spinal cord injury usaf cstars baltimore university of maryland medical center r a cowley shock...

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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