Dr. Arun L NaikSenior Consultant Neurosurgeon

Apollo HospitalBannerghatta Road

Bangalore

Annual cases: 2000055 cases per day2 persons per minutesCost per year : INR 5400

cr

MVA 56% Falls 16% Gunshot Injuries 11% Blunt Assault 6% Diving Accidents 5% Stab Wounds 4% Sport Injuries 2%

Flexion: bilateral facet dislocations wedge fractures of anterior vertebrae,

Disruption of the disc with forward bilateral facet dislocations, and fracture of the pedicle.

Flexion with rotation: Causes unilateral facet dislocation fracture of the vertebra, rupture of supporting ligaments.

Vertical compression/axial loading These usually stable injuries "burst" fracture

Trauma to the cord itself Vertebral columnDistractional forces associated with flexion,

extension, dislocation, or rotationStretching or shearing of the neural elementsCompression and contusion from bone

fragments, ligaments, and hematoma within the spinal canal

EdemaIntramedullary hemorrhageAxonal degenerationDemyelination Ischemia

ParamedicsIntubation?Immobilization

Prolonged time spent in transport

Respiratory compromise

Pain and discomfort in conscious patient

Pressure sore in prolonged use

Airway with attention to spinal protectionBreathingCirculationDisability: NeurologicalExposure of the entire patient for signs of

injury

Nasotracheal intubation (ATLS ): Fallen out of practice

Cricothyroidotomy has also become less common

Intubating laryngeal mask airwayLighted styletElastic bougie devices

• Diminished or absent airway protective mechanisms: intracranial injury or other pathology

• Evidence of airway obstruction in the multiple trauma

• Acute respiratory failure in patients with injuries at C4

• Thoracoabdominal trauma• Inability to cough, clear secretions

The ideal MAP: 80 to 100 mmHgHypertension: Risk of intramedullary

hemorrhage and edemaAdequate volume resuscitationVasopressor therapy

Spinal Shock• Temporary

suppression of all or most reflex activity below the level of injury

• Occurs immediately after injury

• Intensity & duration vary with the level & degree of injury

Neurogenic Shock• The body’s response to the

sudden loss of sympathetic control

• Distributive shock • Occurs in people who have

SCI above T6 (> 50% loss of sympathetic innervation)

• Paralyzed, hypotensive patient with warm, dry, hyperemic extremities, and bradycardia

Rapid neurological assessment: prior to the administration of paralytic agents

Pupils for size and reactivity

GCSExtremities powerRectal tone

Head-to-toe Complete neurological examinationSpinal injury: tenderness, step-off

deformities, edema, and ecchymosesLong bone fracturesSevere soft tissue injuries

Head InjuryChest injury

Chest wallRib fracturesPulmonary

contusionsHemothoraxPneumothorax

Abdominal injuryPelvic injuryBony injury

Plain X raysC spineCXRDL / LS SpineLong bonesPelvis

CT scanMRI

Inadequate plain filmsSuspicious plain film findingsAny fracture / displacement on plain filmsHigh clinical suspicion of injury despite

normal plain films

Anterior cord syndromeCentral cord syndrome

Posterior cord syndromeBrown–Séquard syndrome

Conus medullaris syndromeCauda equina syndrome

• Flexion-rotation force to the spine producing an anterior dislocation or by a compression fracture of the vertebral body• There is often anterior spinal artery compression so that the corticospinal and spinothalamic tracts are damaged• Loss of power as well as reduced pain and temperature sensation below the lesion

Older patients with cervical spondylosis

Hyperextension injury Flaccid (lower motor neuron) weakness of the

arms and relatively strong but spastic (upper motor neuron) leg function

Sacral sensation and bladder and bowel

function are often partially spared

• Hyperextension injuries with fractures of the posterior elements of the vertebrae

• Good power and pain and temperature sensation but there is sometimes profound ataxia due to the loss of proprioception, which can make walking very difficult

Stab injuries, lateral mass fractures of the vertebrae

Power is reduced or absent Pain and temperature

sensation are relatively normal on the side of the injury

The uninjured side therefore has good power but reduced or absent sensation to pin prick and temperature

Loss of bladder, bowel and lower limb reflexes

Injury to the lumbosacral nerve roots results in areflexia of the bladder, bowel, and lower limbs

Primary Injury

Secondary Injury

Hypotension should be avoidedOptimal blood pressure in the first week after

SCI through aggressive volume expansion and the use of pressor agents may improve outcome

SBP in adults should be kept 90 mmHg

Skin careFoley catheterRespiration Low molecular Weight HeparinAdequate analgesiaSpinal bracesManagement of associated injuries

30 mg /kg bolus

5.4 mg/kg/h x 23 hours

MPSS

˂ 8 hours : Better neurologic recovery at 6w / 6 m / 1 yr˃ 8 hours : Worse neurologic function than the placebo group.

3- 8 hoursMPSS> 8 hours

30 mg /kg bolus

5.4 mg/kg/h x 48 hours

Maximize neurologic recoveryRestore normal alignment and correct deformityPromote spinal stability, fusion, or bothMinimize painFacilitate early mobilization and rehabilitationMinimize hospitalization and costPrevent secondary complications

Irreducible anatomic compressive lesion with neurological deficits (spl incomplete or progressive)

Complete injury except MR showing transection of cord

InstabilityNeed for multiple surgical procedures or

associated multiple trauma

Neurologically complete injury of thoracic cord with compression but stable fracture

Incomplete neurological injury with modest compression ( for example 25%)

Central cord syndrome with associated spondylotic compression of cord

Hemodynamic instabilityInadequate resuscitationSevere TBIInsufficient radiological imagingMRI showing complete transaction

Decompressive StabilizationBoth the above

Quick decision of screw dimensions

Decreased deviation between plan and results