Spinal Cord Injury

Posted bythespinebookadminPosted inTopics, Trauma

Background 

  • Injury to spinal cord resulting in temporary or permanent change to sensory, motor or autonomic function 
  • Bimodal 
    • Young – high energy 
    • Elderly – minor trauma + degenerative narrowing of canal 
    • M:F 4:1 
    • Race 
      • Caucasian > Black > Hispanic 
  • Types 
    • Incomplete tetraplegia (34%) – Central Cord 
    • Complete paraplegia (25%) 
    • Complete tetraplegia (24%) 
    • Incomplete paraplegia (17%) 
  • Mechanism 
    • MVA (50%) 
    • Improper immobilization iatrogenic (25%) 
  • Associated injuries 
    • Closed head 
    • Non contiguous spinal fracture 
    • Vertebral artery injury 
  • Prognosis 
    • 1% complete recovery at time of hospital diagnosis 
      • 90% return home and regain independence 
    • Complete SCI 5% chance recovery 
      • If still complete paralysis at 72h – no chance of recovery 
    • Incomplete SCI 50% chance walking 
    • Cause of death 
      • Pneumonia 
      • Heart disease 
      • Subsequent trauma 
      • septicemia 

Complete vs Incomplete 

  • Complete injury (ASIA A) 
    • After spinal shock (bulbocavernosus reflex intact) 
      • Absent reflex means spinal shock 
      • Present reflex means complete cord injury 
      • Tug foley or penis and see if anus contracts 
      • Meaning – not a reliable exam at the moment 
  • Incomplete Injury (ASIA BCDE) 
    • Some preserved sensory or motor function 
    • B-E has Sacral Sparing 
      • Sacral Sparing 
        • Intact Bulbocavernosus 
        • Check 
          • Rectal Tone 
          • Perianal sensation 
  • Clinical classification (various syndromes – see below) 
  • ASIA – method to scale the clinical classification 

ASIA Scale 

  • A 
    • Complete 
    • No motor or sensory 
    • Spinal shock not present (bulbocavernosus present) 
    • No sacral sparing 
  • B 
    • Incomplete 
    • Sensory present no motor 
    • Level is the last healthy level  
    • No motor more then 3 levels below level of neurologic injury 
  • C  
    • Sensory preserved  
    • Half of key muscles grade ❤ 
  • D 
    • Sensory preserved 
    • Half of key muscles grade >3 
  • E 
    • Normal 
  • Naming 
    • Name the level with intact sensation and antigravity (3/5 power) 

Acute Management of SCI 

Short form 

  • ATLS for acute stabilization  
  • Admit to monitored bed 
  • Stabilize/ decoompressiono <24h 
  • MAP >85 
  • Mutldisicplinary care team including PT OT 

Full Form (see Trauma schpeal ATLS) 

  • Activate Trauma Team 
    • 3 RN 
    • Anesthesia 
    • Gen Surgery 
  • 2 Large Bore IVs 
    • Trauma BW 
      • CBC, Lytes, INR PTT, Type and Cross x4, 
      • BUN/Cr, glu, tox screen, beta HCG, cap gases, lactate, myoglobin 
      • Notify blood bank 
  • Monitors 
    • Telemetry 
    • Oximetry 
  • Primary Survey 
    • Airway and C Spine Collar 
      • GCS 
      • Mouth, dentition, bleeding, obstructions 
    • Breathing 
      • Air entry 
      • Saturation 
      • Apply face mask with 100% O2 
    • Circulation 
      • BP 
      • HR 
      • Abdomen 
        • Exam 
        • FAST 
      • Pelvic Stability 
        • Exam 
        • XR 
      • Resuscitation if needed 
        • 2L NS warmed 
        • 2units O -ve uncrossmatched blood 
        • MTP 
          • 1:1:1 ratio of PRBC:Plt:FFP 
    • Disability 
      • GCS 
        • EVM 
        • Eyes 4 spontaneous, 3 speech, 2 pain, 1 non 
        • Verbal 5 spontaenous 4 confused 3 inappropriate 2 incomprehensible 1 none 
        • Motor 6 spontaneous 5 localize 4 withdraw 3 flex 2 extend 1 none 
      • Pupils 
    • Exposure 
      • Long bones 
      • Log Roll spine palpation and DRE 
  • Secondary 
    • Head to toe MSK exam looking for any orthopaedic injuries 
    • Neurologic exam as per ASIA standards 
  • Admit to monitored bed in ICU capable of vasopressor therapy 
  • Hemodynamic monitoring 
    • MAP >85mmHG 
    • T6 and above – dopamine (alpha nand beta) 
      • Need HR and PVR 
    • T6 and below – phenylepherine 
      • PVR only 
  • No evidence for any other medications 
  • Surgery 
    • Timing <24h improves motor conversion 
    • Anesthesia concerns 
      • Bradycardia and hypotension and hypotension in tetraplegic 
      • No succinylcholine in first 48h (hyperkalemia) 
  • Hospital care 
    • Pressure sore prophylaxis 
    • Anticoagulation 
      • Pneumatic compression 
      • LMWH 
    • Respiratory 
      • Monitory 
      • Early trach for tetraplegics 
    • df 

