under 2%
                    Spine clearance
Purpose:
•    to identify accurately and early following blunt injury to the
    spine the presence or absence of a diagnosis of spinal column
    injury
                 Spine clearance
Ensuring that:
• there is no spinal injury to produce avoidable symptoms or
  disability
• there is no “important” fracture
• we avoid overprotection with its attendant risks
                Gold standard?

       - demonstration of a painfree physiological range of
motion in an alert and cooperative patient.

Options:
       - image the spine to identify any fracture
       - provide protection meanwhile
               Spectrum of Stability

• Pure Ligament Injuries




• Pure Bone Fractures
•26yrs male MS, MVA
 • alcohol level – 3 drinks
 • high speed MVA, no seat belt, partially ejected
 • partial paralysis, improved to ASIA C in Emerg
 • Xrays neg, hob elevated, pillow placed, „crack‟ felt
 • loss of motor and sensory function, priapism
 • re-imaged, reduced at 6-8 hours, stabilised
 • C7 ASIA A tetraplegia
•26yrs male MS, MVA




                      C6
•26yrs male MS, MVA




             C6
•26yrs male MS, MVA
   •Elderly male, fall
        • broken ribs, pulmonary contusions, CHI – GCS 11
        • weaned from mechanical ventilation
        • fracture service confirmed normal spinal imaging
        • ICU service insisted on „clinical clearance‟
        • spinal precautions maintained
            • supine
            • log rolled by 4 staff for procedures
            • stiff collar
        • day 10, still not alert, spinal precautions stopped

Morris et al BMJ Sept 2004
Morris et al BMJ Sept 2004
 •Elderly male
      • extensive sacral ulcer - debrided
      • repeated sepsis episodes
      • high dose opioids
      • pneumonia
      • mechanical ventilation




Morris et al BMJ Sept 2004
 •Elderly male
      • extensive sacral ulcer - debrided
      • repeated sepsis episodes
      • high dose opioids
      • pneumonia
      • mechanical ventilation
      • died at 73 days after admission to ICU
      • no spinal injury found before or after death



Morris et al BMJ Sept 2004
       ..first do no harm..



Morris et al BMJ Sept 2004
            Which……..
•   which fracture?
•   which patient?
•   which caregiver?
•   which imaging?
             Unimportant fracture?
• isolated osteophyte avulsion fracture
• isolated transverse process fracture
             • no facet

• isolated fracture of spinous process
             • not lamina

• simple compression fracture <25%
  Stiell et al 1999
         (129 emerg phys and
                               Hoffman et al
         spine specialists)    2000 (NEXUS)
          Which patients?
•   Low/high velocity?
•   Previous spine disease?
•   Alert and compliant?
•   Impaired cognition?
•   Obtunded?
          Which patients?
•   Low/high velocity?
•   Previous spine disease?
•   Alert and compliant?
•   Impaired cognition?
•   Obtunded?
             Xrays in alert patient
                       Stiell et al CMAJ 1997



•   Acute blunt trauma to head or neck
•   Alert and stable patients
•   3979/6855 Xrayed
•   Xray rate varied six-fold
•   No fracture missed
•   Clinical decision rules suggested to save cost by
    using fewer Xrays
The Canadian C-spine Rule for alert and stable trauma patients where
cervical spine injury is a concern.
Any high-risk factor that mandates radiography?
   • Age>65yrs, or
   • Dangerous mechanism*, or
   • Paresthesias in extremities
                             No
Any low-risk factor that allows safe assessment                 Yes
   of range of motion?
   • Simple rear-end MVC#, or                   No
   • Sitting position in ED, or                                Radiography
   • Ambulatory at any time, or
   • Delayed onset of neck pain$, or
   • Absence of midline C-spine tenderness
                            Yes                              Unable
Able to actively rotate neck?
   • 45 degrees left and right
                            Able
                  No Radiography                 From Stiell I et al JAMA Oct 2001
The Canadian C-spine Rule from Stiell I et al JAMA Oct 17 2001



*Dangerous Mechanism:
  •Fall from 1meter/5 stairs
  •Axial load to head eg diving
  •MVC high speed (>100km/hr), rollover, ejection
  •Motorised recreation vehicles
  •Bicycle collision
#Simple    rear-end MVC excludes:
  •Pushed into oncoming traffic
  •Hit by bus/large truck
  •Rollover
  •Hit by high-speed vehicle
$Delayed:

  •Not immediate onset of neck pain
The „NEXUS nos‟
National Emergency X-Radiography Utilization Study (NEXUS)




