Spine and Spinal cord injury - Mahidol University

Spine and Spinal cord injury
Akkapong Nitising M.D.
Division of Neurosurgery
Department of Surgery
Siriraj Hospital Mahidol University

Epidemiology & cost of
care
• In the US
- About 10,000 new cases/year, 10%
are pediatric cases; 8,000 survive the
acute period; 5,000 involve the cervical
spines; while 82% of patients are male.
- a prevalence of 191,000 cases.
- 5.6 billion US$ per year.

• Level of spinal injury
55 % cervical
15 % thoracic
15 % thoracolumbar
15 % lumbosacral area
• Approximately 10% of pts w/ C spine fracture have
a second noncontiguous vertebral column fracture
• Five percent of brain-injured pts have associated
spinal injury, while 25% of spine injury patients
have at least a mild brain injury.

• Etiology
- Motor vehicle accidents & Road
traffic accidents.
- Falls (greater than 10 feet)
- Sports-related injuries
- Recreational injuries
- Violent crimes

Primary and secondary
tissue damage
• Primary injury: mechanical disruption of
axons as a result of stretch or
laceration.
• Secondary injury: free radical
formation, uncontrolled calcium influx,
ischemia & lipid peroxidation, and
apoptosis.

The Primary goal is to
Save Life
• Excessive manipulation and inadequate
immoblization of a patient with a spinal injury
can cause additional neurologic damage.
• As long as the patient’s spine is protected,
evaluation of the spine and exclusion of spine
injury may be safely deferred, especially in
the presence of systemic instability, eg,
respiratory inadequacy and hypotension.

Prehospital management
Immobilization and transportation

• A hard cervical
collar should be
applied on the
scene.

• Log-rolling
techniques during
extrication.

• Further stabilization
with sandbags and
taping.
• Beware of vomiting
and aspiration,
- NG tube

• Immobilization and transportation by
the backboard.
• The patient should be evaluated and
removed from the backboard as quickly
as possible. If not within 2 hrs, the
patient should be logrolled every 2 hrs,
to reduce the risk of decubitus ulcer
formation.

Pediatric trauma
Plane of face is paralelled to
Spine board
• The spine board
need padding.
• A young child’s
chest is raised,
allowing for safe
cervical spine
positioning and
maintenance of the
airway.

Emergency room and
acute management.
• Multidisciplinary team
• Continue to identify and
manage hypoxia,
hypotension, systemic
and spinal injuries.
• Thorough and complete
spinal and neurological
examination.

ATLS
• Primary survey & Resuscitation
A Airway maintenance with
cervical spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability: neurologic status
E Exposure/Environment:
completely undress the patient,
but prevent hypothermia

• Nasal vs. Oral - controversy
dependent on the skill and expertise
(Rhee KJ 1990, Talucci 1988 and Wright 1992)
Keep the neck neutral.

Hypovolemic vs.
neurogenic shock

Neurogenic shock
• Impairment of the descending sympathetic
pathways in the spinal cord causes
vasodilatation of visceral and lower extremity
blood vessels; pooling of blood, and,
consequently, hypotension.
• Loss of sympathetic innervation to the heart,
results in the patient become bradycardic, or
at least fail to become tachycardic in
response to hypovolemia.

Neurogenic shock
• Massive fluid resuscitation may result in fluid
overload and pulmonary edema.
• The blood pressure can often be restored by
the judicious use of vasopressors (dopamine
is agent of choice) after moderate volume
replacement.
• Atropine for bradycardia associated with
hypotension

Findings associated with
spinal injuries
- laceration on face or forehead; vertex
- abrasion of the upper neck
- fractures of mandible
- bruises about the abdomen, from seat belt.
- multiple long bone and pelvic fractures
- tenderness, focal hematoma; widening
spinous processes

Completeness of injury and
Neurologic level
• Complete vs. Incomplete
• Level of the injury

