Brain Injury CourseBrain Injury Course

Acute Spinal Cord InjuryAcute Spinal Cord Injury

Andy Jagoda, MD, FACEPAndy Jagoda, MD, FACEP

Professor of Emergency MedicineProfessor of Emergency Medicine

Mount Sinai School of MedicineMount Sinai School of Medicine

ObjectivesObjectives

• Review the clinical presentation of Review the clinical presentation of patients with acute spinal traumapatients with acute spinal trauma

• Present the grading scales used in Present the grading scales used in describing acute spinal cord injurydescribing acute spinal cord injury

• Discuss the management strategies Discuss the management strategies for spinal cord traumafor spinal cord trauma

• Introduce the potential late sequelae Introduce the potential late sequelae of spinal cord injury of spinal cord injury

Case Study: Spinal Cord InjuryCase Study: Spinal Cord Injury

• 16 yo male 16 yo male

• Trampoline for his birthdayTrampoline for his birthday

• Brought EMS; 2 IV’s, backboard, C-collarBrought EMS; 2 IV’s, backboard, C-collar

• Nasal intubation in the fieldNasal intubation in the field

• VS: P 128; BP 90/55VS: P 128; BP 90/55

• AlertAlert

• No spontaneous movement or reflexes No spontaneous movement or reflexes

SCI: SubtypesSCI: Subtypes

• CompleteComplete: complete transection of : complete transection of motor and sensory tractsmotor and sensory tracts

• IncompleteIncomplete:: Central Cord SyndromeCentral Cord Syndrome Anterior Cord SyndromeAnterior Cord Syndrome Posterior Cord SyndromePosterior Cord Syndrome Brown Sequard SyndromeBrown Sequard Syndrome

Neurologic ExaminationNeurologic Examination

• Document all findingsDocument all findings• Level of consciousnessLevel of consciousness• Motor strengthMotor strength• Sensation to light touch and pinprickSensation to light touch and pinprick• Diaphragm, abdominal, and sphincter Diaphragm, abdominal, and sphincter

functionfunction• DTRs, plantar reflexes, sacral reflexesDTRs, plantar reflexes, sacral reflexes• Position sensePosition sense• Sacral sparing (perineal sensation, Sacral sparing (perineal sensation,

sphincter tone)sphincter tone)

ASIA Impairment ScaleASIA Impairment Scale

• AA: Complete: Complete

• BB: Incomplete: Sensory, but no motor : Incomplete: Sensory, but no motor function below neurological levelfunction below neurological level

• CC: Incomplete: Motor function preserved : Incomplete: Motor function preserved below level; muscle grade < 3below level; muscle grade < 3

• DD: Incomplete: Motor function preserved : Incomplete: Motor function preserved below level: muscle grade > 3below level: muscle grade > 3

• EE: Normal: Normal

Complete CordComplete Cord

• No sensationNo sensation• Flaccid paralysisFlaccid paralysis• Initially areflexiaInitially areflexia

Hyperreflexia, spasticity, positive Hyperreflexia, spasticity, positive planter reflex (days to months)planter reflex (days to months)

• <5% chance of functional recovery if no <5% chance of functional recovery if no improvement within 24 hoursimprovement within 24 hours

Traumatic SCI: ManagementTraumatic SCI: Management

• ABC’s: Treat / prevent hypoxia and ABC’s: Treat / prevent hypoxia and hypotensionhypotension

• Stabilize the spine to prevent additional Stabilize the spine to prevent additional mechanical injurymechanical injury

• R/O other serious injuriesR/O other serious injuries

• Careful neurological examination: level of Careful neurological examination: level of neurological impairmentneurological impairment

• ImagingImaging

• Neuroprotective pharmacotherapy?Neuroprotective pharmacotherapy?

• Early rehabilitationEarly rehabilitation

Guidelines for the Management of Guidelines for the Management of Acute Cervical Spine and SCI. Acute Cervical Spine and SCI.

Neurosurg 2002;Neurosurg 2002;50 (suppl) :1-20050 (suppl) :1-200

• Evidence based practice guidelineEvidence based practice guideline• 22 chapters22 chapters• Chapter on pharmacologic therapy Chapter on pharmacologic therapy

most controversialmost controversial 17 pages of editorial 17 pages of editorial

commentary in the prefacecommentary in the preface

IX. Pharmacological Therapy after IX. Pharmacological Therapy after Acute Cervical Spinal Cord InjuryAcute Cervical Spinal Cord Injury

• Recommendations: CorticosteroidsRecommendations: Corticosteroids Standards / guidelines: NoneStandards / guidelines: None Options: Treatment with methylprednisolone for Options: Treatment with methylprednisolone for

either 24 or 48 hours is recommended as an either 24 or 48 hours is recommended as an option in the treatment of patients with acute option in the treatment of patients with acute spinal cord injury within 12 hours of injury.spinal cord injury within 12 hours of injury.

• B) GM-1 GangliosideB) GM-1 Ganglioside Standards / guidelines: NoneStandards / guidelines: None Options: Treatment of acute spinal cord injury Options: Treatment of acute spinal cord injury

patients with GM-1 ganglioside is an option for patients with GM-1 ganglioside is an option for treatment without clear evidence of clinical benefit treatment without clear evidence of clinical benefit or harm.or harm.

MortalityMortality

• Mortality is highest in the first year Mortality is highest in the first year after injuryafter injury

• Persons sustaining paraplegia at age Persons sustaining paraplegia at age 20 have an average subsequent life 20 have an average subsequent life expectancy of 44 years expectancy of 44 years

• Leading cause of death are pneumonia, Leading cause of death are pneumonia, PEPE Renal failure is no longer a leading Renal failure is no longer a leading

cause of deathcause of death

ConclusionsConclusions

• Management of acute SCI: prevent additional Management of acute SCI: prevent additional injury and provide supportive careinjury and provide supportive care

• Role of methylprednisolone in SCI is Role of methylprednisolone in SCI is questionablequestionable

• Acute SCI above T7 - low sympathetic activity; Acute SCI above T7 - low sympathetic activity; chronic SCI - high sympathetic activitychronic SCI - high sympathetic activity

• Pneumonia, PE, and sepsis are the most Pneumonia, PE, and sepsis are the most common causes of death on patients with common causes of death on patients with chronic SCIchronic SCI