spinal injury and it's current management : cme -

CME ON

Spinal Injury

And It’s Management

1

Prepared by -

Dr. Md Nazrul Islam, MBBS, M.sc.Supervised by -

Dr. Sk. Abbas Uddin Ahmed

MS (Ortho), AO(Basic), AO(Spine).

Presenting by -

Dr. Abdul Hannan

From -

Department Of Orthopaedic & Traumatology,

Shaheed Suhrawardy Medical College Hospital. Dhaka.

Spinal Injury & its Management

Over view


Definition of spinal injury

Anatomy of human spine

Classification of spinal injury

Epidemiology

Pathophysiology of spinal injury

Clinical features of spinal injury

Investigations

Diagnosis

Management

Prognosis

Rehabilitations

Conclusions

Functions of spine

The spine has many functions, the main ones

are listed below-

1.To provide protection of the spinal cord

and associated nerves

2.To allow for movement

3.To support our body frame in an upright

position

4. To allow for flexibility

5. To provide a structural foundation for the

shoulder girdle and the pelvic girdles

6. To act as shock absorbers from load-

bearing

7. To provide a structural base for rib

attachments which protect the heart and

lungs.


“ Spinal injury” may be defined

as-

Injury to the Spinal column (Bony

Column)/Spinal Cord,

or both of them.

Spinal injury can be divided into-

Spinal Column(Bony)Injury.

Spinal Cord injury.

Combined (Both Column &

Cord) Injury.

Definition Of Spinal Injury:


Spinal Injuries

Spinal Column Injury

Bony spinal injuries may or may not

be associated with spinal cord injury

These bony injuries include:

Compression fractures of the

vertebrae

Comminuted fractures of the

vertebrae

Subluxation (partial dislocation) of

the vertebrae

Other injuries may include:

Sprains- over-stretching or tearing of

ligaments

Strains- over-stretching or tearing of

the muscles.


Spinal Cord Injury Cutting, compression, or stretching

of the spinal cord

Causing loss of distal function,

sensation, or motion

Caused by:

Unstable or sharp bony fragments

pushing on the cord, or

Pressure from bone fragments or

swelling that interrupts the blood

supply to the cord causing

ischemia.

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Risk factors:

Alcohol intoxication

Drug abuse

Participation in high-

risk activities:

Diving

Contact sports

Osteoporosis

Epidemiology


50% of SCI’s are complete

50-60% of SCI’s are cervical

Immediate mortality for complete cervical

SCI ~ 50%

Occurs primarily in young males (> 75%

of cases)

Half of these injuries result from MVAs

2/3 of patients are < 30 years old

Other sources of SCI: Falls, sporting

and industrial accidents, gunshot wounds.

Most common vertebrae involved are

C5, C6, C7, T12, and L1 because they

have the greatest ROM.

http://www.freemd.com/alcohol-poisoning/overview.htm



http://www.freemd.com/drug-abuse/overview.htm

http://www.freemd.com/osteoporosis/overview.htm

10 - 15 per million

18 - 35 years

Male - 3:1

RTA 51% - cars

Domestic 16%

Industrial 11%

Sports 16% - diving incidents

Self harm 5%

Epidemiology

Incidence


Cervical 40%

Thoracic 10%

Lumbar 3%

Dorso lumbar 35%

Any 14%

Types of Spinal Injury-


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Incomplete injury:

Some motor or sensory functions is spared

distal to the cord injury. Voluntary sphincter

contraction, toe flexor contraction –present.

Prognosis-Good’

Complete injury:

Total motor & sensory loss distal to the injury

after Spinal shock (usually lasts for 24-48

hrs) is over. When the bulbo cavernosus

reflex is positive & no sacral sensation or

motor function has returned, paralysis will

be permanent & complete in most patients.

PATTERNS OF MULTIPLE SPINAL

INJURY :

Pattern: A. Primary lesion occur between

C5 & C7 with secondary injuries at

T12 or the lumber spine.

Pattern : B. Primary injury at T2-T4 with

secondary injury in cervical spine.

Pattern : C.. Primary injury occur

between T12 & L2 with secondary

injuries from L4-L5.

Acute:

Caused by bone or ligament

disruption that places the normal

elements in danger of injury with any

subsequent loading deformity.

Chronic:

Result of progressive deformity that

may cause neurological deterioration.

CLINICAL INSTABILITY

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Degenerative Disease Of Spine

Spinal Canal Stenosis

Ankylosing Spondylitis

Down's Syndrome

Klippel-feil Syndrome

Arnold-chiari Malformation

Metastatic CA

Osteomyelitis

Rheumatoid Arthritis.

Predisposing factors



Spine consists of alternating

Bony vertebrae

Fibrocartilaginous disc

Supported by musculature.

Motion segment – Two adjacent vertebrae with intervening disc.


