Spinal cord injury: Immediate management and approach. DrSaubhik Das

Spinal cord injury: Immediate management and approach.pptx

1. Spinal Cord Injury: Immediate Management and Approach Dr.Saubhik Das, MS Arthroplasty fellow (SNUBH, Seoul), Assistant Professor, Orthopaedics, Trauma Centre, RIMS, Ranchi, India

2. Vertebral column and associated injury injury Affect 6% of trauma victims High incidence of chest and abdominal injury Multiple system injury-80% Head injury “Lap-Belt” injury

3. Cervical spine #- 2-6% trauma victims Cervical spine # involve More than half of the spine trauma victims Common locations- Cranio-cervical junction(occiput-C2) Cervico -thoracic junction (C7-T1) Thoraco-lumbar junction (T11-L2) High Stress Concentration

4. Spinal cord injury Young male; two peak age group M:F- 4:1 Cause- MVA Fall—minor fall in older Gunshot Sport injuries

5. Location of traumatic spinal cord injury Cervical region- 50 to 64%, most common Incomplete deficit Lumbar- 20-24% Thoracic- 17-19% Children <15yrs- 2-5% SCIWORA Majority incomplete injury Cord injury without vertebral column disruption in older Less common Risk factor-Narrow canal. Central cord syndrome

6. Initial assessment and care-key points ATLS High index of suspicion- investigate properly Unclear findings/persistent symptoms- further evaluation Protect against further injury during evaluation and management Optimize conditions for maximal neurologic recovery Maintain or restore spinal alignment

7. High index of suspicion.. A missed spinal injury can have devastating long term consequences Missed or delayed diagnosis most often attributed to: 1. failure to suspect injury 2. inadequate radiology (44%) 3. incorrect interpretation of radiographs (47%) As such, spinal column injury must therefore be presumed until it is excluded

8. Field care- Can we make an impact? “ 3-25% of cases of permanent neurologic impairment after spinal trauma have been attributed to injudicious manipulation by paramedical personnel, examining physicians, or radiology technicians. ” Francisco de Assiss Aquino Gondim , MD, e-medicine- Spinal Cord Trauma With proper application of spinal precautions, we can positively impact patient outcomes

9. Field care-prevention is the key! EMS tram: Triage- Life, limb, function Extrication and proper immobilization; Rapid evacuation to a level 1 trauma centre No single method of immobilization was found superior over another American College of Surgeons Advanced Trauma Life Support (2012)- Immobilization with cervical collar, tape and spine board superior Bernhard M, Gries A, Kremer P, et al. Spinal cord injury (SCI)—prehospital management. Resuscitation. 2005;66(2):127–139. Neutral flexion-extension alignment- avoid hyperextension Special care- paediatric patient

10. Aims of Immobilization Prevent further damage - Protect the Cord Hold the spine in a comfortable, anatomically correct way Prevent movement of the spine Allow for safe concurrent management of other injuries

11. Complications associated with Spinal Immobilization Pain Increased risk of pressure sores Elevation of ICP Aspiration and limited respiratory function Increased risk of aspirating emesis while strapped on backboard Marked pulmonary restrictive effect of appropriately applied entire body spinal immobilization devices

12. In-hospital care PROTECTION => PRIORITY DETECTION => SECONDARY Multidisciplinary approach Spine care concurrent with resuscitative measures “Spinal precautions”- flat bed, logrolling, transfer with spine board Focus on: Assess gross neurological function during primary survey Severe unstable fracture-dislocation/distraction injury Hemodynamic parameters- Neurogenic shock

13. The higher and more complete the injury, the more severe and refractory the neurogenic shock

14. Neurogenic shock complicate management Loss of sympathetic control Distinct from hemorrhagic shock-different management lasts for 1 to 3 week Fluid overload-pulmonary edema, ARDS

15. Optimize hemodynamic parameters Compromised hemodynamic parameters-poor prognosis of neurologic recovery Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervi - cal cord trauma: description, intervention, and prediction of outcome. Neurosurgery. 1993;33(6):1007–1016; discussion 1016–1017. Invasive monitoring-Central line Critical- Maintain MAP >85 mmHg Vale FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg . 1997; 87(2):239–246.

16. Neurological assessment Follows resuscitation Complete neurological assessment-logrolling Examine-chest/abdomen Perineal reflex and rectal examination paramount

17. Assessment- The American Spinal Cord injury association (ASIA)- validated, reproducible, accurate Assess severity of SCI and potential change over time Hadley MN, Walters BC (2013). Guidelines for the manage- ment of acute cervical spine and spinal cord injuries. Neurosurgery 72: 1–259. Assess Neurological level Complete/incomplete injury- Sacral sparing Sacral sparing-prognostic value Kiwerski J, Weiss M. Neurological improvement in traumatic injuries of cervical spinal cord. Paraplegia. 1981;19(1):31–37. ASIA impairment scale (AIS) categories

18. Repeating this step over time allows for delineation of improvement or decline in neurological function. Prognostic value Stein DM, Menaker J, McQuillan K, et al. Risk factors for organ dysfunction and failure in patients with acute traumatic cervical spinal cord injury. Neurocrit Care 2010;13(1):29 Y 39. doi:10.1007/s1208-010-9359-9.

