Management of a patient with spine and spinal cord injury

This presentation is prepared for management of a patient with sustained spine and spinal cord injury.

1. Spine and spinal cord Injury by Ame Mehadi|Assistant professor| Haramaya University

2. Lecture outline Introduction. Anatomy of the spine and spinal cord. Terminologies in spinal injury. Classification of spinal cord injury. Evaluation of spinal trauma. General management principles. X-ray evaluation of spine trauma. Regional injuries. Overview of peripheral nerve injuries References.

3. Introduction Spinal injuries are usually the result of high-energy injuries, e.g., car accident, falls from a height, assaults etc. Victims are usually young male adults. Fractures can occur with minimal trauma in patients with predisposing conditions such as osteoporosis, spinal tumors, metastasis and infections.

4. Introduction Spinal injury with or without neurologic deficits must be considered in any trauma victim especially in polytrauma. 5% of head injury patients have an associated spinal injury. Approximately 10-30 % of patients with spinal trauma will have spinal cord injury.

5. Introduction 10% of patients with cervical spine injury have a second, noncontiguous vertebral column injury. Delayed or missed diagnosis of spinal injury is not uncommon especially in polytrauma victims, head injured unconscious and intoxicated patients. High index of suspicion of possible spine injury and spine care is vital in caring trauma victim.

6. Introduction Spinal injuries tend to occur at the sites of greatest movement. The approximate percentages of all injuries occurring in the spine are:- Cervical region 55% Thoracic region 15%. Thoracolumbar 15% Lumbosacral 15%

7. Anatomy of spine and spinal cord The spine consists of the vertebral column that protects the spinal cord, supports body weight and provides a partly flexible axis for the body and a pivot point for the head. Important role in posture and locomotion.

8. Anatomy of spine and spinal cord Semi rigid mobile column of repeating units that has multiple sites of attachments of muscle, tendons and ligaments. Surrounds and protects the spinal cord and spinal nerve.

9. Anatomy of spine and spinal cord Extends from the skull to coccyx. 33 vertebrae in 5 regions. 24 moveable and 9 non-moveable. Cervical: C1 –C7. Thoracic: T1-T12 . Lumbar: L1-L5 . Sacrum : S1-S5 Coccyx : Cx1-Cx4.

10. Anatomy of spine and spinal cord There are 4 curves in the spine :- Cervical lordosis . Thoracic kyphosis . Lumbar lordosis . Sacral kyphosis .

11. Anatomy of spine and spinal cord

12. Anatomy of spine and spinal cord

13. Anatomy of spine and spinal cord The spinal cord housed within the vertebral foramen and is therefore protected by bone.

14. Anatomy of spine and spinal cord Three membranes surrounds the cord:- Dura mater Arachnoid mater Pia mater

15. Anatomy of spine and spinal cord The spinal cord extends from the foramen magnum down to the level of L1 VB. Connected to the medulla oblongata at the foramen magnum. Conus medullaris. Cauda equina.

16. Anatomy of spine and spinal cord There are 31 pairs of spinal nerves:- Cervical:-8 pairs. Thoracic:-12 pairs. Lumbar:-5 pairs. Sacral:-5 pairs. Coccygeal:- 1pair.

17. Anatomy of spine and spinal cord Dermatome: -area of skin innervated by the sensory axons within a particular segmental nerve. Knowledge of some of the major dermatome level is invaluable in determining the level of injury.

18. Anatomy of spine and spinal cord Important fiber tracts:- Corticospinal tract. carries motor fibers for voluntary muscle contraction. Spinothalamic tract. transmits pain and temperature sensation. Posterior column . Carries position sense, vibration and some light touch sensation.

19. Terminologies In spinal injury Spinal stability :-ability of the spine under physiologic loads to limit displacement so as to prevent injury or irritation of the spinal cord and nerve roots (including cauda equina) and, to prevent incapacitating deformity or pain due to structural changes. Level of injury :-the lowest level of completely normal function.

20. Terminologies In spinal injury Completeness of lesion:- Incomplete injury -any residual motor or sensory function more than 3 segments below the level of injury. Complete injury -no preservation of any motor and/or sensory function more than 3 segments below the level of injury.