NEXUS:
“Low-Risk” = None of the Listed Criteria
      1. Altered level of alertness
      2. Evidence of intoxication
      3. Posterior midline C-spine tenderness
      4. Distracting painful injury
      5. Focal neurologic deficit

                                     Hoffman JR et al NEJM. 2000;94-99.
                      Radiography?
• Decision Rule positive? Then..
• Xrays - lateral to C7T1, AP, odont.
   • no fracture, normal neurology, abn alignment?
   • flex/ext views if pain permits
   • Xray negative, pain persists - bone scan

• CT - directed
   •   if a region inaccessible
   •   if CR positive
   •   to clarify xray for management
   •   if bone scan positive                    C7
      National Emergency X-
   Radiography Utilization Study
             (NEXUS)
                       Vs
     The Canadian C-spine rule?
Both have:
•Excellent negative predictive value for excluding
patients identified as low risk
•Poor positive predictive value as most „no-low-
risk‟ patients do not have a fracture
Limitations of
    Xray




                 Barba et al J Trauma Oct 2001
Kwon and Albert 2006
The plain radiograph
failed to detect spinal
injury in six patients
(46%), four of whom
had adequate views of
the affected area (Fig.
2).




           C6

   Barba et al J Trauma Oct 2001
Barba et al J Trauma Oct 2001
Selective use of helical CT scanning with plain
radiography increased the accuracy

                                  Barba et al J Trauma Oct 2001
Crim et al Seminars in US, CT and MRI 2001
Crim et al Seminars in US, CT and MRI 2001
• http://www.bcit.ca/appliedresearch/multime
  dia/downloads.shtml
                 Acute SCI Care:
                What is the Evidence?

• Collected Wisdom…
  • From clinical experts
• Evidence-Based Practice…
  • Standards – Class I evidence
  • Guidelines – Class II evidence
  • Options – Class III evidence
                                      www.pva.org




Clinical Practice Guidelines
Consortium for Spinal Cord Medicine       “Consortium”
   Section on Disorders of the Spine and
Peripheral Nerves of the AANS and the CNS.
 Pub Neurosurgery Supp, March 2002 “Neurosurgery”
      Before the Hospital…..
C-spine Immobilisation-
Options:
• Protect the spine
• Expeditious and appropriate transport to the
  nearest capable definitive care medical facility




                                          Neurosurgery
www.tc.bcit.ca/gait/projects/spinal.shtml
     Immediate Management-
             Goals:
•   Resuscitation according to ATLS guidelines
•   Determination of neurological injury
•   Prevention of neurological deterioration
•   Ongoing ID & Tx of assoc injuries
•   Prevention of complications
•   Initiation of definitive management for
    vertebral column injury or SCI
www.bcit.ca/appliedresearch/multimedia/downloads.shtml
                 Suspicion of
               Neurologic Injury


• History
  • Pain/paresthesias
  • Transient or persistent motor or sensory
   symptoms
• Physical Examination
  • Abrasions/hematoma
  • Tenderness
  • Interspinous process widening
       Clinical Assessment



• Neurological Classification:
  •   Use the ASIA International standards
  •   Motor and sensory assessment
  •   ASIA Impairment Scale (A-E)
  •   Clinical Syndromes (patterns of incomplete injury)
                                           Neurosurgery
  ASIA/ISCoS International Neurological
               Standards




American Spinal Injury Association International Standards for Neurological and
       Functional Classification of Spinal Cord Injury (Revised 2002).
       Level of Lesion
“The most caudal normal motor and sensory
 segment on both sides of the body” (ASIA/ISCoS)
               C-Spine Imaging
 • Asymptomatic Patient
    • Option - Xray not needed in alert, sober,
      compliant patient without neck pain and
      tenderness or major distracting injuries
 • Symptomatic Patient
    • Standard – Ap lat and odontoid view
    • Option – discontinue protection after….
      • normal and adequate dynamic radiography, or
      • normal MRI within 48hrs of injury, or
      • at the discretion of the treating MD
Neurosurgery
             Why Passive Dynamic Fluoro?




