Traumatic Paraplegia

A PPT on the traumatic paraplegia

1. TRAUMATIC PARAPLEGIA MODERATORS : DR.T.M.RAVINATH sir DR.B.SUBODH SHETTY sir Presented by Dr.G.SRI HARSHA

2. INTRODUCTION Spinal Cord Injury is an insult to the spinal cord resulting in a change either temporary or permanent in the cord’s motor,sensory,or autonomic function.  The International Standards for Neurological and functional Classification of Spinal Cord Injury( ISNCSCI )is a widely accepted system of describing the level and extent of injury which gave the following terminologies. Tetraplegia -injury to the spinal cord in the cervical region with associated loss of muscle strength in all 4 extremities. Paraplegia -Injury to the spinal cord in the thoracic,lumbar or sacral segments including the cauda equina and conus medullaris .

3. Neural injuries are divided into two broad etiology based categories. Primary Injury -Physical tissue disruption caused by mechanical forces. Secondary Injury -Additional neural tissue injury resulting from the biologic response initiated by the physical tissue disruption. Classification based on the physical Characteristics. Concussion -physiologic disruption without anatomic injury. Contusion (most common)-physical tissue disruption leading to hemorrhage and swelling. Laceration (very rare)-loss of physical continuity i.e , complete transection of neural tissue.

4. Spinal cord injury predominantly occurs in the young males,with a male to female ratio of 4:1. The most common cause of traumatic spinal cord injury is a motor vehicle crash-42%. Falls-27% Gunshot injuries-16%. Sports injuries-7%.

5. The most common site of spinal cord injury is the cervical spine-50-64 %, Followed by lumbar region-20-24% and Thoracic cord-17 to 19%.

6. Brief Anatomy of the Spinal Cord The spinal cord is divided into 31 segments,each with a pair of anterior and posterior spinal nerve roots. On each side the anterior and dorsal nerve roots combine to form the spinal nerve as it exits from the vertebral column through the neural foramina. The spinal cord extends from the base of the skull to the lower end of the L1 vertebral body. The spinal cord is organized into a series of tracts or neuropathways that carry motor and sensory information. The corticospinal tracts are descending motor pathways which decussate in the medulla located anteriorly within the spinal cord . The dorsal columns are the ascending sensory tracts that transmit light touch,proprioception,and vibration information to the sensory cortex. The lateral spinothalamic tracts transmit pain and temperature sensation. Sympathetic ( thoraco lumbar outflow)exits between the C7 to L1. Parasympathetic pathways( Craniosacral outflow) exit between the S2-S4 segments.

7. Cervical vertebra - Add 1 to the vertebral level. Upper thoracic vertebrae - Add 2. Lower thoracic(T7-T9) - Add 3 . At D10 - L1 & L2. At D11 -L3 & L4. At D12 - L5 cord segment. At L1 - All Sacral segments over . Below L1 - Cauda Equina .

8.   Vascular supply It consists of the one anterior and two posterior spinal arteries. The anterior spinal artery supplies the anterior two thirds of the spinal cord. It arises from the union of two arteries arising from the vertebral artery. Posterior spinal artery, two in no. and arises directly from the terminal branch of each vertebral artery(posterior inferior cerebellar artery). The anterior and posterior arteries are supplemented by the radicular arteries,the largest of these is the artery of Adamkiewicz which usually lies on the left side and reinforces the arterial blood supply to the lower end of the spinal cord.

9. Spinal Cord Injuries Proper Complete injury of the spinal cord is defined by the absence of the sensory and motor function in the lowest sacral segment. Sacral sensation refers to the sensation at the anal mucocutaneous junction and deep anal sensation. Sacral motor function is voluntary anal sphincter contraction on digital examination. Incomplete injury have partial preservation of the sensory or motor in the lower sacral segment. For the patient to be sensory incomplete they must demonstrate either sensory preservation in the S4-S5 or deep anal sensation. For the patient to be motor incomplete they must demonstrate either voluntary anal sphinchter contraction or presence of lower extremity motor function more than three levels below the designated motor level of injury.

10. Initial assessment and care- All trauma patients are at risk for spinal injury. Proper extrication of the patient and immobilization of the spine are critical to avoid further neurological injury. Immobilizing the patient in a Kendricks Extrication device is an effective means in spinal emergencies. Other options for immobilization include hard cervical collar,sandbags,spine board.

11. Logrolling of the patients is an important maneuver in the field transportation of the patients

12. Emergency room care- Differences between the neurogenic and hemorrhagic shock should be identified

13. The American Spinal Injury Association(ASIA ) provides a useful format for guiding in the assessment of the neurological injury.

14. The essential elements in the examination in the neurologic function include strength assessment of the 5 specific muscles in each limb and pinprick sensation testing at 28 specific points on each side of the body. On each side of the body five muscles representing the segments of the lumbar cord are score on a 5-point muscle grading scale.The sum of all 20 muscles yields a total score for each patient with a maximum possible score of 100.

15. For the 28 sensory dermatomes on each side of the body sensory levels are scored on a 0-2 scale with a total score of 112.