Pathophysiology 

  • Primary Injury – damage to neural tissue due to direct trauma 
    • Irreversible 
  • Secondary Injury – damage due to 
    • Decreased perfusion 
    • Lipid peroxidation 
    • Free radical /cytokines 
    • Cell apoptosis 
    • METHYLPREDNISONE can limit secondary injury by address the first three of the above 
  • Classification: Primary vs Secondary SCI 
    • Primary (usually trauma) 
      • Mechanical disruption 
      • Transection 
      • Extradural pathology (ie: Mets) 
      • Distraction of neural elements 
    • Secondary 
      • Vascular injury 
      • Hypoperfusion (shock) – “stroke” of spinal cord 
      • Can evolve into complete injury or spread proximally 
      • Injury typically rises 1-2 levels 

ASIA Classification Steps 

  1. Is spinal shock present? 
    • Check bulbocavernosus 
      • Squeeze glans or clitoris or tug foley 
      • Internal and external anal sphincter should contract 
      • Reflex mediated by S2-4 
    • Absence means Spinal Shock 
    • One of first reflexed to return 
    • Normal reflex with absence of sensory and motor – Complete SCI 
  2. Determine sensory and motor deficit and level of injury 
    • Level = intact sensation and antigravity 
    • Sensation (light touch + pin prick) 
      • Highest level with bilateral 2/2 sensation 
    • Motor 
      • Highest level with (>3/5 power) on both sides 
      • Pain limitation is 5*/5 
    • Neurologic level – lowest segment with bilateral sensation and antigravity muscle power 
  3. Injury complete/incomplete? 
    • Complete 
      • No sacral sparing 
        • No perianal sensation (LT, pinprick) 
        • No voluntary anal contraction 
        • No deep anal pressure 
      • 0/5 motor 0/2 sensation 
      • Bulbocavernosus reflex present 
    • Incomplete 
      • Sacral sparing 
      • Palpable/ visible muscle contraction below level of injury 
      • Sensation present below level of injury 
  4. Determine grade 
    • A – complete (they can have a Zone of Partial Preservation) 
    • B – sensory preserved (ONLY CAN BE ANTERIOR CORD) 
    • C – half of muscles below have less than grade 3 
    • D – half of the muscles below have grade 3 
    • E – normal (previously abnormal exam/ SCI) 

Evaluation 

  • Primary Survey 
    • Airway – C Spine Collar 
    • Breathing – respiratory complications are number 1 cause of death in SCI 
      • Intubation 
        • Diaphragmatic Innervation (Injury above C5) 
      • Respiratory Muscle Fatigue 
      • Associated lung 
      • Loss of Central Drive (head injury, EtOH, drug) 
      • REALIZE: autonomic disruption- bradyarrhythmias during intubation/ suctioning 
        • Pre-oxygenate to 100% 
        • Atropine as needed 
      • Dysfunction by level 
        • C2 – Vital Capacity (VC) 10%, no couh 
        • C3-6 – VC 20%, cough weak/ineffective 
        • High T – VC 30-50% weak cough 
        • Low T – minimal dysfunction 
    • Circulation 
      • If NO OTHER CAUSES, consider Neurogenic Shock 
        • Mx: 
          • Goal – HR 60-100 sBP 90 
          • Bradycardia – Atropine PRN 
          • Hypotension – 
            •  Isotonic Crystalloid 2L (max) 
              • Do no overressucitate – risk of ARDS 
            • Ionotropes – Dopamine 
          • Avoid hypothermia 
    • Disability 
    • Exposure –  
      • obvious injuries to head/spine 
      • Seat belt sign – TL flexion distraction injury 
    • Other 
      • NG tube – high risk Ileus – aspiration pneumonitis 
      • Pressure sore prevention – denervated skin prone to ulcers 
        • Frequent turns (q1-2h)  
        • Remove prominences 
        • DC board ASAP 
  • Secondary 
    • C Spine – examine face and scalp, obvious deformities in head habitus (rotation – facet dislocation), palpate posterior C Spine 
    • TL – log roll 
    • Full ASIA neurologic examination 