• Key muscle groups
C5 = Elbow flexors
C6 = Wrist extensors
C7 = Elbow extensors
C8 = Finger flexors
T1 = Finger abductors
L2 = Hip flexors
L3 = Knee extensors
L4 = Ankle dorsiflexors
L5 = Long toe extensors
S1 = Ankle plantar flexors

ASIA (American Spinal Injury Association)
score

Completeness
• Complete (ASIA grade A)
Complete loss of motor and sensory
function below level of lesion
• Incomplete (ASIA B – D)
Any neurological function below the level
of lesion, including preservation of
perineal sensation (sacral sparing)

Level
• Motor level
The most caudal key muscle with at least gr.
3 power. The remaining cephalad key
muscle groups must have grade 5 strength.
• Sensory level
the most caudal segment of the spinal cord
with normal sensory function.

Spinal shock
• “ .. All phenomena surrounding physiologic or
anatomic transection of the spinal cord that
results in temporary loss or depression of all
or most spinal reflex activity below the level of
injury.”
(Atkinson PP Atkinson JLD Mayo Clin Pro 1996;71:384-9)
• Loss of somatic motor, sensory, and
sympathetic autonomic function due to spinal
cord injury.
(Kiss Z, Tator CH 1993)

Spinal shock
• The exact mechanism is unknown but may
be related to temporary electrolyte or
neurotransmitter effects on impulse
conduction
• Etiologies: primary axonal and cellular
dysfunction, ionic conduction block caused
by sodium/potassium shift, maintenance of
spinal inhibitory pathways, hyperpolarization
of caudal neurons, and loss of fusimotor
drive in caudal spinal segments.

Spinal shock
• Return of the Bulbocavernosus reflex
heralds time course out of spinal shock.
• However, in practical motor and
sensory deficits detected one hour
or later after SCI are due to
physical cord injury rather than to
spinal shock.

Incomplete spinal cord
syndromes

Central cord syndrome
• First described by
Schneider in 1954.
• Typically occurs in
hyperextension injury
with inbucking of the
ligamentum flavum
compressing the spinal
cord within an area of
preexisting cervical
spine stenosis

Central cord syndrome
• Greater motor weakness in the upper
extremities than in the lower extremities with
varying degree of sensory loss.
• Somatotopically organized corticospinal tract,
with the leg fibers lateral and the arm fibers
medial in the cord
• Involvement of the anterior horn cells in the
necrotic center of the cord.

Anterior cord syndrome
• Patients present with motor
paralysis, loss of pain and
temperature, but are spared
proprioception and vibration
sense.
• It occurs with hyperflexion
and axial-loading injuries;
central disk herniation,
teardrop fracture, and burst
fracture.
• Blockage of the Anterior
spinal a.?
• Less favorable prognosis

Brown-Séquard syndrome
• First described in 1850
• Hemisection of the spinal cord
• Ipsilateral motor weakness,
ipsilateral loss of
proprioception, and
contralateral pain and
temperature loss beginning 1
to 2 levels below the level of
injury.
• Good prognosis for recovery

Conus medullaris syndrome
• Typically found between spinal levels of T11 and L2 –
transition zone
• Both upper and lower motor finding – mixtures of cord
and root syndrome.
• The most common - complete sacral cord damage with
variable injury and sparing of lumbar roots.
• The prognosis for recovery of bladder and bowel
function is relatively poor.

Cauda equina syndrome
• An injury to the nerve roots
• Can be seen with a fracture
or acute disk herniation
from L2 and below.
• Asymmetrical paralysis,
sensory loss, and areflexia;
including loss of bowel and
bladder control.
• Has a significant capacity
for recovery.

Bell’s cruciate paralysis
• First described by Bell in
1970
• Weakness or paralysis of
the hands and arms with
relative preservation of
lower extremity strength.
• cervicomedullary injury –
the most common is C2
fracture.
• Midline damage to the
rostral portion of the
pyramidal decussation

Guidelines for screening pts
with suspect C spine (ATLS)
1. para/quadriplegia –> unstable spine
2. Awake/alert/intact/no neck pain/no tender ness –
remove c collar and pts move their neck and no
pain
- > no x ray
3. awake/alert/intact with neck pain/tenderness
- > x rays with or without CT
if normal
- > flex/ext
4. Altered LOC or pediatric
- > x rays with or without CT and evaluated by
specialist

Radiographic evaluation
cervical spine
• indicated in patients with
- midline neck pain
- palpation tenderness
- neurologic deficits referable to the cervical
spine
- altered level of consciousness
• Lateral, AP, and open-mouth odontoid
view.