Anatomy of the spine is usually

described by dividing up the spine

(Bony vertebrae) into 3 major bony

sections:

The cervical,

The thoracic, and

The lumbar spine in which the spinal

cord is embedded.

(Below the lumbar spine is a bone

called the sacrum, which is part of

the pelvis).

Each section is made up of individual

bones called vertebrae. There are 7

cervical vertebrae, 12 thoracic

vertebrae, and 5 lumbar vertebrae.

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• Anterior column = anterior 2/3 of

the vertebral body, disc, and annulus,

and the anterior longitudinal ligament)

• Middle column = posterior 1/3 of

the vertebral body, disc, annulus, and

the posterior longitudinal ligament

• Posterior column = pedicles, laminae,

facets, capsule, and the interspinous

and supraspinous ligament.

injury is said to be stable if only one

of the columns is involved.

damage to two or more columns or

risking neurological injury (ie damage

to the middle column) - unstable.

Stability of Spine-

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Primary mechanism of cord injury can

be due to four kinds of mechanical

forces.

a. Impact with persisting compression e.

g. fractures, dislocations, and disc

herniations.

b. Impact with no persisting compression

e. g. hyperextersion injuries.

c. Distraction e. g. hyperflexion injuries.

d. Laceration/ Transection: Penetrating

injuries, fracture dislocation.


Most likely to occur at sites of

maximum mobility•Adults C6

•Children <8 yrs old C2.

Pathophysiology of spinal

cord injury:


Secondary injury mechanisms that may be

involved are:

a. Systemic shock: Profound hypotension, and

bradycardia (often lasting for days) follows

cord injury and there may be a compromise of

an already damaged cord.

b. Local microcirculatory damage: may be due

to mechanical disruption of capillaries,

hemorrhage, thrombosis and loss of

autoregulation.

c. Biochemical damage: may occur due to

excitotoxin release (glutamate), free radical

production, arachidonic acid release, lipid

peroxidation, eicosanoid production, cytokines

and electrolyte shifts.

25% of spinal cord injuries occur after primary

injury.

Primary injury results from focal injuries (eg

avulsion, contusion, laceration and intra-

parenchymal hemorrhage) and diffuse lesions

(e.g. concussive and diffuse axonal injury).

Further mechanical disruption can result from

external compression or angulation and

ischemic damage from occlusion of arterial

supply.

Primary injury


Secondary injury

Immediately after an acute spinal cord

injury major reduction in blood flow occurs

at the level of the lesion. Becomes

progressively worse over the first few hours

if left untreated. Pathophysiology

underlying this ischaemia is unclear but

involves both systemic and local effects.

Putative local mechanisms include

vasospasm, endothelial swelling or damage,

haemorrhage causing obstruction of small

blood vessels, loss of autoregulation and

impaired venous drainage.21

Results from:

•Cellular hypoxia

•Oligaemia


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Secondary injury-Spinal Injury & its Management

Secondary Injury Cascade

Current understanding

Primary Neurological damage

Direct trauma, haematoma & SCIWORA < 8yrs old

In 4hrs - Infarction of white matter occurs

In 8hrs - Infarction of grey matter and irreversible paralysis

Secondary damage

Hypoxia

Hypoperfusion

Neurogenic shock

Spinal shock


Factors affecting the severity of

a spinal lesion-

Loss of neural tissue - obvious

Vertical level – Higher up, the

greater the damage

Transverse plane – What Diameter

has a lesion



Pain

Breathing difficulty

Sensitivity to stimuli

Muscle spasms

Loss of sensation

Loss of reflex function

Loss of autonomic activity

Loss of bowel control

Loss of bladder control

Sexual dysfunction

Loss of function, such as mobility or sensation

Paralysis

Common features of spinal

injuries are-

“Level" of cord lesion is conventionally the

most caudal location with normal motor and

sensory function.

Motor level = the last level with at least 3/5

(against gravity) function

NB: this is the most important for

clinical purposes

Sensory level = the last level with preserved

sensation

Radiographic level = the level of fracture on

plain XRays / CT scan / MRI

NB: spine level does not correspond to

spinal cord level below the cervical

region.


Spinal shock may mimic a complete cord

lesion with total loss of motor and sensory

function distal to injury. However if lesion is

incomplete some function will return

99% of patients with a complete lesion over

24 h will not show functional recovery

Patients with partial lesion may regain

substantial or even normal neurological function

even though the initial neurological deficit may

be severe

Presence of bulbocavernous reflex or anal-

cutaneous reflex indicates sacral sparing and a

more favorable prognosis.



A. Clinical laboratory tests.

Laboratory tests will be guided by

clinical assessment of patient (history

and physical examination).

In addition to routine investigations

diagnostic imaging is very important.

