Avoiding Spinal Cord DisastersThe Key is Early Recognition

J. Stephen Huff, MD, FACEPUniversity of Virginia

Departments of Emergency Medicine and NeurologyJune 25 - 27, 2009

Spinal Cord DisastersThe Key is Early Recognition

• Injury patterns

• Differential diagnosis

• Cases

• Pitfalls

• Pearls

Spine or Spinal Cord?

Spinal Cord Syndromesand Injury Patterns

• Complete

• Incomplete– Anterior– Posterior – Central Cord– Brown-Sequard– Cauda equina lesion– Conus medullaris lesion

Spinal Cord Syndromesand Injury Patterns

• Complete– Transverse sensory pattern– Transverse motor pattern

• What’s the level?

Motor levels

• C4 level – quadriplegia

• C5 level + deltoid, biceps

• C6 level + wrist extensors, brachioradialis

• C7 level + triceps

• T1 level + finger abductors

Motor levelsT2 – T12 paraplegic

• L1 intact – Iliopsoas (hip flexion)

• L2 + hip adductors

• L3 + quadriceps

• L4 + tibialis anterior (dorsiflexion)

• L5 + hamstrings

• S1 + gastrocs (plantarflexioin)

Motor

• Weakness

– Sudden or progressive

• Fatigability

• Clumsiness

• Atrophy / fasciculations

Patterns of sensory loss

• Bilateral segmental loss

• Pinprick loss alternating with position & vibration loss

• Sacral sparing

• Sacral loss

Reflexes

• Reflex assessment may be unreliable in acute lesions

• Autonomic reflexes

• “Spinal Shock”

Pitfalls

• Time constraints

• Incomplete history

• Incomplete examination

• Unusual presentations

“Levels”

• Vertebral

• Cord

• Disability

• Function

• => say what you mean…

Imaging

• Plain radiography

• CT

• MRI

• Myelography

Case 1 - multiple trauma

• Unrestrained driver

• Head injury

• Intubated at scene

• Immobilized / IV’s

Case 1 - arrival

• Intubated / unresponsive

• Hypotensive

• Stable chest

• Rigid abdomen

Case 1 - Management

• Airway verified

• Resuscitation continued

• Examination

• Ancillary tests

Case 1 - Pressure problems

• Hypotensive…

• No fractures on early xrays

– CXR

– Pelvis

• Peritoneal lavage negative

• ? Why hypotensive?

Neurogenic Shock

• “Vasogenic shock”– Diagnosis of exclusion– Fluids– Pressors

• Not “spinal shock”

Pitfalls – complete lesions

• Failed recognition

• ABCD

• Attributing hypotension to the spinal cord injury erroneously

• Steroid stumble

Case 2 - football player

• Tackling injury

• Ambulatory after accident

• Immobilized

• Helmet on….

Case 2 - football player

• Awake, alert

• Strength exam normal

• Severe pain upper extremities

• Grip good

Central Cord Syndrome

• Upper extremity symptoms

• Lower extremities intact

• Variable sensory findings

• Variable bladder dysfunction

Central Cord Syndrome

• “Burning Hands” in football players with spinal cord injuries….

• Cord at risk

• Narrow canal – etiology?

• Advanced imaging

• Restriction of play?

Case 3 – chest pain

• 53 year-old man with chest pain and upper back pain

• Left-sided, sharp, + movement

• Hx COPD, sarcoidosis, CHF, pulmonary embolism, diabetes

• On prednisone, metformin, diuretic

• Wheelchair at times, active

Case 3 – chest pain

• Afebrile

• CXR, CT-PA obtained

• WBC 23,000

Case 3 – chest pain

• Leukocytosis attributed to steroids

• Pain medications, discharged

Case 3 – Clinical course

• Returned 48 hours with leg weakness

• Blood cultures + Staph aureus

• MRI- epidural fluid collection

Sensory

• Paresthesias-positive

• Negative symptoms

• Pain – Local pain– Radicular pain– Diffuse burning/aching

Compressive lesions

– Spinal epidural hematoma– Spinal epidural abscess– Disciitis– Disc– Neoplasm– Metastatic tumors– Primary CNS tumor

Spinal Epidural Abscess

• Acute, sub-acute, and chronic

• Thoracic location more common

• Extends 4-5 levels

• Triad– Back pain– Fevers– Progressive neurologic dysfunction

Spinal Epidural Abscess

• Risk factors– Intravenous drug abuse– Diabetes– Chronic renal failure– Alcoholism– Immunosuppression– Instrumentation

Spinal Epidural Abscessdiagnosis

• MRI diagnostic test of choice

• ESR elevated

• LP relatively contraindicated

Spinal Epidural AbscessTherapy

• Surgical decompression

• Antibiotics*– Staph coverage– MRSA

• Prognosis related to pre-op state

Compressive lesions

– Treatment generally similar…– Diagnosis…

• Exclude remedial causes…

– Steroids … – Decompression…– XRT for tumors…

• “the only XRT emergency….”

Case 4 – crack in neck

• Awakened with severe neck pain

• Became weak on way to ED

• Right-sided weakness– No facial droop – No speech difficulty

Case 4 – crack in neck

• At arrival, weak right arm and leg

– 4/5

– Left side normal

• Additional history– Strong family history of stroke– No medical history other than mild

hypertension

Spinal Epidural Hematoma

• Sudden, severe back pain

• Radicular component

• Progressive neurologic deficits

Spinal Epidural Hematoma

• Anticoagulant use

• Thrombocytopenia

• Liver disease / alcoholism

• Instrumentation

• MRI imaging modality of choice

Case 5

• 16 year old

• Abrupt inability to walk

Case 5

• Awake, alert

• Sitting on side of bed

• Lifting legs with arms

• Sensory level at umbilicus

Case 5

• Normal tone

• Normal reflexes

• “Don’t worry about me…”

“Hysterical paraplegia”

• Untenable patterns

– Sensory loss

– Motor loss

• Normal muscle tone

• Normal reflexes

• No bladder dysfunction

“Hysterical paraplegia”

• Beware diagnosis

• Positive findings…

• Ask for help…

• Lumbar puncture?

“Stable” vs. “unstable”

• Mechanical

• Deficit

• General condition

Low lesions

• Conus medullaris lesion

• Cauda equina lesion– Overlap / coexist– Sphincter involvement– UMN vs. LMN– Bilateral vs. unilateral

Nontraumatic etiologies of spinal cord dysfunction

• Demyelination– Multiple sclerosis / Transverse myelitis– Stroke

• AVM / SAH– Syringomyelia– Traumatic– Tumor

• Idiopathic spastic paraparesis– HIV myelopathy– Other myelopathies

• Compressive lesions

THINK REVERSIBLE

Avoiding Spinal Cord DisastersThe Key is Early Recognition

J. Stephen Huff, MD, FACEPUniversity of Virginiajshuff@virginia.edu