16. Spinal shock It was first defined by Whytt in 1750 as a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes , following a spinal cord injury (SCI). Reflexes in the spinal cord caudal to the SCI are depressed ( hyporeflexia ) or absent ( areflexia ) while those rostral to the SCI remain unaffected. It should be distinguished from the neurogenic shock which is characterized by the hypotension and loss of reflexes below the spinal level of injury.

17. Bladder in Paraplegia UMN Bladder or Automatic Bladder or Spastic Bladder . Lesion cranial to the S1-S3. Detrusor Sphincter Dysynergia . Partial voiding(intact local reflex arc). Residual volume. Difficulty to express. Loss of voluntary control. LMN Bladder or Aitinomous Bladder or Flaccid Bladder . Lesion interupting the reflex arc(S1-S3). Partial emptying of the bladder. Residual volume larger than the UMN bladder. Easy to manually express. Loss of voluntary control.

18. Diagnostic Modalities. 1.Plain Xray -AP and Lateral views of the TL and LS spine should be obtained.

19. Points to be noted in AP View . Isolated fractures of the transverse process. Loss of vertebral height. Widening of the interpedicular distance. Vertebral translation. Increased interspinous distance. Horizontal split in the body at the level of pedicles.

20. Points to be noted in lateral view Loss of anterior vertebral body height. Kyphosis . Spinous process widening. Loss of posterior vertebral body height. Translation. Spinous process fracture.

21. 2.CT Scan . Advantages : Most accurately depicts bony injuries.  Sensitivity and specificity > 95% . Concomitant multi-slice CT of chest, abdomen and pelvis can be done to detect visceral injuries. Extent of vertebral body comminution . Retropulsion of bone fragments. Lamina fracture. Pedicle fracture.

22. Reverse Cortical sign The retropulsed fragment that has rotated more than 180 degrees so that the cortical surface is opposed to the cancellous surface of the main vertebral body. Severe disruption of the posterior ligamentous complex Due to 180° rotation the fragment will not unite with the main vertebral body Anterior decompression is usually preferred.  Contraindication for ligamentotaxis .

23. 3.MRI - Indications : Patients with neurological deficit.  Patients with suspicious PLC injury. Advantages : In patients with neurological deficit, MRI accurately depicts the extent of cord compression, edema, hemorrhage and the presence of cord transection .  Determines extent of injury to posterior ligamentous complex. . Helps to identify multi-level non-contiguous  injuries. Disadvantages : Cost and availability. Delay in definitive management.

24. Bony compression of spinal cord. Hyperintense signal changes in cord. Hyperintense signal in the PLC. Marrow edema in adjacent bones. Epidural hematoma. Cord transection . Multilevel injury.

25. Role of Steroids in the Acute Spinal Cord Injuries

26. Methylprednisolone is not recommended for the following circumstances. The multiply injured patient. Penetrating spinal cord injury. Patients with glucose intolerance or diabetes mellitus. Patients with multiple medical comorbidities or with impaired immune system. Elderly patients. Patients with a complete thoracic spinal cord injury

27. Thoracolumbar Injuries in Brief

28. Denis three column concept of stability.

29. McAfee’s Classification of fractures of Thoracolumbar spine 1. Wedge Compression Fractures -isolated failure of the anterior column and result from forward flexion. 2. Stable Burst Fractures -anterior and middle columns fail and there is no loss of integrity of the posterior elements. 3. Unstable Burst Fractures -All the three columns are disrupted.There is a tendency for the posttraumatic kyposis .

30. 4 . Chance fractures -Horizontal avulsion injuries of the vertebral bodies caused by flexion around an axis anterior to the ALL.The entire vertebra is pulled off by the tensile force . 5 . Flexion Compression Fractures -Flexion occurs at an axis posterior to the ALL.The anterior column fails in compression whereas the middle and the posterior columns fail in tension . 6. Translational Injuries -these are characterized by the malalignment of the neural canal which has been totally disrupted.all the three columns fail in shear.

31. Management of Thoracolumbar injuries Stable injuries of the spine can be managed with braces.

32. The operative decision making is dictated by the -Morphology of the fracture. -The status of PLC. -Neurologic status of the patient. -Other medical comorbidities

33. Indirect Decompression The indirect approach to decompress the spinal cord by ligamentotaxis is a technique that utilizes the posterior instrumentation and a distraction force applied to the intact posterior longitudinal ligament to reduce the retropulsed bone fragments from the spinal canal by tensioning the posterior longitudinal ligament.

34. Ligamentotaxis .

35. Direct Decompression 1.Posterior Approach- This is one of the most commonly used approach for the thoracolumbar injuries. Advantages are it reduces the morbidity associated with the anterior approach like decreasing the operative blood loss,avoids visceral injury.decreases the operative time. Transpedicular screw fixation is the gold standard approach now for the treatment of thoracolumbar injuries.

36. 2.Closed Reduction Primary reduction is performed by positioning of the patient onto a frame to create lordosis . 3.Pedicle screws . Pedicle screws are inserted into the vertebrae cephalad and caudal to the fracture level on both sides. 4.Rod contouring The contouring of the rod depends on the site of the fracture following the natural curvature of the spine .

