Spinal Cord/column Injuries Para441 Neurological Injuries Dr Oteir, PhD 2 3 4 5 Key things How many vertebrae? How many peripheral nerves? – 8, 12, 5, 5, 1 Myotomes Dermatomes 6 9 Motor and sensory tracts Pain and temperature interpretation (Spinothalamic). – Painful stimuli enter the sensory nerve root in the dorsal horn. – Crosses to the opposite side of the cord – Ascends to the contralateral parietal lobe Both motor and pain pathways anterio-lateral cord – anterior spinal artery flow compromise!!. 10 11 Spinal reflexes Rapid and protective motor response to painful stimuli Before interpreting the stimulus as pain Results in muscle jerk Muscle jerk but not pain?! 12 13 14 Spinal Cord Injuries 3%-25% of spinal cord injuries occur during – field stabilization – transit to the hospital, or – early in the course of therapy As many as 10% of patients w/ cervical spinal cord injury are initially neurologically intact Assume a cervical spine injury – – – – multisystem trauma altered LOC blunt injury above the clavicle Remember CCR and NEXUS? t: @alaa_oteir 15 Spinal Cord Injuries Emphasis first is on preventing injury, then secondly, to prevent extension of injury When to suspect? – Young – Elderly – Mechanism of injury SCI can be – complete – Incomplete – bony or ligamentous t: @alaa_oteir 16 Spinal Cord Injury Pathophysiology Hemorrhages are seen in the central gray matter Zone of hemorrhage, edema & necrosis spreads from central area to involve up to the entire diameter of the cord w/i 6-24 hrs Damage to the gray an interruption of nerve conduction in the fiber tract, – isolates the region of the body below the level of injury from cerebral control t: @alaa_oteir 17 Pathophysiology Progressive loss of function for 1st 24hrs related to – – – – – associated secondary injury Edema disc compression Hematoma hypoperfusion to the spinal cord As edema subsides & circulation is reestablished, function may improve slightly Spinal Shock – State of transient physiological reflex depression of cord function below level of injury with associated loss of sensorimotor function • duration is variable t: @alaa_oteir 18 Neurogenic Shock Results from impairment of descending sympathetic pathways in the spinal cord causing loss of vasomotor tone & sympathetic innervation of the heart – Causing vasodilation of visceral & LE vessels, pooling of blood (hypotension) – Loss of cardiac sympathetic tone (bradycardia) – Vasopressors are often needed to restore blood pressure Triad of hypotension, bradycardia, hypothermia t: @alaa_oteir 19 Spinal Cord Injury *suspect in all patients that suffer blunt trauma* Common types: -Whiplash; soft tissue injury of spine -Incomplete injury; some preserved sensory-motor function -complete injury; total loss of movement & sensation below the lesion -sacral sparing; preservation of some sensory perception in perianal region and/or voluntary contraction of rectal sphincter t: @alaa_oteir 20 Spinal Cord Injury Bony vs Ligamentous – Most injuries do not involve the cord itself. – Both types of injuries require stabilization – Unable to clear c-spine with distracting injuries, altered LOC and pain in neck region. • Re-immobilize patients for transfer if C-Collar removed without the above criteria. Complete vs. Incomplete – Complete SCI; ? – Incomplete SCI; ? t: @alaa_oteir 21 Spinal Cord Syndromes Central cord syndrome •Damage to corticospinal tract •Commonly seen with hyperextension/flexion •Disproportionately greater power loss in upper extremities than in lower extremities •Have sacral sparing t: @alaa_oteir 22 Spinal Cord Syndromes Anterior Cord Syndrome – Complete motor paralysis with loss of pain/temperature (proprioception/vibration preserved) – Usually seen in flexion injuries – Often associated with burst fractures with fragment retropulsion into canal – Caused by compression of anterior spinal artery resulting in anterior cord ischemia or direct compression of anterior cord – Hyperesthesia below lesion t: @alaa_oteir 23 t: @alaa_oteir 24 2. Brown Squared Syndrome •Hemitransection of cord •Ipsilateral motor loss & loss of position sense •Contralateral dissociated sensory loss of pain & temperature •Begins 1-2 levels below the level of injury