Dr Matt Wiles

Consultant in Neuroanaesthesia & Neurocritical Care

Sheffield Teaching Hospitals NHS Foundation Trust

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Management of Spinal Cord Injury (in Critical Care by an Anaesthetist)

Objectives

• Describe the physiological basis, and evidence for, the treatment strategies in the spine cord injured patient, including:

– Immobilisation

– Steroids

– Blood pressure optimisation

– Surgery

Dürer’s Rhinoceros

Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981

• Incidence 15-40 per million per annum cf TBI 4000 per million

• Median age 47.2 years

Year Number Median age % aged > 50 years

Traumatic Coma Data Bank 1984-1987 746 25 15

UK Four Centre Study 1986-1988 988 29 27

EBIC Core Data Survey 1995 1005 38 33

Rotterdam Cohort Study 1999-2003 774 42 39

Austrian Severe TBI Study 1999-2004 492 48 (mean) 45

TARN Review 2003-2009 15 173 39 (mean) Not reported

Italian TBI Study 2012 1366 45 44

RAIN Study (UK) 2008-2009 2975 44 Not reported

Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981

0

5

10

15

20

25

30

35

40

45

50

RTC Fall>2m Fall<2m Sports Other

AllInjuries CordInjuries

Epidemiology of SCI

Incidence by location

Cervical 75%

Thoracic 10%

Lumbar 10%

Incidence of fractures with SCI

Cervical 40-50%

Thoracic >95%

Lumbar > 85%

Epidemiology of SCI Hasler et al. J Trauma 2011; 72:975-981

• Median age 47.2 years

• 66% male

• 3.5% had cervical spine injuries

– 10.3% in those with GCS 3 to 8

– only 23% had neurological symptoms [0.8% of total]

– 25% had injuries to other regions

• 16% head

• 16% extremities

• 14% chest

SCIWORA Hendrey et al. J Trauma Acute Care Surg 2002; 53:1-4

• NEXUS data

• n=34,069; 2.4% cervical spine injury

• 27 patients SCIWORA [0.08% of total]

SCIWORA Hendrey et al. J Trauma Acute Care Surg 2002; 53:1-4

• NEXUS data

• n=34,069; 2.4% cervical spine injury

• 27 patients SCIWORA [0.08% of total]

• Included > 3000 children

– None had SCIWORA

Distribution of Bony Injuries Goldberg et al. Ann Emerg Med 2007; 38:17-21

• 1496 cervical spine injuries (2.4%)

• 30% clinically insignificant

• Fractures:

Spinal Level % of total

C1 8.8

C2 23.9

C3 4.3

C4 7.0

C5 15.0

C6 20.3

C7 19.1

} C1-2=33%

} C5-7=54%

Distribution of Bony Injuries Goldberg et al. Ann Emerg Med 2007; 38:17-21

• 1496 cervical spine injuries (2.4%)

• 30% clinically insignificant

• Dislocations/subluxations:

Spinal Interspace

% of total

C1-C2 10.0

C2-C3 9.1

C3-C4 10.0

C4-C5 16.5

C5-C6 25.1

C6-C7 23.4

C7-T1 3.9

} C5-7=58%

Airway & Cervical Spine

• Cervical spine 5% & Spinal cord 2.5%

• Triggers for intubation: – Inability to maintain and protect own airway regardless of

conscious level

– Inability to maintain adequate oxygenation with less invasive manoeuvres (PaO2 < 13kPa)

– Inability to maintain normocapnia (spontaneous PaCO2 <4.0 kPa or > 6.0kPa)

– GCS ≤8

– Patients undergoing transfer with: • Deteriorating conscious level (≥2 points on motor scale)

• Significant facial injuries

• Seizures.

Manual In-line Stabilisation

• Origin uncertain – ATLS guidance 1984

• Data from cadaveric studies, healthy volunteers and case series (n=96)

• Direct laryngoscopy/intubation cause less cervical movement than a jaw thrust

• Several studies suggest MILS has no effect on cervical segment movement

Method Grade 1 Grade II Grade III

Optimal positioning 129 26 2

MILS 75 48 34

Cervical Collars Sundstrøm et al. Journal of Neurotrauma 2014

• Most spinal injuries are stable; – those that are unstable have already caused irreversible

damage

• Collars do not immobilise the cervical spine • Exaggerated rate of secondary SCI without collars • Numerous associated complications

• Authors suggest: – Spinal board with head blocks & straps – Collars only for difficult extrication – Unconscious, nonintubated trauma patients should be transported in

modified left lateral

Clearing the Spine

Why bother?

