acute management of spinal cord injury · acute management of spinal cord injury dan rutigliano,...

Acute Management of Spinal Cord Injury

Dan Rutigliano, D.ODirector of Inpatient Trauma

Stony Brook Trauma Center

No financial disclosures

OVERVIEW

• Spinal anatomy/classification

• Evaluating a patient with suspected spinal injury

• Broad management principles of spinal injury

• Hypovolaemic vs neurogenic vs spinal shock

SPINAL CORD INJURY: EPIDEMIOLOGY

In the United States, the incidence of spinal cord injury in 2010 was approximately

40 per million persons per year, or approximately 12,400 annually

• Causes in the United States are:

- Motor vehicle accidents: 48 percent

- Falls: 16 percent

- Violence (especially gunshot wounds): 12 percent

- Sports accidents: 10 percent

- Other: 14 percent

Prior to 2000, the most frequent occurrence was a young male with a median age of

22. Since that time, the average age has increased to 37 years in 2010, presumably

as a reflection of the aging population.

Males continue to make up 77 to 80 percent of cases.

Alcohol plays a role in at least 25 percent of TSCI

ANATOMY

Location of Spinal Injuries

55% in cervical region

(mobile and exposed)

15% in thoracic region

(less mobile and protected)

15% in thoracolumbar region

(fulcrum)

15% in lumbosacral region

ANATOMY

• Upper cervical region is wide from foramen

magnum to lower part C3

- 1/3 die at scene from apnea

- those that survive are usually

neurologically intact when they reach

the hospital

ANATOMY

• Below C3 the diameter of the spinal canal is smaller

- vertebral column injuries are more likely to produce spinal

cord injuries

• Most thoracic spine fractures are wedge compression fractures

without spinal cord injury

- high association with a complete spinal cord injury because

of narrow thoracic canal

• Thoracolumbar junction is where the inflexible thoracic spine

meets the strong lumbar spine making it an area vulnerable to

injury

ANATOMY

• Multiple ascending and descending tracts

in the spinal cord

• 3 clinically relevant ones

- lateral corticospinal tract

- Controls motor functions on SAME side

- spinothalamic tract

- transmits pain and temp sensations

from the OPPOSITE side

- dorsal columns

- transmits proprioception and vibration

senses from the SAME side

ANATOMY

Dermatome- area of

skin supplied by

a single spinal

nerve or cord

segment

Myotome- the

muscle/s

supplied by a

single spinal

nerve or cord

segment

SPINAL CORD INJURY: CLASSIFICATION

• Injuries to the spinal cord can be categorized in

numerous ways

- Incomplete paraplegia (incomplete thoracic injury)

- Incomplete quadriplegia (incomplete cervical

injury)

- Complete paraplegia

- Complete quadriplegia


Injuries may have complete or incomplete

neurological symptoms

• Complete injury patients demonstrate total

and flaccid paralysis, total

anesthesia/analgesia, and no tendon reflexes

• Incomplete injury will demonstrate partial

paralysis w/ altered sensation and preserved

sacral function (sacral sparing)

SPINAL CORD INJURY: CLASSIFICATIONS

Different patterns of injury

can result in various

“syndromes”

• Central Cord Syndrome

• Anterior Cord Syndrome

• Posterior Cord Syndrome

• Brown-Sequard

Syndrome

• Cauda Equina Syndrome


Spinal injuries can also be described as:

• Fractures

• Fracture-dislocations

• Penetrating injury

• Spinal Cord Injury without Radiographic

Abnormalities (SCIWRA)

SPINAL CORD INJURY: EVALUATION

Signs and Symptoms:

• Pain

• Tingling, numbness and weakness in periphery

• Loss of sensation or paralysis below the level of

injury

• Respiratory distress

• Incontinence

• Priapism


Evaluation and care starts with the ABCs of trauma

• A=airway

- Need to establish an airway while maintaining c-

spine immobilization

- Place a definitive airway early if respiratory

compromise is suspected- typically with high

cervical injury (C3/4/5)