    Neutral                      Flexion                   Post- flexion
Undiagnosed ligamentous injury can result in catastrophic neurological deficit.
          System Oriented Approach
• Airway
• Breathing
• Circulatory
Neurologic Classification
Spinal Imaging
• GastroIntestinal System
• Genitourinary System
• Skin                           BCIT/VHSP
          Airway

• Risk Associated with Level
  of Injury
• Decision to Intubate
• Airway Intervention
        Risk Associated with Level of
                   Injury


Intercostal Muscles                     Accessory
                                        Muscles C1-7
T1-11




 Diaphragm                         Abdominal Muscles
 C3-5                                         T6-12
              Risk Associated with
               Level of Injury cont’d


• Ventilatory Function
  • C1 - C7 = accessory muscles
  • C3 - C5 = diaphragm
   “C3-4-5 keeps the diaphragm alive!”
  • T1 - T11 = intercostals
  • T6 - L1 = abdominals
                 Decision to Intubate:
• Need for Artificial Airway is Usually Related to Resp Compromise
  e.g.

   • Loss of innervation of the diaphragm
       (C 3-4-5 keep the diaphragm alive)
   •   Fatigue of innervated resp muscles
   •   Hypoventilation
   •   V/Q mismatch
   •   Secretion retention
   •   Associated injuries
             Decision to Intubate
        Related to Neurological Level

• Occiput - C3 Injuries
  (ASIA A & B)
   • Require immediate intubation
     and ventilation due to loss of
     innervation of diaphragm
           Decision to Intubate
      Related to Neurological Level
                     cont’d



• C4-C6 Injuries (ASIA A & B)
  • Serious consideration for prophylactic
    intubation and ventilation if:
     • Ascending injury (requires serial M/S assessment
       by a trained clinician)
     • Fatigue of unassisted diaphragm
     • Inability to clear secretions
       Co-Morbidities to Consider…

• Advanced age
• Premorbid conditions
• Chest trauma
• Hx of aspiration
• Head injury or substance
  abuse
• Acute ileus
           Airway Intervention



• Maintaining Spinal Precautions
  • Supine position
  • Maintain neutral C-spine
  • Remove rigid collar and sandbags
  • Manually stabilize C-spine
               Airway Intervention        cont’d




• Manual Stabilization of
  C-spine
  • 2 person technique:
        – 1st person to provide manual
          in-line stabilization (not traction) of C-
          spine
        – 2nd person intubates
Resp Muscle Innervation
                 Breathing
Cough Function
• C1-C3 = absent
• C4 = non-functional
• C5-T1 = non-functional
• T2-T4 = weak
• T5-T10 = poor
• T11 & below = normal
            Breathing     cont’d




Vital Capacity (acute phase)
• C1-C3 = 0 - 5% of normal
• C4 = 10-15% of normal
• C5-T1 = 30-40% of normal
• T2-T4 = 40-50% of normal
• T5-T10 = 75-100% of normal
• T11 and below = normal
C 3,4,5 ….

       Keep the
       Diaphragm Alive!
        Breathing         cont’d



• SCI Respiratory Sequale
  • Atelectasis
  • Ventilatory failure
       • (PaCO2 > 50mmHg and pH < 7.30)
  •   Increased secretions
  •   Pneumonia
  •   Pulmonary emboli
  •   Pulmonary edema
  Breathing        cont’d

Baseline Resp Assessment
• First Impression
   • Distress?
   • Increased WOB?
   • Increased secretions?
   • Difficulty with clearing secretions?
         Breathing         cont’d


Baseline Resp Assessment
• Clinical Observations
  •   RR
  •   Type of ventilation and FiO2
  •   Resp muscle activity
  •   Skeletal Integrity
  •   Breathing pattern
  •   Chest mobility
  •   Cough Function
       Breathing      cont’d




Baseline Resp Assessment
• History
  • Smoker?
  • Asthma, TB, bronchitis, etc?
  • Recent cold or productive cough?
          Breathing    cont’d




Baseline Resp Assessment
• Physical Findings / Radiology/ Lab
   •   Auscultation
   •   VC
   •   CXR
   •   ABG’s
      Breathing        cont’d




• Ongoing Monitoring
  • SpO2
  • EtCO2
  • ABGs
  • Daily CXR
  • VCs
      Breathing     cont’d


• Intervention
   • O2 therapy
   • Assisted ventilation PRN
   • Medications (bronchodilators)
   • Positioning and mobilizing
   • Chest physio
   • Assisted Cough
                          Circulatory
   Spinal Shock                         Neurogenic Shock
• Temporary suppression of all      • The body’s response to the
  reflex activity below the level
  of injury                           sudden loss of sympathetic
• Occurs immediately after            control
  injury
• Intensity & duration vary         • Distributive shock
  with the level & degree of
  injury
                                    • Occurs in people who have
• Once BCR returns, spinal
  shock is over                       SCI above T6 (> 50% loss of
                                      sympathetic innervation)
Clinical Signs of Neurogenic Shock