21. Terminologies In spinal injury Spinal shock :- transient loss of all neurologic function below the level of the spinal cord injury(SCI). ..flaccid paralysis, and areflexia. Neurogenic shock:- results from impairment of the descending sympathetic pathways in the spinal cord. This condition results in loss of vasomotor tone and loss of and sympathetic innervations to the heart…

22. Terminologies In spinal injury Sacral sparing:- preserved sensation around the anus, voluntary rectal sphincter contraction or voluntary toe flexion.

23. Classification of spinal cord injury Spinal cord injuries classified according to:- 1. Level of injury—quadriplegia, paraplegia 2. severity of neurologic deficits– complete /incomplete quadriplegia, paraplegia 3. spinal cord syndrome, central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome 4. morphology—fractures, fracture dislocations, SCIWORA, penetrating injury.

24. Evaluation of spinal trauma Advanced trauma life support (ATLS)method is the safest way to approach trauma patients. It addresses the major life-threatening problems in the following order:- Airway :-protecting C-spine, establish definitive airway. Breathing :-oxygenation and ventilatory support. Circulation:- replace fluids for hypovolemia, differentiate hypovolemic from neurogenic shock.

25. Evaluation of spinal trauma Disability : -brief neurologic examination. Determine level of consciousness and assess pupils. Determine GCS score. Determine paralysis/paresis. Extremities:- check for fracture and dislocations. History on mechanism of injury, duration of injury, etc.

26. Evaluation of spinal trauma Spine assessment:- Palpation- logroll the patient carefully. Deformity/swelling Grating crepitus Increased pain with palpation(tenderness). Contusions, and lacerations/penetrating wounds. Ask patient presence or absence of pain, paralysis or paresthesia

27. Evaluation of spinal trauma Determine the level of spinal cord Injury- Motor function Muscle strength(grading power) assessment (see table) Level of quadriplegia/paraplegia/nerve root level.(see table)

28. Evaluation of spinal trauma British Medical Research Council Scale of Muscle Strength. Grade Strength M0 No contraction (total paralysis) M1 Flicker or trace contraction M2 Active movement with gravity eliminated. M3 Active movement against gravity M4 Active movement against resistance M5 Normal strength NT Not testable

29. Evaluation of spinal trauma Raises elbow to level shoulder- Deltoid, C5 Flexes forearm-Biceps , C6 Extends forearm, Triceps-C7 Flexes wrist and fingers, C8 Spreads fingers, T1 Flexes hip – iliopsoas , L2. Extends knee – quadriceps, L3,4. Flexes knee – hamstrings, L4,5,to S1. Dorsiflexes big toe – extensor hallucis longus , L5. Plantar flexs ankle – gastrocnemius , S1.

30. Evaluation of spinal trauma Sensation test sensation to pinprick.(see table for grading). ssess the dermatome and most caudal dermatome that feel the pinprick. Additional sensory exam Psition , vibration

31. Evaluation of spinal trauma Sensory grading scale:- Grade Description absent 1 Impaired (partial or altered sensation) 2 normal NT Not testable

32. Evaluation of spinal trauma Deep tendon and superficial abdominal reflexes Rectal exam Perianal sensation Voluntary external anal sphincter contraction X-rays and other imaging studies

33. General management principles The aim of spinal injury management includes:- preserve neurological function Relieve reversible nerve or cord compression Stabilize the spine Rehabilitate the patient.

34. General management principles Apply rigid cervical collar and a long backboard. Oxygenation and crystalloid fluid resuscitation. Urinary bladder catheterization –urine output monitoring and prevent bladder distention. Insert NGT- prevent gastric distention and aspiration. Analgesics. Deep vein thrombosis prophylaxis.

35. General management principles Definitive treatment according to the region and degree of spine injury. Skull traction Rigid cervical collar Hallo vest traction spine instrumentation and fusion fusion procedures Rehabilitation It should be started immediately

36. X-ray evaluation of spine trauma. Adequate lateral view For cervical spine 1.Lateral view which show from cranio-cervical to cervico-thoracic junction. 2.Posteroanterior view. 3.Open mouth view to see the odontoid process of the C2.

37. X-ray evaluation of spine trauma Ap view film Open-mouth odontoid view

38. Assessment of cervical spine x-ray:- Alignment Check the bone Check intervertebral discs Soft tissue spaces

39. X-ray evaluation of spine trauma. Flexion – extension lateral view of Cervical spine. To disclose occult instability. For neurological intact, no subluxation ,conscious and cooperative patient.

40. X-ray evaluation of spine trauma. Thoracic and lumbar x-rays:- Usually antero-posterior and lateral views. Assess alignment and bone contour.