• B=breathing

- evaluate for any associated symptoms to

indicate underlying pulmonary trauma

- monitor for accessory muscle use to indicate

impending respiratory collapse

- use supplemental oxygen to prevent hypoxia



• C=circulation

- identify and control any bleeding from injuries

- Maintain a normal blood pressure to prevent

secondary spinal injury

- ? spinal shock- aggressive fluid resuscitation,

pressers may be required



• D=disability

- Check patient’s GCS status

- exam for equal and reactive pupils

- evaluate all 4 extremities for signs of weakness or

loss of sensation

- perform a rectal exam to evaluate for sphincter tone

- evaluate for priapism, bulbocavernosus reflex



• E=exposure

- remove all clothes to fully evaluate for injuries

- carefully log roll the pt to palpate the spine and paraspinal

regions

‣ identify all areas of pain with palpation

- patients with high spinal injuries may be vasodilated and

unable to regulate temperature

‣ Cover patients with warm blankets

SPINAL INJURY: EVALUATION

Adjuncts to primary survey

• Done after completion of ABCs

• Patient should be on continuous monitoring of vitals

• CXR and pelvic x-rays typically performed

• FAST exam- bedside ultrasound to evaluate for bleeding in

the abdomen as a source of hypotension

• Placement of Foley catheter, OGT

• Obtain a full medical history- important to ask about use of

anticoagulants!


Spinal Imaging

• X-rays- not done as first line, provided limited

information, can be difficult to obtain needed views

• CT scan- gold standard for defining bony injuries,

typically done as 1st line imaging as part of the

trauma “pan scan”

• MRI- useful to identify ligamentous injury or

contusions/compression of the spinal cord


Identify the level of spinal cord injury

• Make note of both sensory and motor

deficit levels

ANATOMY

Dermatome- area of

skin supplied by

a single spinal

nerve or cord

segment

Myotome- the

muscle/s

supplied by a

single spinal

nerve or cord

segment


Identify the level of spinal cord injury

• Make note of both sensory and motor

deficit levels


American Spinal Injury Association (ASIA)

Classification

• Allows for standardized classification of spinal cord

• Based on

• severity of neurological deficit- A=complete to

E=normal

• the neurological level- identify the most caudal

segment with normal function

SPINAL CORD INJURY: MANAGEMENT

Phases of injury

• Primary spinal cord injury- injury to spinal cord

directly related to fractures, dislocations,

compression, bleeding

• Secondary spinal injury- resulting from prolong

mechanical instability or subsequent episodes

of hypotension, hypoxia, infections


Management principles:

Stabilize the primary source of injury; prevent any

secondary injury from occurring

• Immobilization

• IV fluid resuscitation

• Medications

• Surgery


Strict immobilization

• 5% of patients with existing injury experience a worsening or

new onset of symptoms after arriving to the ED- poor

immobilization techniques

• use a cervical collar

• if a pt needs intubation must maintain inline cervical

stabilization

• These are potentially difficult intubations

• maintain patients flat and on bedrest until appropriate bracing

is in place if appropriate


IV fluid resuscitation

• maintain SBP > 90mm Hg

• Normal saline bolus

• If blood pressure is refractory to fluid

resuscitation consider neurogenic

shock


Hypovolemic Shock vs Neurogenic


Neurogenic Shock:

• Mechanism- impairment of descending sympathetic pathways

in the cervical or upper thorax (usually above T6)

- Leads to a loss of vascular sympathetic motor tone

‣ Results in peripheral vasodilation, pooling of blood and

hypotension

- Loss of sympathetic stimulus to the heart (injury above T1)

‣ Results in bradycardia and lack of reflexive tachycardia

response to hypotension


Neurogenic Shock vs Spinal shock


Spinal Shock:

• Mechanism- transient loss of voluntary and reflexive

neurologic function below the level of injury

- Spinal cord dysfunction maybe transient but can last

days to months

- flaccid paralysis, bowel and bladder incontinence,

priapism

- first reflexes to return are bulbocavernosus and babinski


Neurogenic Shock

• Management

- Hypotension:

‣ Bolus of crystalloid fluids- may require large amounts but beware of fluid overload and

pulmonary edema

‣ Vasopressors- typically a pure alpha-blocking agent such as phenylephrine

‣ Goal is to maintain end organ perfusion- warm extremities, MAP >65mm Hg, UO

>0.5cc/kr/hr

- Bradycardia: treatment only needed if persistent hypotension

‣ Atropine given for acute therapy

‣ Pacemaker can be needed rarely in refractory cases

‣ Avoid over-zealous vagal stimulation such as NT suctioning, ETT manipulation, carotid

massage


Medical therapy:

