this guy may need emergency spinal surgery…….€¦ · • example: cervical vertebral...
TRANSCRIPT
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THIS GUY MAY NEED EMERGENCY SPINAL SURGERY…….
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RECOGNIZING SPINAL CORD EMERGENCIES
• Spinal cord injuries are uncommon but:
1) they must be recognised early,
2) to make the correct diagnosis,
3) so that the correct treatment can be instituted,
4) to possibly prevent permanent loss of function.
• Differential diagnosis includes: (Spinal cord compression 2ndry to) 1) Vertebral fractures 2) Space occupying lesion 3) Spinal infection 4) Abscess 5) Vascular / haematological
damage 6) Severe disc herniation 7) Spinal stenosis
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RECOGNIZING SPINAL CORD EMERGENCIES
• Most important information comes from the history & clinical evaluation…..
• Physicians / health care workers must look for red flags
• CT & MRI can clearly define anatomy but have a high false positive rate
• Early consultation with a Spinal / Neuro specialist indicated
IN THE HISTORY:
• 1) Pain: Location, radiation, duration, severity, Night pain? What exacerbates or relieves it?
• 2) Morning stiffness: Rheumatological arthropathy?
• 3) Paresthesia, numbness, weakness
• 4) Bowel & bladder symptoms
• 5) B & B symptoms associated with peri-anal numbness – think Cauda Equina Syndrome
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CLASSIFYING SPINAL CORD “INJURIES”
• TRAUMATIC – PENETRATING – NON-PENETRATING
• NON-TRAUMATIC – CAUDA EQUINA – INFECTIONS – TUMOURS
• SPINAL EMERGENCIES: – Can be life threatening
– Can be limb threatening e.g. Paralysis
– In Traumatic injuries: - Not always obvious - Often associated with other injuries
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How do we broadly classify spinal emergencies?
TRAUMATIC VS NON-TRAUMATIC NON-TRAUMATIC TRAUMATIC
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TRAUMATIC CAUSES SUB-DIVIDED INTO:
NON-PENETRATING PENETRATING
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NON-TRAUMATIC CAUSE SUB DIVIDED IN:
CAUDA EQUINA TUMOUR & INFECTIONS
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GENERAL RULES WHY WE PERFROM SPINAL SURGERY
• 1) INSTABILITY - If we suspect that the spine
will not be able to withstand physiological loading
• 2) NEUROLOGY - If the patient has significant
neurological fall-out or if the neurology is progressing
• 3) DEFORMITY - If we predict that the patients’
spine will deform in the near future secondary to the underlying pathology
SURGICAL STRATEGY THEREFORE IS:
1) STABILIZE THE SEGMENT
2) DECOMPRESS THE NEUROLOGICAL STRUCTURES
3) CORRECT THE DEFORMITY
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GENERAL INDICATIONS FOR SURGERY
1) Infectious
2) Neoplastic
3) Myelopathy
4) Progressive neurologic deficit
5) Stable neurological deficit with radicular pain
6) Refractory to non-operative therapy
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WHAT IS EMERGENCY VS URGENT? ABSOLUTE EMERGENCY SURGERY: – IMMEDIATELY, e.g. Bi-facet dislocation or Cauda Equina Syndrome
EMERGENT SURGERY:
– WITHIN 6 HOURS, e.g. Spinal Infection, systemically sick
URGENT SURGERY:
- NEXT AVAILABLE LIST, e.g. successfully reduced Bi-facet dislocation
DELAYED EMERGENT SURGERY:
- PLANNED 24-48+ HOURS DELAY, e.g. Burst fracture
SEMI-ELECTIVE:
- NEXT WEEK, e.g. tumour / TB surgery without progressive neurology
ELECTIVE:
– NEXT MONTH, e.g. stable spinal stenosis
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Some case examples of traumatic vs non-traumatic spinal injuries and the indications for surgery
• TRAUMATIC – PENETRATING – NON-PENETRATING
• NON-TRAUMATIC – CAUDA EQUINA – INFECTIONS – TUMOURS
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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Cervical Vertebral dislocation C5/C6
• PATHOLOGY: Complete dislocation with bilateral vertebral artery occlusion
• SURGERY: Anterior or Posterior decompression & fusion
• TIMING: Absolute Emergency – ASAP
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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Lumbar Burst fracture at L3
• PATHOLOGY: Unstable Burst with retro-pulsion of bone into the canal, no neurology
• SURGERY: Posterior +/- Anterior instrumented fusion
• TIMING: Delayed Emergent Surgery
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Example of a scoring system to decide on surgery in Traumatic Cases
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NON-PENETRATING TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Epidural Haematoma
• PATHOLOGY: Bleeding in a confined space resulting in a “space occupying lesion” with neurological fall-out
• SURGERY: Laminectomy, evacuate haematoma
• TIMING: Emergency list
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PENETRATING TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Low velocity GSW T9/T10
• PATHOLOGY: Stable fracture, bullet in canal, no neurological fall-out
• SURGERY: Laminectomy & removal only indicated if on-going neurology
• TIMING: Often delayed for 2 weeks – pseudo capsule
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PENETRATING TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Stab wound Thoracic spine
• PATHOLOGY: Stable injury, in-complete neurological fall- out, no CSF leak
• SURGERY: Not indicated unless CSF leak or progressive neurological fall out
• TIMING: Immediate if acute change in neurology, otherwise no surgery
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NON-TRAUMATIC SPINAL CORD “INJURIES”
• EXAMPLE: Lumbar L3/L4 Spinal Infection
• PATHOLOGY: Acute Pyogenic Discitis vs Chronic infection (Fungal / TB)
• SURGERY: Tissue biopsy / washout
• TIMING: Pyogenic = Urgent – next available list, Chronic (e.g. TB) = semi-elective
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NON-TRAUMATIC SPINAL CORD “INJURIES”
• EXAMPLE: Epidural Abscess
• PATHOLOGY: Pyogenic Epidural Abscess with neurological fall-out
• SURGERY: Laminectomy, decompression, wash out & tissue biopsy
• TIMING: Emergency list
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NON-TRAUMATIC SPINAL CORD “INJURIES”
• EXAMPLE: Spinal Tumour
• PATHOLOGY: Intra-dural, extra-medullary mass, patient gradually became myelopathic
• SURGERY: Laminectomy, decompression, & tissue biopsy
• TIMING: Semi-Elective list unless sudden onset myelopathy
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NON-TRAUMATIC SPINAL CORD INJURIES
• EXAMPLE: Cauda Equina Syndrome
• PATHOLOGY: Large lumbar disc herniation with loss of bowel & bladder function, saddle anaesthesia and bilateral lower limb weakness
• SURGERY: Laminectomy, discectomy & decompression
• TIMING: Absolute Emergency (Delayed surgery = risk of permanent neurological deficit)
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IN SUMMARY Every spinal referral should be treated as an absolute emergency
and then down graded as more information becomes available
When dealing with a spinal emergency:
1) History and mechanism of injury important
2) Rapid clinical examination
3) Appropriate imaging to identify the pathology
4) Urgent refer to a spinal surgeon if progressive neurology or instability
Don’t let the sun go down on progressive neurology
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