41. X-ray evaluation of spine trauma Anteroposterior view

42. X-ray evaluation of spine trauma. CT scan of the spine . Alignment Vertebral canal 3D reconstraction

43. X-ray evaluation of spine trauma. Axial CT scan showing burst fracture with narrow vertebral foramen

44. X-ray evaluation of spine trauma MRI of spine. Incomplete spine injury Posttraumatic disc prolapse Hematoma Soft tissue and ligament injury

45. X-ray evaluation of spine trauma MRI showing C6/C7 subluxation with disc prolapse.

46. X-ray evaluation of spine trauma PA film showing thoraco-lumbar injury.

47. Regional injuries Cervical Spine Injuries Mechanism of injury:-axial loading, flexion, extension, rotation, lateral bending, and distraction or a combination of the above. Cervical fractures represent 20 -30% of all spinal fractures. Cervical fractures are divided into those of axial (C0-2) and subaxial (C3 – 7).

48. Regional injuries 1. atlanto –occipital(craniocervical) dislocation . Uncommon injury. Patients die of brainstem destraction and apnea. Cervical traction not indicated

49. Regional injuries 2. Atlas fracture(C1) The most common C1 frature is a burst frcture ( Jefferson fracture) The ususal mechanism of fracture is axial laoding. Fracture occur in more than one place. Patients rarely have a cord injury. Usually treated in a halo jacket or rigid collar.

50. Regional injuries 3. Axis (C2) fractures Odontoid fractures patients with this fracture have a 5-10% chance of neurological deficit. Classified into:- Type I – which involve the tip of the peg. .

51. Regional injuries Type II –commonest fracture which occurs at the junction of the body and neck. Type III – fractrue which extends into the body of the axis, it is stable fracture.

52. Regional injuries . Posterior element fractures Traumatic spondylolisthesis of C2 on C3 (Hangman fracture). It is a fracture of the pars interarticularis of C2.

53. Regional injuries Hyperextension & distraction is usual mechanism of injury. Commonly occurs in RTA and falls from a height. Treatment ranges from immobilization in collar to open reduction & internal fixation.

54. Regional injuries 4. C3 to C7 ( subaxial ) fractures Can be caused by different mechanisms. Common level of subluxation is C5/C6. closed reduction by traction and anterior or posterior fixation need for the treatment.

55. Regional injuries Thoraco- lumbar fractures/ dislocation. Caused by a combination of hyperflextion and rotation injury. Mostly high energy trauma due to MVA or falls from a height.

56. Regional injuries 90% of dislocation above T10 level result in complete paraplegia. Unstable fracture dislocation at these level needs instrumented fixation and fusion.

57. PERIPHERAL NERVE INJURIES Epidemiology of peripheral nerve injury Results in considerable disability across the world. In peacetime, it results from MVA, penetrating traumas, falls, and industrial accidents. In wartime, much more common injury, and results from gunshot, blast and sharp weapons. Peripheral nerve injury may be seen isolated or often accompany CNS injury, adjacent bone or joint injuries.

58. PERIPHERAL NERVE INJURIES Epidemiology of peripheral nerve injury Peripheral nerve injury accounts 2 to 3 % level I trauma center admitted patients. Radial nerve injury is the most common injury follwed by ulnar and median nerves in the upper extremity. Sciatic is most frequent followed by peronial and rarely tibial nerves in the lower extremity.

59. PERIPHERAL NERVE INJURIES PERIPHERAL NERVEOUS SYSTEM. Consists of all the neural elements outside of the CNS- the cranial and spinal nerves. It provides the connections between the CNS and all other body organ systems. The PNS consists of somatic and autonomic components.

60. Peripheral nerve anatomy Peripheral nerves comprises neural and non-neural elements. It contains three components:- 1.Conducting axons 2. Insulating Schwann cell. 3. Connective tissue matrix

61. Peripheral nerve anatomy Myelinated fibers-individually ensheathed by Schwann cells. Unmyelinated fibers:-fibers ensheathed in groups.

62. Peripheral nerve anatomy Connective tissues compartments supporting the nerve fibers:- endoneurium . Perineurium . Epineurium .

63. Grading of peripheral nerve injury Two types of classification of PN injury grading systems: Seddon classification. Sunderland classification.