B. Diagnostic imaging.

1. X-RAY

2. CT SCAN

3. MRI


Indications for screening radiology. History of

trauma and:Not fully conscious

Drowsy or intoxicated

Focal neurological deficit

Midline cervical tenderness

Other painful injury that may mask neck pain, particularly fractures

Screening radiology of choice is CT of spine.

Additional indications are-oExtremes of age

oMechanism of injury highly suggestive of cervical spine injury

oSignificant facial trauma

Sensitivity approximately 98% and considerably higher than plain radiography. May miss soft tissue

injury and spinal cord injury in the absence of bony

injury.

Although CT may miss soft tissue and

spinal cord injury, MRI is a sensitive

alternative method.

Almost never an emergency

Exception: cauda equina

syndrome

Shows tumors and soft tissues (e.g.,

herniated discs) much better than CT

scan.

Risk of transfer to MRI ability of MRI to

detect soft tissue injury may fall after

72 hour.

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The term SCIWORA (spinal cord injury without

radiologic abnormality) originally referred to

spinal cord injury without radiographic or CT

evidence of fracture or dislocation.

However with the advent of MRI, the term has

become ambiguous. Findings on MRI such as

intervertebral disk rupture, spinal epidural

hematoma, cord contusion, and hematomyelia

have all been recognized as causing primary or

secondary spinal cord injury.

SCIWORA should now be more correctly

renamed as "spinal cord injury without neuro-

imaging abnormality" and recognize that its

prognosis is actually better than patients with

spinal cord injury and radiologic evidence of

traumatic injury.

SCIWORA(spinal cord injury without

radiologic abnormality)

Incidence 3-5% (x-ray/CT)

Higher incidence in paediatric

population (34.8%)-

The relatively large size of the

head. inherent skeletal mobility.

cord vulnerable to damage.

Higher incidence above 60 yo-

Posterior vertebral spurs due to

spondylosis. Ligamentum flavum

bulging due to loss of disc height.

Risk of central cord syndrome after

hyperextension injury.

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History-

1. Mechanism of injury

2. Misdiagnosis - head injury, acute

alcoholic intoxication and multiple

injuries.

3.Decreased level of consciousness

or comatose patients may not

complain of neck pain.

4. Profuse bleeding from face and

scalp may divert attention from

cervical spine injury

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General examination:a) Head and earb) Spinous process and interspinousligaments palpationc) Elbows may be flexed if a spinal cordinjury causes loss of function below bicepsand may be extended if the paralysis ishigher.d) Penile erection and incontinence of thebowel and bladder- significant spinalinjury.e) Flaccid paralysis of the extremities –Quadriplegiaf) Chest abdomen and extremities – Otherinjuries.

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Accurate and detailed neurological

evaluation – very important

Level of consciousness- Pupillary size and

reaction, epidural or subdural haematoma,

depressed skull fracture.

Evaluation of sensory (pinprick), motor and

reflex function.

Important dermatome landmarks are-

• Nipple line –T4

• Xiphoid process-T7

• Umbilicus –T10

• Inguinal region –T12,L1

• Perineum and peri-anal region (S2,S3&S4)

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Pre-Hospital

Management.

Hospital

Management.

Primary(Pre-hospital)

management-

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Initial treatment of patients with cord injury

focuses on two aspects - preventing further

damage and resuscitation.Immobilization with a hard cervical collar (in case of

cervical spine injuries) and care in transportation of

patient is of paramount importance if the spine is

unstable.

Resuscitation is aimed at airway

maintenance, adequate oxygen saturation of

peripheral blood, restoring blood pressure

to acceptable limits, preventing

bradycardia, done simultaneously to prevent

any ischemic damage to the already

compromised cord.

Secondary (Hospital)

Management:

Medical Management Conservative (General)-

Conservative (Medical)-

Surgical ManagementSurgical Decompression

Surgical Stabilization

Fixation of Vertebra

Fixation of Spine

Artificial disc implantation


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Conservative(General)-


.

Resuscitation according to ATLS guidelinesDetermination of neurological injuryPrevention of neurological deteriorationOngoing ID & Tx of assoc injuriesPrevention of complications Initiation of definitive management for vertebral column injury or SCI

Immediate Management-

Goals:

Aim is to prevent extension of primary

injury, to reduce secondary injury and to

treat complications-

Follow ATLS principles-

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Conservative(General)-


A irway; protect Spine

B reathing

C irculation

D isability, Dx and Rx shock

E xpose patient

And

Treat Secondary survey.

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Conservative(Medical)-

Conservative treatments of spinal disorders

have improved significantly over the years.

Of the many conservative non-surgical

treatments that are currently available, a few

of the most commonly practiced treatments

are -

•Epidural Steroid Injection

•Intradiscal thermoplasty (IDET)

•Nucleoplasty

•Facet Injections, and/or Medial Branch

Blockade

•Radio Frequency Rhizotomy or Denervation.


http://pages.sbcglobal.net/joel.baker/_uimages/DSCN0024.JPG

Depending on the circumstances, when surgery is

required.