19. Spinal cord lesion Overview 1. Complete SCI = No motor or sensory function below injury level 2. Incomplete SCI = Any Sensory/motor function below level of injury Incomplete spinal cord lesions 1. Central Cord syndrome 2. Brown Sequard Syndrome 3. Anterior spinal cord syndrome 4. Posterior spinal cord syndrome

20. Neurological assessment-unresponsive patient Difficult Continuous reevaluation until complete examination possible Radiological modality Spinal precaution maintained until cleared

21. Neurological assessment Spinal shock- confusion Depressed spinal reflexes caudal to injury-axonal depolarization Typically resolve within 24-48 hours—may take weeks-months First sign of recovery- appearance of delayed plantar reflex easily missed Other reflexes- cremasteric, anal wink and bulbocavernous

22. Spinal Shock Temporary suppression of all reflex activity below the level of injury Occurs immediately after injury Intensity & duration vary with the level & degree of injury Once BCR returns, spinal shock is over 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)

23. Neurological state worsen in first 72 hours- maximum cord swelling Examination between 72 hours to 1 weeks more accurate Brown PJ, Marino RJ, Herbison GJ, et al. The 72-hour examination as a predictor of recovery in motor complete quadriplegia. Arch Phys Med Rehabil . 1991;72(8):546–548. Do not attribute neurologic deficit to intoxication, the effect of drugs, or pain from extremity injuries. This dangerous assumption may limit proper management of neurologic injury.

24. Imaging Goal-cleared spine (history, examination and imaging) No patient should deteriorate because of missed injury Who need a X-ray?- two prediction rules National emergency X-ray utilization study criteria (Nexus) Canadian C-spine rule Canadian C-spine rule have better sensitivity and specificity Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000;343. Clearing thoraco-lumbar spine- only AP and Lat view

25. Plain radiography Cervical spine- three standard view (AP, Lat, open mouth) Open mouth view increases sensitivity Full visualization important ( upto T1)- swimmer’s view or CT Ambiguity- dynamic imaging (flexion/extension), oblique view, or CT Dynamic imaging-under supervision; dangerous in unresponsive patients Prevertebral soft tissue

26. CT scan Superior for osseous pathology Supplanting X-ray for initial evaluation- helical CT Valuable in Obtunded patient- screening CT for spine clearance

27. MRI Delineation of soft tissue, ligament, facet joint, cord condition Occult fracture/ligamentous injury Degenerative spine, osteoporosis, ankylosed spine Surgical planning Increased cord signal, cord hemorrhage- prognostic value Flanders AE, Spettell CM, Tartaglino LM, et al. Forecasting motor recovery after cervi - cal spinal cord injury: value of MR imaging. Radiology. 1996;201(3):649–655.

28. Sequence of imaging Imaging and other non-life saving measures should not supersede life saving measures “Trauma Series” Suspicion- Additional imaging, CT MRI if radiograph and CT inconclusive Pay careful attention to any discrepancy between neurologic level and radiographic level of injury. Noncontiguous vertebral injury level (15%), haemorrhage, ligamentous disruption, or other process causing cord compression.

29. Spinal clearance-key points Spinal immobilization is a priority in multiple trauma, spinal clearance is not The spine should be assessed and cleared when appropriate, given the injury characteristics and physiological state Imaging the spine does not take precedence over life saving diagnostic and therapeutic procedures Three groups: Awake, asymptomatic Awake, symptomatic Obtunded , unresponsive

30. Cervical spine clearance criteria Awake, asymptomatic No midline cervical tenderness No neurological deficit Normal alertness and mentation No intoxication No distraction injury Awake, symptomatic Continue immobilization until asymptomatic Discontinue immobilization following normal and adequate dynamic radiograph Doubt: Normal X-ray/CT; Discontinue immobilization following normal MRI within 48 hours of injury Discontinue immobilization at the discretion of treating physician

31. Cervical spine clearance criteria Contentious Continue immobilization until asymptomatic Discontinue immobilization following normal MRI within 48 hours of injury Discontinue immobilization at the discretion of treating physician Obtunded, unresponsive

32. Special consideration Children SCIWORA- MC <10 yrs Without bony/ligamentous disruption Fracture through hypertrohic zone of endplate High capacity of recovery Elderly High mortality (60%) Bed rest, Halo, Traction poorly tolerated Minor trauma >65yrs Spinal cord injury without instability- bulging ligamentum flavum. Remains undiagnosed. Don’t send home.