Imaging 

  • MRI 
    • MRI findings most consistent with ASIA A is hematoma within the cord 

Management 

Acute 

  • Field **important – up to 25% injuries occur from improper immobilization/ transport 
    • Immobilize 
      • Rigid Cervical Collar 
      • Firm Spine Board with lateral support devices 
    • Leave all helmets/ pads on 
  • ATLS – ABCs  
  • Admission to ICU 
  • MAP of 85-90 mmHg for 7 days post injury 
    • Sekhon and Fehlings 
  • High Dose Methylprednisone – NASCIC III -> no evidence, however controversial (paper by Dr. Fehlings) 
    • Some evidence if injury <8hours ago (see below) 
    • “reduce TNF ALPHA EXPRESSION” 
    • Decreased cord hemorrhage – not correlated with improved outcomes though 
    • NASCIC 3 SAYS IF <8H, give 30mg/kg plus 5.4mg/kg for 24h 
      •  Contraindications to steroid therapy include injuries that occur greater than 8 hours prior to presentation, pregnancy, gunshot wounds, patients under the age of 13, and brachial plexus injuries.  
    • Risks of MPSS 
      • Wound infection 
      • GI bleeding 
      • Mortality same 
  • Closed Reduction with Axial Traction 
    • Indication:  
      • AO patient  
      • neuro deficits  
      • compression due to fracture or dislocation 
    • Reasons to stop 
      • Overdistraction 
      • Worsening neurologic exam 
      • Failure to obtain reduction 
  • Surgery 
    • Indication 
      • Direct compression of neural elements 
        • Facet dislocation, cauda equina 
    • Early decompression within 24 hours – evidence supports this with no increased complications 
  • Other 
    • DVT prophylaxis – c/I hemorrhage, coagulopathy 
    • Monosialotetrahexosylganglioside (GM-1) – controversial? Faster recovery? 

Definitive Treatment 

  • Bracings and Observation 
    • GSW  
      • Except 
        • Progressive neuro deterioration with bullets in spinal canal 
        • Cauda equina 
        • Retained bullet fragment in thecal sac (CSF breaks down bullet causing lead poisoning) 
    • Met Cancer Patient with <6mo life expectancy 
  • Surgical Decompression and Stabilization 
    • Decompression within 24h for SCI increases likelihood of recovery (Fehlings et al) STASCIS 
      • No increased risk of mortality or complications 
    • Indications 
      • Most incomplete SCI 
        • Dc when neuro plateau or worsen 
        • Can facilitate nerve root recovery of 1-2 levels 
      • Most complete SCI 
        • Decompression within 24h for ASIA A increases likelihood of recovery 
        • Stabilize spine to facilitate rehab and minimize need for halo or orthoses 
        • Can facilitate nerve root recovery of 1-2 levels 
        • Consider for tendon transfers 
          • Deltoid to Tricep for C5 or C6 
    • GSW IF: 
      • Retained in CSF 
      • Progressive worsening with bullet in canal 
      • Cauda Equina 

Rehabilitation 

  • Goals 
    • Reassess and identify mechanism for reintegration into community based on functional level and daily needs 
    • Patients learn transfer techniques, self-care retraining and mobility skills 
  • Restoring hand function 
    • Limiting factor for many patients 
    • Tendon transfers – timing?? 
      • Indication for C5 Deltoid to Tricep 
        • C5 for COMPLETE SCI at C5 or 6  
        • Why – allows opposing elbow extension to elbow flexion 
        • How – detach deltoid and anchor the tendon sutured into the triceps muscle 
  • Modalities – functional electrical stimulation?? 
    • Functional electrical stimulation – works on skeletal muscle improves hand function 
Level Patient Function 
C1-C3 – Ventilator dependent with limited talking.  – Electric wheelchair with head or chin control 
C3-C4 – Initially ventilator dependent, but can become independent - Electric wheelchair with head or chin control 
C5 – Ventilator independent – Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself – Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function  
C6 – C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself (wrist extension and supination intact) – Independent living; manual wheelchair with sliding board transfers, can drive a car with manual controls 
C7 – Improved triceps strength – Daily use of a manual wheelchair with independent transfers 
C8-T1 – Improved hand and finger strength and dexterity – Fully independent transfers 
T2-T6 – Normal UE function – Improved trunk control – Wheelchair-dependent 
T7-T12 – Increased abdominal muscle control – Able to perform unsupported seated activities; with extensive bracing walking may be possible 
L1-L5 – Variable LE and B/B function – Assist devices and bracing may be needed 
S1-S5 – Various return of B/B and sexual function – Walking with minimal or no assistance 