Surgery may be considered if the spinal cord is

compressed and when the spine requires

stabilization.

The surgeon decides the procedure that will

provide the greatest benefit for the patient.

The common procedures which we perform are-

Surgical Decompression

Surgical Stabilization

o Spinal fusion

o Fixation of Vertebra

o Fixation of Spine

Discectomy, foramenotomy and

laminectomy(Some times needed).

Artificial disc implantation. 41


Surgical -

Surgical Decompression and/or Fusion-

Indications

o Decompression of the neural elements

(spinal cord/nerves)

o Stabilization of the bony elements (spine)

Timing

o Emergent

Incomplete lesions with progressive

neurologic deficit

o Elective

Complete lesions (3-7 days post injury)

Central cord syndrome (2-3 weeks post

injury).

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Surgical -

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Surgical -


33


Surgical–Spinal fixation implants:


Skin Breakdown

Osteoporosis and Fractures:

Pneumonia, Atelectasis, Aspiration:

Heterotopic Ossification:

Spasticity:

Autonomic dysreflexia:

Deep vein thrombosis:

Cardiovascular disease:

Syringomyelia-

Neuropathic/Spinal Cord Pain-

Respiratory Dysfunction-

Miscellaneous

pressure sores, Greatly increase cost and morbidity

Pokilothermia in patients with lesion above T1

hyponatraemia common in first week.

There are many complications of spinal Injury,

the followings are most common-

Rehabilitation after spinal injury (SI) focuses

on the patient learning how to live life when

faced with physical, occupational, and

emotional challenges.

After SI, everything can change, and you

can face many issues including mobility,

regular exercise and maintaining a level of

fitness, communication challenges, and

activities of daily living.

Rehabilitation may be accomplished at a

hospital, outpatient clinic, home, or a

combination.


http://www.spineuniverse.com/conditions/spinal-cord-injury

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Accredited rehabilitation centers

provide SCI patients with a team of

professionals and many resources. Some

of the professionals include:

oOccupational Therapist

oPhysiatrist.

oPhysical Therapist:

oRehabilitation Nurse.

oSpeech and Language Pathologist.

oTherapeutic Recreational Specialist.

oVocational Rehabilitation Therapist.

oRehab Psychologist


http://www.spineuniverse.com/treatments/what-physiatrist

http://www.spineuniverse.com/treatments/physical-therapy/what-can-physical-therapy-do-me-0

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Prognosis The main determinant of outcome is the patient's neurological

grade at the time of admission with patients having complete motor

and sensory myelopathy showing the worst prognosis.

Other predictive factors include rectal tone status, admission blood

pressure and pulse status, reflexes, and medical and surgical

management since injury.

The time course of recovery is also prolonged and recovery itself

often incomplete.

Taking all grades and locations into considerations a study concluded

that while the majority of cases improved within a year, even at 3

years post injury 23.3% continue to improve whereas 7.1%

deteriorated. The trend continued in the 5th year post injury also with

12.5% and 5.5% respectively showing further improvement and late

deterioration. Hence prolonged rehabilitation at a comprehensive

spinal rehabilitation center is the management of spinal cord injuries.


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“Neurological disorders are the most

complicated problems known to medical

science today, and we require the best

scientific minds and technology in order to

find cures.”

W. Dalton Dietrich, Ph.D., scientific director,

The Miami Project to Cure Paralysis


Pre-hospital & hospital both phases are equally

important for SI management.

Surgical intervention improves recovery period, quality of

life and Rehab, reduces morbidity/ mortality .

SI is neglected and poorly managed. Research is sparse

and data is missing. The demographics, epidemiological

pattern of SC in the developing world is different from the

developed world and this should be considered while

formulating polices for the SI in future.

Trauma evacuation protocols need to be developed and

pre hospital care of suspected SI patient should be

improved.

Regional and national spinal injury centers providing

comprehensive treatment and multidisciplinary rehabilitation

should be established.


From-

Department Of Orthopedics’ & Traumatology

Shaheed Suhrawardy Medical College Hospital.


3/26/201154

Associate Prof. Dr. P. C. Debenath

Associate Prof. Dr. Sheikh Abbas Uddin.

Associate Prof. Dr. Ziaul Haq

Associate Prof. Dr. Shamimul Haq

Associate Prof. Dr. Monowarul Islam

Associate Surgeon Dr. Md. Aminur Rahman

Assistant Prof. Dr. Kazi Shamimuzzaman

Assistant Prof. Dr. A T M Bahar Uddin

Dr. Abdul HannanAnd

Dr. Md Nazrul IslamResident Surgeon,

Department of Orthopedic & Traumatology.

Shaheed Suhrawardy Medical College Hospital.


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