33. Gunshot injury Rarely cause instability Location not associated with prognosis Waters RL, Sie I, Adkins RH, et al. Injury pattern effect on motor recovery after trau - matic spinal cord injury. Arch Phys Med Rehabil . 1995;76(5):440–443. Decompresion may be harmful Yashon D, Jane JA, White RJ. Prognosis and management of spinal cord and cauda equina bullet injuries in sixty- ve civilians. J Neurosurg . 1970;32(2):163–170. Surgery for dural repair-CSF leak/Laparotomy

34. Pathophysiology Primary Injury 1. Mechanical Injury 2. The most common mechanism is impact plus persistent compression; impact with transient com- pression, distraction, and laceration or transection. Secondary Injury 1. Vascular Abnormalities 2. Free Radicals/Lipid Peroxidation 3. Excitotoxicity Electrolyte disturbances 4. Inflammation 5. Edema

35. The magnitude of the secondary insults are determined by the energy transferred to the spinal cord at the moment of injury and the subsequent development of additional systemic factors such as hypotension and hypoxia Targets of almost all management strategies for patients with spinal cord injury

36. System Oriented Approach to SCI Respiratory Circulatory GI System Pharmacologic therapy DVT prophylaxis

37. Respiratory High risk- higher the level and more severe the injury Hypoxemia- exacerbate secondary injury Multifactorial: respiratory muscle dysfunction Ventilation-perfusion defect Poor cough reflex Increased secretion, aspiration Neck swelling 6. Other factors- pulmonary contusion, pneumo and hemothorax , atelectasis, pneumonia

38. Decision to intubate More than 50% patients with cervical spine injury requires intubation Respiratory management is one of the most important aspects of the immediate critical care management of spinal cord injury and should employ rigorous chest physiotherapy, secretion clearance devices, bronchodilators, and assisted coughing devices. Stein DM, et al, Neurocrit Care.18 B 2012 Neurocritical Care Society. link.springer.com /article/10.1007%2Fs12028-012-9759-0.

39. Standard laryngoscopy and orotracheal intubation safe Maintain In-line cervical stabilization 2 person technique

40. Circulatory: Haemodynamic and cord perfusion Risk of cardiovascular collapse Hypotension leads to spinal cord ischaemia and secondary injury—positive feedback loop Options: 1. Avoid hypotension 2. 1 st line: Initial resuscitation with crystalloids-euvolemia 3. 2nd line: Vasopressor in refractory cases- Neurogenic shocks Maintain MAP 85-90mmHg for first 7 days if possible

41. Correlation between MAP and Neurologic recovery

42. GI system Risk of aspiration is high due to: 1. cervical immobilization 2. local cervical soft tissue swelling Delayed gastric emptying Parasympathetic reflex activity is altered, resulting in: decreased gut motility and often prolonged paralytic ileus.

43. Minimizing Risk for Aspiration: Nasogastric tube Stress ulcer prevention Hypercatabolic state: Enteral nutrition within 72 hours

44. Pharmacologic Therapy –Methylprednisolone; current trend Minimize secondary injury NASCIS I/II/III Improvement in NASCIS II/III Significant difference-however, magnitude of effect small Practised widely

45. Criticized severely- statistical analyses, lack of standardizations in treatment, failure to show significant functional recovery, lack of minimum injury inclusion criteria etc. Highly debated High complications- Sepsis, pneumonia, pulmonary and GI bleeding Use declined

46. DVT prophylaxis High risk of DVT and PE in first few months Various methods- LMWH, Pneumatic compression device, IVC filter Timing- be initiated within 72 hours of injury (if no systemic contraindication) and continued for at least 8–12 weeks , but may be discontinued soon in patients with useful lower-extremity motor function

47. IVC filter At present there is no class I or II evidence. Existing class III evidence supports the notion that IVC filters do not prevent formation of DVT, may be ineffective at prevention of PE may themselves carry significant morbidity. IVC filters may be effective with established venous thromboembolic disease in patients who fail and/or have contraindications to systemic anticoagulation

48. Indication for surgery Deformity correction Stabilization of the spine Decompression of neurologic elements Ambiguity: Does timing of spinal cord decompression after trauma in patients with complete SCI’s improve outcome? The Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) suggested that surgery within 24 hours was associated with improved neurologic outcomes in patients with cervical spinal cord injury. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012;7(2):e32037. doi:10.1371/ journal.pone . 0032037. In thoracic and lumbar fractures, considerably less consensus exists on timing and necessity of surgical intervention.

49. Prognostic factors Severity of injury (AIS) Patients with complete cervical injuries that remain complete within the first 24 hours of admission are unlikely to regain significant ambulatory function (1% to 3%) Younger patients fare much better than older folks Intermedullary haemmorrhage signifies a worse neurologic and functional outcome.

50. Prognosis- ASIA. Role of MRI

51. Summary Spinal immobilization can reduce the likelihood of neurological deterioration in patients with unstable C-spine injuries following trauma Immobilization of the entire spinal column is necessary in patients until a spinal cord/column injury has been excluded or until the appropriate treatment has been initiated Appropriate classification of SCI patients (ASIA impairment scale) within ED to ensure prompt evaluation and treatment

52. Summary Unresponsive patient requires diligent care, continuous reevaluation and protection until spine is cleared Beware of multiple level noncontiguous injury Helical CT becoming standard of care for screening Indentification and treatment of neurogenic shock Proper management of respiratory and hemodynamic compromise Methylprednisolone therapy for acute spinal cord injury is not recommended Communication, coordination and multidisciplinary team effort

53. Thank you