der spinale neurologische notfall update» · spinal cord emergencies • traumatic • non -...
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Der spinale neurologische Notfall
Prof. Dr. A. Curt, FRCPC
Spinal cord emergency
«Orthopedics Update»
Wirbelsäule
2015
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Spinal cord emergencies
• traumatic
• non - traumatic– primary (myelitis, syringomyelia, intramedullary
tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital– (meningo-myelocele, diastematomyelia, tethered cord..)
«Orthopedics Update»
Wirbelsäule
2015
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Spinal cord disorders:„the neurological examination is key!“
«Orthopedics Update»
Wirbelsäule
2015
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«Orthopedics Update»
Wirbelsäule
2015
![Page 5: Der spinale neurologische Notfall Update» · Spinal cord emergencies • traumatic • non - traumatic – primary (myelitis, syringomyelia, intramedullary tumors..) – secondary](https://reader031.vdocuments.us/reader031/viewer/2022013019/5dd08f5ad6be591ccb6194a0/html5/thumbnails/5.jpg)
Spinal cord emergencies
• traumatic
• non - traumatic– primary (myelitis, syringomyelia, intramedullary
tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital– (meningo-myelocele, diastematomyelia, tethered cord..)
«Orthopedics Update»
Wirbelsäule
2015
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Sport injuries
«Orthopedics Update»
Wirbelsäule
2015
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Traffic accidents
«Orthopedics Update»
Wirbelsäule
2015
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Emergency management
«Orthopedics Update»
Wirbelsäule
2015
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Rettungs-Bergungskette medizinische Akutversorgung
ASIA Protokolin-/komplett
funktionelle AusfälleLäsionshöhe
neurologischesDefizit
klin. Untersuchungen
RöntgenCTMRI
Wirbelsäulen-verletzung
Bildgebung
RückenmarkConus/Cauda
periphere Nerven
neurogeneLäsionen
Neurologie
PolytraumaIntensivmedizin
Akute Komplikationen
ZusatzverletzungenBegleiterkrankungen
labortechn. Untersuchungen
Anamneseklinische Untersuchung
zeitlicher Verlauf
traumatischeQuerschnittlähmung
Diagnostische Abklärung einer akuten traumatischen Querschnittslähmung, Leitlinien DGN 2010
«Orthopedics Update»
Wirbelsäule
2015
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Time is spine(early treatment)
Decompression surgery
Stabilization
Cardiovascular management (ICU guidelines)
Controlled mobilization
MethylprednisoloneNo evidence!
«Orthopedics Update»
Wirbelsäule
2015
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Spinal cord emergencies
• traumatic
• non - traumatic– primary (myelitis, syringomyelia, intramedullary
tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital– (meningo-myelocele, diastematomyelia, tethered cord..)
«Orthopedics Update»
Wirbelsäule
2015
![Page 12: Der spinale neurologische Notfall Update» · Spinal cord emergencies • traumatic • non - traumatic – primary (myelitis, syringomyelia, intramedullary tumors..) – secondary](https://reader031.vdocuments.us/reader031/viewer/2022013019/5dd08f5ad6be591ccb6194a0/html5/thumbnails/12.jpg)
«Orthopedics Update»
Wirbelsäule
2015
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AnamneseZeitlicher VerlaufUntersuchungsbefund
Bildgebung (MRT, CT, Myelographie)Rückenmark‐Kompression?
Tumor intra‐/extramedullärSpondylitis,‐diszitis, AbszeßWS‐degenerative UrsachenBlutung intra‐/extramedullär
Liquor: Pleozytose; IgG‐Index, OKBMRT: KM‐Anreicherung
JA
NEIN
JA
Myelitis transversa
Infektiöse/parainf. Myelitis
Multiple SkleroseADEM
Neuromyelitis optica SystemischeAutoimmunerkrankung
Spinale IschämieAVMSuperfizielle SideroseStrahlenmyelopathieMetabolisch/toxischpsychogen
NEIN
Ggf. Staging‐Diagnostik (CT, MRT, Szintigraphie, PET)
Direkter Erregernachweis, spez. AK, PCR
cMRT, VEP, AP‐4,AK Antikörper SerologieOrganbeteiligung (Bildgebung, Biopsie)
CSF, cMRT, evozierte Potentiale
MRT (DWI, FLAIR, SWI),selektive spinale AngiographieSerum: Cobalamin, Folsäure, Vit B12 u 6, Methylmalonsäure, Kupfer, Coeruloplasmin
Diagnostische Abklärung nicht‐traumatischen QuerschnittlähmungDGN Guidelines 2010
«Orthopedics Update»
Wirbelsäule
2015
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Red flags
«Orthopedics Update»
Wirbelsäule
2015
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Red flags
Distribution of pain:
• bilateral pain
• clumsy hands/feet
• altered temp sen.