t: @alaa_oteir 25 Spinal Fractures Mechanisms of Injury – Axial loading (most common injury is compression to T12-L1) – Extremes of flexion, hyperextension, and hyperrotation – Excessive lateral bending – Distraction Any injury above the clavicle search for a cervical spine injury May need to maintain c-spine immobilization until able to properly clear spine t: @alaa_oteir 26 Jefferson Fractures •Fracture of C1 ring from axial loading •Unilateral or bilateral fracture of anterior and posterior arches of C1 •**unstable fracture t: @alaa_oteir 27 C 2 Fractures •1/3 of cervical spine fractures at C2 •60% of C2 fractures are odontoid fractures; other’s are Hangman’s fracture (extends through pedicles of C2) •Odontoid fractures •Type I – avulsion of the tip of dens •Type II – base of dens; most common •Type III – fracture line extends into body of axis t: @alaa_oteir 28 C3 – C7 fractures ½ of fractures occur at C6-C7 Most common subluxation is at C5-C6 t: @alaa_oteir 29 Types of Fractures Anterior wedge compression fracture – loss of body height at anterior portion of body Burst fracture – compression fracture extending to posterior third of vertebral body Chance fracture – splitting injury which begins posterior and proceeds inferiorly through the vertebral body; seatbelt injuries Fracture-dislocation – uncommon; but usually cause complete deficits due to narrow canal t: @alaa_oteir 30 Spine Fracture Management ABC’s Spine immobilization Alleviate pain & muscle spasm **Avoid secondary injury – Prevent decubitus ulcers Definitive treatment: – de-compressive laminectomy – fusion – instrumentation t: @alaa_oteir 31 Anterior Wedge Fracture t: @alaa_oteir 32 Thoracic Spine Transverse Process Fracture t: @alaa_oteir 33 Chance fracture (posterior) t: @alaa_oteir 34 Burst Fractures t: @alaa_oteir 35 Spinal Cord Assessment Assessment after ABC’s & life-threatening injuries addressed External Exam; check for – Deformity – Line of demarcation Motor Exam – – – – Strength Reflexes Range of motion Motor nerve function t: @alaa_oteir 36 VS alterations w/ Spinal Injuries Heart rate – ↓ rate may indicate neurogenic shock, drugs (use vasopressors) – May not see ↑ HR w/ shock Respiratory rate – Denervation of respiratory muscles • C4 and above – no respiration • C5-6-7 – phrenic nerve • T1-T6 – intercostal innervation Blood pressure – Low blood pressure may indicate neurogenic shock or hypovolemia Temperature; Loss of regulating ability t: @alaa_oteir 37 Spinal Cord Management Have high index of suspicion Assess the need for immobilization – Immobilize the spine if necessary Tight glucose control Complication of SCI – Cardiovascular complications • Dysregulation with vasodilatation due to loss of sympathetic tone – Respiratory complications • Phrenic nerve dysfunction if injury above C4 • Intercostal nerve dysfunction if injury below C4 – Musculoskeletal complications • Need to treat spasticity t: @alaa_oteir 38 Further avoidance of complications Assess abdomen for distension Optimize venous return by turning pt slowly Perform passive ROM all extremities every 2-4 hrs Avoid hypotension – Use dopamine, dobutamine, neosynephrine Note: – **hypotension is not always caused by hypovolemia in trauma patients; skin is warm, flushed, and dry in neurogenic shock (this is not the case in hypovolemic shock) t: @alaa_oteir 39 Transport Issues with SCI Patients with cervical cord level injury are at risk for CO2 retention; – Monitor ETCO2, depth and rate of breathing. Hypotension due to Neurogenic Shock – Injury above T6 Patients are at high risk for hypothermia due to poikilothermic – Lesions above T1 Immobilize any patient not meeting clearance criteria Reassess patients’ motor and sensory levels after each transfer or move i.e. ER bed to EMS cot. Chart it! Watch for skin breakdown if patient has been on long spine board for extended period. t: @alaa_oteir 40 Other Pre-transport Considerations Assess ability to maintain airway & clear secretions – Cough ability, presence of gag reflex Assess pateint’s need for hemodynamic stability Bowel/bladder assessment Other considerations – Excessive patient movement during transport – Length of transport t: @alaa_oteir 41 THANK YOU t: @alaa_oteir 42