Plain x-ray – Cervical spine
C1

CT scan
• Delineate bony
anatomy and
evaluation of canal
compromise.
• Subluxation may be
missed – overcome
by sagittal
reconstruction.

• CT scan at 3-mm interval should be obtained
through suspicious areas identified on the
plain films, or through the lower cervical
spine, if it is not adequately visualized on the
plain films.
• CT images through occiput – C2 may also be
more sensitive than plain film for detection of
fractures of these vertebrae

Lateral flexion/extension
• If the screening
radiographs (x-ray +
CT) are normal, C
spine flex/ext may be
done in
- pts w/o altered LOC
who c/o neck pain to
detect occult stability
• All movement should
be voluntary
• Pts w/ pure
ligamentous injury

MRI
• Ability to image soft
tissue injuries;
muscle, ligaments
and discs.
• To detect the
presence of
hematoma in the
spinal cord or
canal.

Radiographic evaluation
thoracic and lumbar spine
• Indications for screening radiographs –
same as cervical spine.
• AP and lateral plain x-ray with axial CT
at 3-mm intervals through suspicious
areas.

Treatment
• Surgery - Indications
- Neural decompression
- Stabilization of the spine
- Deformity correction
• Timing of surgery: Early vs. Late ?
- Traction of cervical spine dislocation
(Hadley MN et al. Neurosurgery 1992)
- Others - controversy

Prognostic factors for
recovery
• Complete or incomplete:
complete C injuries 24 hrs: 1-3%
regain ambulatory function
• Level: C > TL
• Age: young > old
• MRI finding: Intramedullary hemorrhage
– worse outcome

Emergency room
management
• Cervical Traction
- realign and stabilize the spine
- one of the fastest way to increase the spinal
canal
- Two absolute contraindications
1) Occiput-C1 dislocation
2) Comminuted skull (temporal bone
fracture)

Occipito-Cervical Dislocation HIGH
ENERGY
RESPIRATORY ARREST
NEUROGENIC SHOCK
25 year old, high speed MVA
Apneic, hypotensive, and
unconscious at scene - intubated
and rapidly transported to
emergency room
ASSOCIATED
HEAD INJURY
Facial fractures, closed head injury,
R femur fracture
No upper or lower extremity motor /
sensory function (spinal shock)
SIGNIFICANT
NEUROLOGIC
INJURY

• Five pounds per level for reduction; i.e.
a C5-6 dislocation would require 30 lb
traction. Serial imaging and
neurological examination are
mandatory.
• Use of muscle relaxants, analgesics,
and sedatives may facilitate the
process.
• To maintain stabilization use 5-10 lbs.

• 30 yrs old female
• Motor vehicle
accident
• C4 complete cord
lesion
• Respiratory
insuffiency

C3 C3-C4 facet
C5
C6
C7
C5-C6
C4

Closed reduction

Odontoid fracture

Atlantoaxial dislocation

os odontoideum w/ C1-2
dislocation

C1 lateral mass & C2 pedicle
screws

Hangman fracture

Subaxial (C3-C7) Cervical
spine injury

Thoracic spine injury

Research
• Two categories
1. Agents that can be given during the
acute phase of the injury.
2. those that limit secondary injury
mechanisms or promote regeneration.

• Drugs of the future
Neurotrophins – promote the survival and
regeneration of injured nerve cells
Drugs that prevent apoptotic cell death
• Transplantation – cellular therapy
Schwann cells
OSG (Olfactory ensheathing glia)
Embryonic spinal cord cells
Neural progenitor (stem) cells
Antibodies that neutralize the inhibitory proteins
within myelin