                      Clinical Triad
                      • Hypotension

                      • Bradycardia

                      • Hypothermia
     Hemodynamic State

Unopposed parasympathetic outflow can lead to cardiac
dysrhythmias and hypotension (most common within first
14 days)

    • Hypotension is due to loss of
      vasomotor tone-peripheral pooling
      of blood and decreased preload
    • Most common dysrhythmia is
      bradycardia
               Circulatory Assess
•   Level of SCI?
•   Complete or incomplete?
•   Heart rate and rhythm?
•   B/P? Premorbid hypertension?
•   LOC?
•   U/O?
•   Volume status?
       Hemodynamic Instability: Intervention


• First Line:
  Volume |Resuscitation (1-2 L)
• Second line:
  Vasopressors-
  (dopamine/norepinephrine) to
  counter loss of sympathetic tone
  and provide chronotropic support
  to the heart
          Hemodynamic Instability:
               Intervention

• Goal:
  Resolution of shock and restitution of
  tissue perfusion

• What is the desired BP to assure good
  perfusion of the injured spinal cord?
  (Vale 1997: 85 mmHg MAP?)
Concurrent Neurogenic and
   Hemorrhagic Shock

             In multi-trauma patients…
             Careful and diligent search
              for bleeding is imperative
Hemodynamics and Cord
         Perfusion

• Options:
  • Avoid hypotension
  • Maintain MAP 85-90mmHg
   for first 7 days if possible



                                  Neurosurgery
             Bradycardia: Intervention

• Prevention:
  • Avoid vagal stimulation
  • Hyperventilate and hyperoxygenate prior to
    suctioning
  • Pre-medicate patients with known hypersensitivity
    to vagal stimuli
• Treatment of Symptomatic Bradycardia:
  • Atropine 0.5 - 1.0 mg IV
        GI System

• Risk of aspiration is high d/t:
   • cervical immobilization
   • local cervical soft tissue swelling
   • delayed gastric emptying
• Parasympathetic reflex activity is altered, resulting in:
   • decreased gut motility and
   • often prolonged paralytic ileus.
            GI Intervention


• Minimizing Risk for Aspiration:
   • Nasogastric tube

• Minimizing Risk of Gastric Ulceration:
   • IV Ranitidine 50mg IV q8h
           GU System

• All ASCI patients initially managed with
  indwelling urinary catheter
Skin Care: Common Sites of Pressure Sores

  Occiput
 Sacrum

 Trochanter

 Ischium

 Ankle

 Heel
       Skin Intervention
• Remove spine board

• Turn or reposition individuals with SCI initially every
  2 hours in the acute phase if the medical condition
  allows.




                                                    Consortium
40 Hrs Post SCI
10 Days Later
       Pain Management
IASP Proposed 2 Broad Types:

• Nociceptive: Musculoskeletal and Visceral
   • Responds well to opioids and NSAIDS




                                       www.iasp-pain.org
      Pain Management

• Neuropathic: Above Injury/At Injury Level/Below Injury
  Level
   • Somewhat sensitive to Morphine
   • More sensitive to anticonvulsants (gabapentin)
     and tricyclics (nortryptiline)


                                       www.iasp-pain.org
       Pharmacologic Therapy

• Option: Methylprednisolone




                               Neurosurgery
MPSS Evidence
• NASCIS II (1992)
   • 30mg/kg IV loading dose + 5.4 mg/kg/hr (over
      23hrs) effective if administered within 8 hours of
      injury
• NASCIS III (1997)
   • If initiated < 3hrs continue for 24 hrs, if 3-8 hrs
      after injury, continue for 48hrs (morbidity higher -
      increased sepsis and pneumonia)
              Both studies criticized for methodology
    MPS Clinically Effective?
     • Meta-analysis showed insufficient evidence to support
       use of high dose MPSS in ASCI as a treatment
       standard or guideline for treatment.

     • Weak clinical evidence to support MPSS as per
       NASCIS II but not NASCIS III protocol as an option
       for treatment.



Canadian Association of Emergency Physicians Jan 2003
                Transfer Checklist
 Spinal immobilisation        NG insitu
 Airway risk is identified    Foley catheter
   ETT if PaCO2 =             Skin is protected
     50mmHg or                 Level of SCI documented
     greater                   X-rays, CT, MRI
                                accompany patient
 Supplemental O2
                               Family contacts
 Assisted ventilation PRN
                                documented
 MPSS in progress if
  appropriate

				
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