• Avoidance of skin damage secondary to collars (6-67%)

– Ulceration

– Sepsis

• 30 degree head-up tilt to reduce pneumonia

• Exacerbation of raised ICP

• Increased demands on nursing care

• Exacerbation of agitation especially in TBI

Clearing the Spine

• 7 missed injuries of which 3 unstable

• Sensitivity/Specificity of CT >99.9% (cf NEXUS 99%)

• -ve LR < 0.001%

• 1 in every 4776 patients have missed injury

(My) Rules for Clearing the Spine

• HRCT CT of C-spine (1-2 mm slices) – C0 – T2 (but T4 better)

– Reported by consultant MSK/neuroradiologist

– Discussed with spinal/neurosurgical consultant

• [Consider AP/lateral C-spine radiographs]

• CT reconstructions of thoracolumbar spine

• AP/Lateral radiographs thoracolumbar views

• NB. Semi-rigid collar (Aspen/Philadelphia) in interim

Neurological Deterioration after Surgery

• Due to prolonged deformation and/or hypotension

– Hyperflexion worse than hyperextension

• Both are unlikely during DL

• AFOI may not be safer

– Several claims in US Closed Claims Database

• 5% patients with SCI will deteriorate

– Early (24 h)

– Later (1-7 days)

– Late (weeks [post-traumatic ascending myelopathy])

Steroids for Acute SCI Bracken MB; Cochrane Database 2012

NASCIS II

• Design – Multicentre, prospective, randomised, double-blind trial.

• Patients – 487 patients with acute spinal cord injury (95% follow up)

• Exclusions – Injuries below L1, children

• Randomisation – Treatment 1: Methlyprednisolone 30 mg kg-1 bolus, then

5.4 mg kg-1 h-1 for 23 hours

– Treatment 2: Naloxone 5.4 mg kg-1 bolus, then 4.5 mg kg-1

h-1 for 23 hours

– Treatment 3: Placebo

NASCIS II

• Assessment

– Motor scale (0-5) in 14 muscle groups (total 70)

– Sensory (Pin prick & touch) in 29 dermatomes (total 58)

• (Author’s) Results

– Patients receiving steroids within 8 h had a statistically significant improvement of 5 points on the motor score at 6 months and 1 year (P=0.03)

• Safety

– Wound infection & PE doubled in steroid group (NS)

NASCIS II

• All +ve results are from post hoc analyses

• Time cut off (8 h) is arbitrary

• 78 discrete post hoc tests

• 60 t-tests for neurological outcomes

• Correct hypotension (SBP <90mmHg) ASAP (III)

• Target MAP 85-90 mmHg for 7 days post injury (III) – Compared to historical controls

– >50% with cervical injuries will require vasopressors

– Complications common in first 7 days post injury • Hypotension, bradycardia

• Ventilatory failure on average 4.5 days post injury

• Intubation rates: ≥C5 100% cf 79% ≤ C6

Breathing

1. Fatigue of innervated muscles

2. Chest trauma

3. Ascension of the spinal lesion

4. Retained secretions

5. Abdominal distension splinting diaphragm

• Close observation

• Physiotherapy plus humidified oxygen

• Early tracheostomy

Circulation

1. Spinal shock

2. Coexisting (missed) traumatic injuries

• If lesion > T6, may need vasopressor support

• Caution with excessive fluids

• Target MAP > 80 mmHg

• ? Role of relative hypercarbia

General ICU Care • Normoglycaemia

– <10 mmol/l associated with improved outcome

• Feeding – Enteral ideally, within 72 hours, full rate by 1/52

• VTE prophylaxis – 15-20% risk of VTE; IPC then LMWH after 72 hours

• Stress ulcer prophylaxis – 10% risk of stress ulcers

• Chest physiotherapy – 70% pneumonia rate

• Pressure area/eye care

• Specialised mattresses or beds

• Removal of hard collars

Summary

• Avoid hypotension & hypoxia

• Hypotension in SCI is bleeding until proved otherwise

– Trust no-one, believe nothing, give oxygen

• There is no place for steroid therapy

• Much of the best care is supportive & “SHO work”

– LMWH

– Stress ulcer prophylaxis

– Aperients

• Surgical timing is still uncertain

Any questions.....

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