64. Grading of peripheral nerve injury Seddon classification:- Neurapraxia Mildest grade of nerve injury Reduction or complete blockade of conduction across a segment of nerve. Axonal continuity is maintained. Conduction is preserved both proximal & distal to the lesion but not across the lesion. Usually caused by compression, ischemia etc.

65. Grading of peripheral nerve injury Conduction is restored once the derangement is corrected and remyelination occurs. It is reversible injury, and a full recovery can occur within days to weeks. 2. Axontmesis :- More severe grade of nerve injury Interruption of the axons with preservation of the surrounding connective tissue which support axonal regeneration.

66. Grading of peripheral nerve injury Distal Wallerian degenaration of the axon occur on subsequent several days. Recovery occur by axonal regeneration. Peripheral nerve regenerate at a rate of approximately 1mm/day or 1 inch /month. 3. Neurotmesis The severest grade of peripheral nerve injury. Characterized by disruption of the axon, myelin connective tissue components the nerve. Recovery through regeneration cannot occur.

67. Grading of peripheral nerve injury Sunderland classification Five grades Grade I =Neurapraxia Grade II =Axontmesis Grade II=disruption of only the endoneurium. Grade IV=disruption of endoneurium &perineurium. Grade V= disruption of endoneurium, perineurium , & epineurium=Neurotmesis.

68. Mechanism of Peripheral Nerve Injury Identifying the mechanism of injury helps in grading of peripheral nerve injury. Compression Ischemia Traction Laceration Blunt closed trauma often causes stretch and compression but leaving the nerve in continuity.

69. Mechanism of Peripheral Nerve Injury Sharp injuries may cause complete or partial nerve laceration. Gunshot injuries often leaves nerves in continuity but produce intraneural damage secondary to cavitation effects.

70. Clinical Evaluation Clinical history :- symptoms like pain, dysesthesias, partial or complete loss of sensory and motor function. Physical examination:- strength of individual muscle or muscle group, sensory examination for touch, pinprick, two-point discrimination, vibration, and proprioception. Tinel’s sign test to localize a nerve injury. ( Tinel’s sign -paresthesias, elicited by tapping along the course of the nerve.)

71. Clinical Evaluation Clinical history and examination answers the following points:- The lesion is central or peripheral ? Diffused or local PNS lesion? Complete or partial injury? What is the grade of the PN injury? Is the lesion is improving or further neurological deterioration

72. Electrodiagnostic evaluation of Peripheral Nerve Injuries Includes :- Nerve conduction studies, sensory and motor. Electromyography(EMG). These diagnostic modalities distinguish neurapraxic injury from axonometric neurotmesis grades of injuries. The absence of a nerve conduction response in a distal nerve segment indicates a loss of axons caused by either an axonotmesis or neurotmesis grade of injury.

73. Electrodiagnostic evaluation of Peripheral Nerve Injuries Electromyography done two to three weeks after an injury to the peripheral nerves distinguishes neurapraxic injury from axonotmesis and neurotmesis grade of peripheral nerve injury. EMG performed on neuraprxic injury remains normal while it shows fibrilations, fasciculations and positive sharp waves in the affected muscles after axonotmesis or neuotmesis grade of peripheral nerve injury.

74. Imaging of Peripheral Nerve Injuries Radiography Computed tomography (CT scan) Magnetic Resonance Imaging (MRI)

75. Guidelines of Management of Peripheral Nerve Injuries Traumatic peripheral nerve injuries divided into open and closed injuries for the treatment decision. Open injuries with acute sharp lacerating and clean injuries-> immediate repair. Open injuries with ragged or contused delayed surgical repair after an interval of 2 to 3 weeks to allow for scar formation.

76. Guidelines of Management of Peripheral Nerve Injuries Closed traumatic nerve injury Usually caused by stretch and/or compressive forces. The injured nerves may not be transected , instead a lesion in continuity may produce, neuraprxic, axonotmesis or neurotmesis grade of injury. Need to be followed with serial clinical and electrodiagnostic examinations.

77. Guidelines of Management of Peripheral Nerve Injuries Neuapraxic and axonotmetic grades of injuries donot reqire surgical interventions. Patients with complete nerve transections (neurotmesis) reqire surgical exploration and repair.

78. References 1. Advanced Trauma Life Support for doctors, student course manual 7 th edition. 2. Sue Corbett, Introduction to Spine Surgery, AOSPINE international. 3. Mark S. Greenberg. Hand book of neurosurgery. 7 th edition. Internet resources.

79. Thank you. Questions?