spinal cord injury usaf cstars baltimore university of maryland medical center r a cowley shock...
TRANSCRIPT
SPINAL CORD INJURY
USAF CSTARS Baltimore
University of Maryland Medical Center
R A Cowley Shock Trauma Center
OBJECTIVES
• Review spinal cord anatomy and neural pathways
• Identify and treat neurogenic shock, spinal shock, and specific patterns of cord injury
• Describe initial evaluation and management principles of the trauma patient with spinal cord injury
• Recognize specific radiographic findings of spinal cord injury
EPIDEMIOLOGY
• Incidence (all trauma patients)– Cervical: 4.3%– Thoracolumbar: 6.3%
• Males: 70% (M:F ratio = 4:1)• Mechanism (Most to least common)
– MVC– Fall– Act of Violence– Sport Activity
INJURY LOCATION
• Cervical: 55%– High (Oc-C2): 25%– Subaxial (C3-C7): 75%
• Thoracic: 30%
• Lumbar: 15%– Most common at thoracolumbar junction– L1 accounts for 16% of all injuries
ANATOMY
• Vertebral Column– Cervical: 7– Thoracic: 12– Lumbar: 5– Sacral: 5 (fused)– Coccygeal: 3 – 5 (fused)
DERMATOMES
NEURAL PATHWAYSCORTICOSPINAL TRACT
Ipsilateral
Motor
Control
NEURAL PATHWAYSSPINOTHALAMIC TRACT
Contralateral
Pain
&
Temperature
NEURAL PATHWAYSDORSAL COLUMNS
Ipsilateral
Proprioception
&
Vibration
MECHANISM OF ACUTE INJURY
• Direct Space Occupying Lesion: Focal injury at site of impact
• Direct Non-Space Occupying Lesion: Stretch, shear, compressive forces
• Secondary Injury: Due to compromise of blood supply
SHOCK
• Neurogenic– Systemic phenomenon– Hypotension, Bradycardia, Hypothermia
• Spinal Shock– Temporary loss of reflex activity below injury– Flaccid paralysis– May last up to 48 hours
• Management– Assume hypovolemic– Volume, followed by pressors
NEUROLOGIC INJURY PATTERNS
• Classification– Complete: No motor or sensory function
caudal to level– Incomplete: Not complete– Spinal cord must have recovered from
spinal shock prior to classification
NEUROLOGIC INJURY PATTERNS
• Anterior Cord Syndrome– Injury to anterior 2/3– Loss of motor, pain,
temperature below level of injury
– Preservation of proprioception and vibration
– Prognosis is poorest of all cord syndromes
NEUROLOGIC INJURY PATTERNS
• Central Cord Syndrome– Upper extremity deficit >
lower extremity deficit– Loss of arm and hand
function– Less impairment of leg
movement– Prognosis varies
NEUROLOGIC INJURY PATTERNS
• Brown-Sequard Syndrome– Damage to one side of
spinal cord– Loss of ipsilateral motor– Loss of contralateral pain
and temperature– Prognosis varies
EVALUATION & MANAGEMENT
• ABCs– Presume spinal cord injury is present– Immobilization: Cervical collar, backboard– Definitive airway– Maintenance of blood pressure– Spine precautions: Immobilization and log-
rolling
EVALUATION & MANAGEMENT
• Secondary Survey– Examination may be altered; loss of
sensation– Presence of other life-threatening injuries– Oxygenation/ventilation difficulty with
cervical injuries– Thorough radiographic evaluation
during/following resuscitation
EVALUATION & MANAGEMENT
• Cervical Spine Clearance – Clinical– Awake, alert, oriented– No intoxication– No midline tenderness– No focal neurologic injury– No distracting injury
EVALUATION & MANAGEMENT
• Pharmacologic Prophylaxis– Initiate for:
• Neurologic symptoms attributable to SCI• Blunt mechanism• Less than 8 hours from injury
– Protocol• Methylprednisolone (30 mg/kg) bolus followed by infusion at 5.4
mg/kg/hr for 23 hours• If injury is 3 - 8 hours out, continue infusion for 48 hours
– Outcome (Class II)• Better recovery of neurologic function at 6 weeks, 6 months,
and 1 year• No difference in mortality and morbidity
EVALUATION & MANAGEMENT
• Thoracolumbar Spine– Characteristics
• Stabilizing effect of ribs and chest wall• Injury is usually compressive• Deficit usually due to:
– Lack of space for spinal cord– Tenuous arterial blood supply– Energy required to inflict injury
EVALUATION & MANAGEMENT
• Thoracolumbar Spine– Clinical Manifestations
• Lower extremity paralysis• Loss of sensation• Bowel & bladder dysfunction
– Evaluation• Physical Exam• Radiographic: AP & Lateral films, CT spine
EVALUATION & MANAGEMENT
• Penetrating Spinal Cord Injury– 12% of traumatic SCIs– Initial management focuses on life-
threatening issues– Surgical Intervention
• Deferred until stable patient• Goals are debridement, decompression,
removal of fragments, & dural closure• Rarely indicated in complete injuries
RADIOGRAPHIC ASSESSMENT
• Cervical Spine– Adequacy requires base,
C1-C7 and T1– Lateral C-Spine Film: May
miss 15% of injuries and requires additional views (AP, Odontoid, or CT scan)
– Assessment• Soft tissue swelling• Contour and Alignment• AP canal diameter• Fracture lines, step offs,
displacement
RADIOGRAPHIC ASSESSMENT
• Cervical Spine– Soft Tissue Guidelines
• Less than 6 mm at C2• Less than 22 mm at C6
– Instability• Displacement of > 3mm
adjacent vertebrae• Angulation difference > 11
mm adjacent vertebrae (implies ligamentous injury)
RADIOGRAPHIC ASSESSMENT
• Thoracolumbar Spine– Spinous process
alignment– Pedicle
widening/symmetry– Vertebral and disc
height– Vertebral body contour
SPECIFIC INJURIES
• C-1 Fracture– Rarely involves
neurologic deficit– Posterior arch is most
common– Jefferson Fracture (4-
part fracture)– Others: Lateral mass,
anterior arch of C1, transverse process fracture
SPECIFIC INJURIES
• Atlantoaxial Joint Injury– Etiology: Transverse
ligament disruption– Extremely unstable– High risk for neurologic
deficit
SPECIFIC INJURIES
• C-2 Fracture– Type I: Tip of Dens– Type II
• Junction of Dens & Body
• Most common
– Type III: Through body at base of C-2
SPECIFIC INJURIES
• Lower Cervical: C3 – C7
• Thoracolumbar Fractures
SUMMARY
• Spinal cord anatomy and syndromes
• Identification of “spinal cord related” shock and treatment
• ABCs & spinal cord injury evaluation and management
• Radiographic findings in spinal cord injury
QUESTIONS
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