• Corticosteroids- Aimed at reducing the extent of secondary spinal damage

- Most trials have used high dose methylprednisolone

‣ to be given within 8 hrs from time of injury

‣ bolus first given followed by IV infusion for 24-48hrs

- Insufficient evidence to routinely recommend

‣ Early studies (NASCIS I&II) showed no increased complications or mortality, however larger

and later studies have raised significant concerns related to sepsis and mortality

‣ In 2013, based upon the available evidence, the American Association of Neurological

Surgeons and Congress of Neurological Surgeons stated that the use of glucocorticoids in

acute spinal cord injury is not recommended

‣ Position statements from the Canadian Association of Emergency Physicians, endorsed by the

American Academy of Emergency Medicine, concur that treatment with glucocorticoids is a

treatment option and not a treatment standard.


Management of co-morbidities of the injury

• Respiratory compromise- Pulmonary complications, including respiratory

failure, pulmonary edema, pneumonia, and pulmonary embolism, are the most

frequent category of complications after injury

- early intubation and ventilator support as needed

- Tracheostomy is performed within 7-10 days unless extubation is imminent

• Venous thrombosis- Deep venous thrombosis (DVT) is a common complication

of spinal injury, occurring in 50 to 100 percent of untreated patients, with the

greatest incidence between 72 hours and 14 days

- All spinal cord injury patients should receive DVT prophylaxis as soon as

possible

- Early consideration for placement of an IVC Filter if pt is quadriplegic



• Pain control. After spinal injuries, patients usually require pain relief.

• Pressure sores. Pressure sores are most common on the buttocks and heels and

can develop quickly (within hours) in immobilized patients.

- Backboards should be used only to transport patients with potentially unstable

spinal injury and discontinued as soon as possible.

- After spinal stabilization, the patient should be turned side to side (log-rolled)

every two to three hours to avoid pressure sores.

- Check for pressure sores under cervical collars

• Urinary catheterization. Typically an indwelling urinary catheter is used to avoid

bladder distention.

- Three or four days after injury, intermittent catheterization should be

substituted, as this reduces the incidence of bladder infections



• Gastrointestinal stress ulceration. Patients with spinal injury, particularly those that affect the

cervical cord, are at high risk for stress ulceration. Prophylaxis with proton pump inhibitors is

recommended upon admission for four weeks

• Paralytic ileus. Bowel motility may be silent for a few days to weeks after injury. Patients

should be monitored for bowel sounds and bowel emptying, and should not ingest food or

liquid until motility is restored

• Temperature control. Patients with a cervical spinal cord injury may lack vasomotor control

and cannot sweat below the lesion. Their temperature may vary with the environment and

need to be maintained.

• Functional recovery. Occupational and physiotherapy should be started as soon as

possible. Psychological counseling is also best offered to patients and relatives as early as

possible.

• Nutrition- nutritional support should be provided early after injury- ideally within the first

24hrs if patient is stable

- Enteral or PO feeding is the prefer route.


Surgical Fixation

• Cervical Traction

- Gardner-Wells tongs

‣ Provides temporary stability of the cervical spine

‣ Contraindicated in unstable hyperextension injuries

‣ Weight depends on the level (usually 5lb/level, start with 3lb/level, do

not exceed 10lb/level)

‣ Cervical collar can be removed while patient is in traction

‣ Pin care: clean q shift with appropriate solution, then apply povidone-

iodine ointment

‣ Take XRays at regular intervals and after every move from bed

SPINAL CORD INJURY:MANAGEMENT

SPINAL CORD INJURY : CONCLUSIONS

Take Home Messages:

• Over 1/2 of spinal cord injuries occur in the cervical spine

• C-spine immobilization is critically early in patients with

suspected injury to prevent further damage

• Consider early intubation and ventilation for patients with

evidence of high cervical injuries before they show signs of

respiratory distress

• The principles of ATLS “ABCs” still apply to fully evaluate

the patient and treat any associated injuries

SPINAL CORD INJURY: CONCLUSIONS

Take Home Messages:

• Neurogenic shock is a triad of hypotension, bradycardia,

and peripheral vasodilation

• In trauma patients, neurogenic shock is a diagnosis of

exclusion

• Avoid over-zealous fluid resuscitation- consider

vasopressors if blood pressure is refractory to treatment

• Early consultation with a spinal specialist for surgical

fixation

Questions?

Thank you!

acute management of spinal cord injury · acute management of spinal cord injury dan rutigliano,...

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