Prognosis 

  • 1% complete recovery at time of hospital diagnosis 
    • 90% return home and regain independence 
  • Complete SCI 5% chance recovery 
    • If still complete paralysis at 72h – no chance of recovery 
  • Incomplete SCI 50% chance walking 
    • Central Cord ASIA C/D 
      • <50 years old most can walk 
      • >50 years old 40% walk 
    • B – 1/2 walk 
    • C – 3/4 walk 
    • D – nearly all walk 
  • Cause of death 
    • Pneumonia 
    • Heart disease 
    • Subsequent trauma 
    • Septicemia 
  • Level and Recovery of Complete SCI (Waters et al.) 
    • T9 or above – none regained LE function 
    • T9 or below – some function 
    • T12 – 20% could walk with orthoses/ crutches 
  • Recovery (Harrop et al.) of Complete and Incomplete SCI 
    • 92% of Conus patients improved one ASIA level at least 
    • 22% of TL patients improved one ASIA level at least 
  • Schouten et al. reviewed initial assessment and management of the patients with spinal injury. Approximately one half of patients with ASIA B injuries, 3/4 of patients with ASIA C injuries, and nearly all patients with ASIA D injuries recover enough lower extremity strength to ambulate. They also advocate for decompression within 24 hours, citing the STASCIS study.  

Complications 

  • Skin 
    • Prevention –  
      • don’t leave on the backboard in ER 
      • Proper bedding 
  • Spasticity (occurs after spinal shock resolved) 
  • VTE – DVT prophylaxis 
  • Urosepsis – common cause of death, strict aseptic technique, do not allow bladder to over-distend 
  • Loss of supraspinal control of Sympathetic NS 
    • Sinus Bradycardia – most common arrhythmia following SCI 
    • Orthostatic and Supine Hypotension – lack of sympathetic tone 
    • Autonomic Dysreflexia – unchecked visceral stimulation (lesions higher than T6) 
      • Sympathetic dysregulation (stimulus in abdomen) 
      • Autonomic dysreflexia is defined as an increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs (sweating, piloerection, facial flushing), or symptoms (headache, blurred vision, nasal congestion) due to a stimulus such as overdistended bladder or bowel impaction. Guidelines for treatment of autonomic dysreflexia include 1) patient immediately placed in a sitting position if the person is supine. 2) clothing or constrictive devices need to be loosened 3) troubleshoot etiologies for bladder distention or bowel impaction 4) a SBP >150 mmHg may need to be treated with nifedipine or nitrates 5) close monitoring of symptoms, blood pressure, and heart rate for at least 2 hours. 
      • Presentation: 
        • Bradycardia 
        • Hypertension 
        • Headache, agitation 
      • Mx: 
        • Put patient seated 
        • Loosen all constrictive clothing 
        • Troubleshoot etiologies 
          • Bladder distention 
          • Bowel impaction 
          • Undiagnosed fracture – pathologically weak bones 
          • infection 
        • SBP >150 – nitrates 
        • Monitor vitals at least 2 hours 
       
  • Major Depressive Disorder – 11% 

Pediatric SCI 

  • ATLS 
    • Head cutout on board 
  • Conus is L3 in newboard, migrated up to L1 
  • Usually ISCI 
  • Prognosis is better when younger than 8 years old 
  • Risk of deformity 
    • 90% ASIA A get scoliosis (if before puberty) 

SCIWORA 

  • SCI without Radiographic Abnormality 
  • Common under age 10 
  • Class the Injury Secerity 
    • Complete Transection – poor outcome 
    • Major hemorrhage – poor outcome 
    • Minor hemorrhage – 40% improved 
    • Edema only – 75% improved, 25% became normal 
    • normal 
  • So severity of injury is best predictor of ourtomce 

4x increase chance of RC tears in wheelchair patients 

C3 

  • Ventilator 
  • Limited talking 
  • Electric wheelchair head or chin control 

C4 

  • Ventilator initially 
  • Electric WC head o chin control 

C5 

  • Cannot feed – No wrist extension or supination 
  • Electric WC hand control 

C6:  

  • Can feed, big jump from C5 
  • Independent living 
  • Manual WC with sliding board 
  • Drive car with manual controls 

C7:  

  • Triceps:  
  • Manual WC independent transfer 
    • Not fully 

C8-T1 

  • Hand and finger dexterity 
  • Full independent transfers 

“CONVERSION” 

A – 80% staying A, 20% chance improving 

B –  

Small gains in SCI spectrum will make a difference in “meaningful recovery” means different thing for different people