37. 5.Rod insertion The rods are introduced to the distal screw heads on both sides and tightened. The rod is then inserted into the proximal screw heads without tightening. 6.Decompression If it is decided to perform an indirect decompression, this is done at this stage. If indirect decompression proves to be insufficient, a direct decompression eg , posterior or transpedicular decompression are undertaken.

38. 2.Anterior approach- The indications include: The presence of a traumatic disc herniation causing neurologic injury. The need to remove a portion or entire vertebral body followed by reconstruction for stability, or for relief of symptomatic neural compression Ventral epidural hematoma. Kyphotic angulation with ventral compression. An anterior decompression can be done through a partial or total corpectomy , both including discectomies above and below the fractured vertebra. If a vertebral body or a disc lesion compresses the spinal cord, it should be removed with the respective decompression technique.

39. Step 1: Discectomy Discectomy always precedes corpectomy , because it allows the surgeon to visualize the upper and lower limit of the spinal canal. For partial corpectomy , discectomy is done for the disc adjacent to the fractured end plate. For a complete corpectomy , discectomy is done both above and below that fractured vertebra.

40. Step 2 - Corpectomy In a second surgical step, a total or a partial corpectomy is undertaken. A total corpectomy involves removal of the entire vertebral body and adjacent discs. Partial corpectomy involves removal of fractured ends of vertebral body and adjacent discs.

41. Step 3- Reconstruction . 1.Total corpectomy Anterior reconstruction of the disc space or vertebral body following a complete corpectomy can be performed using an autograft or allograft, strut graft, or a synthetic or metallic cage (expandable or non expandable). Additional bone grafting can be used from the corpectomized vertebral body and the removed rib.

42. 2.Partial corpectomy The anterior reconstruction of the vertebral body is performed using a mesh or tricortical iliac crest bone graft. The bone graft stemming from the vertebral body is transplanted to bridge the segment

43. 4 Stabilization Application of plate instrumentation The appropriate size plate is chosen by using a measuring forceps to determine plate length. A plating template is then applied to the remaining vertebral bodies to make sure the plate fits flush on the bone. A drill guide is used to drill holes within the vertebral body.

44. Anterior rod screw system Another form of anterior instrumentation is using a single rod construct after placing a strut graft with a bone screw above and below the fusion site. Some fixation systems are designed to place two rods in parallel to one another to provide the potential for standalone anterior fixation.

45. Rehabilitation in spinal cord injuries . Rehabilitation following SCI is most effectively undertaken with a multidisciplinary, team-based approach, as follows. Physical therapists. Occupational therapists. Rehabilitation nurses. Psychologists.

46. 1.Pressure ulceration(Bed Sores). Stage I: Non- blanchable erythema . Stage II: Partial thickness. Stage III: Full thickness skin loss. Stage IV: Full thickness tissue loss.

47. 2.Spasticity: It is a velocity-dependent increase in muscle tone and occurs commonly following spinal cord injury. Regular muscle stretching and joint range of motion prevents this. Oral medication include Baclofen 200mg tid .

48. 3.Thromboembolic disease The increased risk of thromboembolism is likely due to venous stasis and hypercoagulability . Pneumatic compression devices can be used for the first 2 weeks. Unfractionated heparin (5000 U SC every 12 hours) or a low-molecular-weight heparin (30 mg SC every 12 hours), such as enoxaparin , can be administered for 2-3 months following injury.

49. 4.Bladder management: Acute bladder management is by use of an indwelling catheter, as the bladder is likely to be flaccid. Selection of a bladder drainage method ideally is made following urodynamic evaluation. Clean intermittent catheterization is a method available to those with good hand function or to skilled attendants. The patient is instructed to limit fluid intake, and catheterization is performed every 4-6 hours. Reflex voiding into a condom catheter is an option available to men with reflex bladder contractions. Problems can include urinary retention or high intravesical voiding pressure due to detrusor -sphincter dyssynergy . Voiding pressure sometimes can be decreased by alpha-blocking agents such as terazosin or tamsulosin .

50. 5.Bowel Management . A typical problem is stool that is too hard because of the prolonged colonic transport time, which leads to drying of the stool. Intervention includes maintenance of adequate intake of fluid and fiber, with fiber acting as a sponge to hold moisture within the stool. Docusate sodium (100 mg PO bid) can increase the ease with which water enters the stool . Another problem is incontinence. The goal is to establish a set time for daily bowel evacuation, ideally after a meal to take advantage of any gastrocolic reflex.

51. 5.Neuropathic Pain . Neuropathic pain following spinal cord injury (SCI) is perceived at or below the level of injury. Anticonvulsants may be particularly useful in cases of lancinating electrical pain. Gabapentin (initial dose of 100 mg PO tid , gradually titrated upward) typically is used, with precautions for sedation. Tricyclic antidepressants like amitryptiline may be useful for more constant diffuse pain.

52. 6.Functional Rehabilitation: With regard to recovery below the level of the lesion, ASIA A patients typically do not show significant recovery in this area. Individuals who are in ASIA B have approximately a 31% chance of improving to grade D at 1-year follow-up, while those with initial grades of C have a 67% likelihood.