• girdle/belt like
«Orthopedics Update»
Wirbelsäule
2015
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Degenerative spinal canal stenosisSpinal canal encroachments and instability
«Orthopedics Update»
Wirbelsäule
2015
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Segmental Sensory Assessment
Large Diameter(tactile)
Small Diameter (temperature, pain)
Contact Heat Evoked Potentials CHEPS
Somato-sensory Evoked Potentials SSEPS
«Orthopedics Update»
Wirbelsäule
2015
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Segmental Sensory Assessment
Contact Heat Evoked Potentials CHEPS
Somato-sensory Evoked Potentials SSEPS
Large Diameter(tactile)
Small Diameter (temperature, pain)
«Orthopedics Update»
Wirbelsäule
2015
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Kramer J, et al.. D-SSEP and EPT for the assessment of posterior cord function in SCI. J Neurotrauma 2008
Segmental Sensory Assessment
Improved diagnosis of spinal cord disorders with contact heat evoked potentials. Ulrich A, Haefeli J, Blum J, Min K, Curt A.Neurology 2013
«Orthopedics Update»
Wirbelsäule
2015
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Snake – eyemyelopathy
Improved diagnosis of spinal cord disorders with contact heat evoked potentials. Ulrich A, Haefeli J, Blum J, Min K, Curt A.Neurology 2013
«Orthopedics Update»
Wirbelsäule
2015
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Snake – eyemyelopathy
High sensitivity of contact-heat evoked potentials in "snake-eye" appearance myelopathy.Ulrich A, Min K, Curt A.Clin Neurophysiol 2015
«Orthopedics Update»
Wirbelsäule
2015
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C6
«Orthopedics Update»
Wirbelsäule
2015
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police officer, ♂ 51 yrsthermal hypaesthesia
Ulnar SSEP
Tibial SSEP«Orthopedics Update»
Wirbelsäule
2015
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«Orthopedics Update»
Wirbelsäule
2015
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Red flags
Walking signs:
• unsteadiness
• fatigue
• weakness(limb or bilateral)
«Orthopedics Update»
Wirbelsäule
2015
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Calcified disc herniation T10/11Back pain, left leg painBladder - bowel normalUnlimited walkingMale 53 years
Calcified disc herniation T7/8Lower back painDysesthesia left legLower limb reflexes increasedFemale 36 years
«Orthopedics Update»
Wirbelsäule
2015
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dCHEP dSSEPSpinalis AnteriorSyndrome
Patient with complete paralysis due to spinalis anterior syndrome with loss of thermal and pain sensation below T7 but preserved light touch where accordingly dSSEP remained normal but dCHEP were abolished below the level of lesion.
C7
C3
T7
T10
«Orthopedics Update»
Wirbelsäule
2015
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Intraspinal – epidural haemorrhage
Post Op
Acute, non traumatic epidural haemorrhage
male, 31 years,physiotherapist, paraplegia T3 AIS B,became paralyzed within 60 min
«Orthopedics Update»
Wirbelsäule
2015
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Intraspinal – epidural haemorrhage
Although patient received decompression surgery within 6 hours after onset of symptoms he suffers from established (chronic) paraplegia (AIS-B)
T3
T3
Spinal cord damage as a sequel of spinal cord compression due to
epidural haemorrhage
«Orthopedics Update»
Wirbelsäule
2015
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Intraspinal – epidural haemorrhage
Post ORPre OR
Sub-acute onsetMale 63 yrs, marcumar therapyAIS-C, able to stand and walk indoors
«Orthopedics Update»
Wirbelsäule
2015
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Red flags
Bladder signs:
• frequency
• voiding
• incontinence
«Orthopedics Update»
Wirbelsäule
2015
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Arterio-venous malformation of spinal cord
Lower limb fatigue and bladder urgency!
«Orthopedics Update»
Wirbelsäule
2015
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Meningeoma at thoracic cord level
Lower limb pain and bladder urgency!
«Orthopedics Update»
Wirbelsäule
2015
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Spinal metastases
constant & increasing
«Orthopedics Update»
Wirbelsäule
2015
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Take home message: Red flags
Walking signs:
• unsteadiness
• fatigue
• weakness(limb or bilateral)
Bladder signs:
• frequency
• voiding
• incontinenceLecture can be found on:www.balgrist/Zentrum für Paraplegie
Distribution of pain:
• bilateral pain
• clumsy hands/feet
• altered temp sen.
• girdle/belt like
«Orthopedics Update»
Wirbelsäule
2015
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…the spinal cord works not wireless yet, and we have ways toassess it….
«Orthopedics Update»
Wirbelsäule
2015
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Supplement«Orthopedics Update»
Wirbelsäule
2015
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The examination
of motor function
is key!!«Orthopedics Update»
Wirbelsäule
2015
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«Orthopedics Update»
Wirbelsäule
2015
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«Orthopedics Update»
Wirbelsäule
2015
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Thank you for your attention!
«Orthopedics Update»
Wirbelsäule
2015