Acute Spinal C ord Injury - PowerPoint Presentation

Slide1

Acute Spinal Cord Injury

Dr

Raj Kumar

Yadav

Assist. Prof., PMR

MBBS 18/07/19

Slide2

Every slide has 4 to 5 statements.

Out of these 1 statement is false

Identify it

Slide3

SCI is a devastating life threatening event.

Currently 2,25000-2,28000 individuals living in U.S. with sequelae of SCI including permanent paralysis.

Male: female- 1:4

Age: 16-30

yrs

majority

Slide4

Leading causes-

motor

vehicle

accidents- 47.5

%

sports

-22.9%

violance-13.8

%

Falls- 8.9

%

Slide5

Acute

SCI: complex, multifaceted

.

Mechanical trauma cause direct neuronal

damage

However

a

small

no. of axons are lost as a result of secondary pathophysiological

events-

hypo

perfusion, ischemia, and biochemical and inflammatory changes

Salvaging as little as 10% of adult axons can makes walking a potential goal.

Slide6

Common Injuries

Slide7

C-Spine Flexion Injury

Occurs during Cervical

flexion

with axial loading

C5- least commonly injured

Anterior

wedging

+/-

retropulsion

of

bony fragments into spinal canal is present

Slide8

Cervical - Facet dislocations

Unilateral

Occurs in Flexion/rotation injury,

C5-C6 is

most common

More

likely to be

complete

• Bilateral

Occurs in Flexion injury,

C5-C6 is most common

More likely to be complete

Slide9

Cervical hyperextension injury

Occurs in Acceleration-deceleration

injury

Due to Falls

,

MVCs

C4-C5

most

common involvement

Do not Often

results in a central cord syndrome

Slide10

Jefferson Fracture

It is C1

burst

fracture

Usually UNSTABLE

with

no

neuro

findings

Due to Axial

loading of

atlasCommon in contact sports

Slide11

Hangman Fracture

C1

burst

fracture

Bilateral

fracture

from deceleration injury

Common in Head

hitting

windshield

Mostly stable

Slide12

Chance Fracture

It is T12-L2

transverse

fracture through

posterior

elements and

vertebral

body

Common in lap

belt

injury

Caused by Hyperextension of thorax4. Degree of injury depends on

movement

of bony elements

Slide13

Management at Injury Site

Slide14

Critical factors in recovery:

Late pre hospital recognition of injury

Prompt resuscitation

Stabilization of injury

Avoidance of additional neurological injury and medical complications.

Slide15

Prehospital management

- 3

to 25 percent of SCIs occur after the

initial traumatic

insult, either during transit or early in the course of

treatment.

Four responsibilities of

prehospital

(infield) care are:

initial evaluation

a

dequate resuscitationmobilization of the suspected fractured area

s

afe extrication, and transportation

Slide16

Initial Evaluation

Steps of Trauma PRIMARY SURVEY

are:

A

irway maintenance with cervical spine control;

B

reathing and ventilation management;

C

irculation with hemorrhage control;

D

isability (neurological status) limitation

E

xposure/

E

nvironmental control (covering the patient while preventing hyper- or hypothermia)

Slide17

Evaluation

Secondary survey includes:

a detailed Head to toe evaluation

Quick motor examination : grip strength & a foot dorsiflexion evaluation

Gross sensory examination.

Signs of incontinence, urinary retention, priapism, or loss of anal sphincter tone are usually not found in SCI.

Slide18

All

evaluations must take place in full spinal

immobilization

In an unconscious patient assume that cervical spine is injured until radiography of its entire length prove otherwise.

Even

in the absence of any of the

clinical

findings, the patient must be placed in a rigid collar and backboard and immobilize for transport.

Resuscitation begins

after

the

secondary

survey

Slide19

IMMOBILIZATION

All major trauma

victims must be

immobilized

P

atients complaining of neck pain or neurological

symptoms must be

immobilized

A

ny patient with altered mental status of uncertain cause must be immobilized.

Flexed position of spine is critical to prevent any further damage to the cord.

Slide20

Immobilization

Secure the neck first by a cervical collar.

When

removing a patient from a seated position, a cervical collar is first placed on the

patient.

Immobilize

the entire spine using a

soft

board.

Slide21

Slide22

Extrication and Transportation

After proper immobilization, a safest method of extrication and transportation should be adopted.

After proper immobilization, a

fastest

method of extrication and transportation should be

adopted.

Minimum Three persons are required during extrication

S

coop stretcher &

Kendric

extrication devices(KED) are used for extrication

Slide23

Scoop stretcher & KED

Slide24

Patient on vacuumed mattresses

Slide25

Goals of Medical Management in a hospital:

1. Normalize vital signs.

2. Minimizing the neurological damage caused during the primary injury

3. Prevent aspiration

4. Preventing further cord injury secondary to hypo perfusion, ischemia, and biochemical and inflammatory changes

Slide26

Management in Hospital

Slide27

Spinal Stability- neurological and mechanical:

Neurologic stability denotes a state in which, under the stresses that are imposed, no further neural damage is caused.

Mechanical stability refers to the relative motion of vertebral segments under the physiologic loads of everyday activity.

Slide28

Spinal Stability

To assess mechanical stability: Dennis’ 3 column theory used.

A column can be disrupted by either fracture or ligamentous disruption.

Disruption of three or more columns imparts instability.

Flexion & Extension X-ray films are done in conscious patients with no neurological deficits.

Slide29

Imaging:

Computerized tomography (CT):

provides highly detailed axial images of each vertebral segment

inferior to MRI for delineating fractures.

can demonstrate

nondisplaced

fractures not discernible on plain x-ray.

an excellent method for evaluating and quantifying the degree of spinal canal compromise.

Slide30

Imaging

MRI:

M

odality of choice for evaluating the spinal cord and neural elements.

C

an reveal edematous soft tissues, in either the anterior or posterior cervical spine.

Do not offer information regarding the integrity of the ligamentous structures

Can detect presence of herniated disc material in the spinal canal or foramina

Slide31

Closed Reduction and Immobilization

Most mechanically stable thoracolumbar injuries without neurologic deficit can be treated

nonoperatively

Nonoperative

treatment should not be considered in stable injury patterns with limited potential for progressive deformity and neurologic compromise.

Slide32

Operative Treatment

The indications for surgical intervention of spinal cord injuries depend on

pattern of injury.

alignment and stability of the vertebral fracture.

neurologic status of the patient.

overall medical condition of the patient do not affect decision

Slide33

T

SURGICAL Management:

decompress the neural elements by anterior decompression or Posterior decompression

spine stabilized by instrumentation.

spinal

orthosis

- for 1 month

.

Slide34

TREATMENT MODALITIES

METHYLPREDNISOLONE-

stabilize membranes, inhibit lipid peroxidation, suppress

vasogenic

edema by restoring the blood-central nervous system (CNS) barrier

enhance the spinal cord blood flow, inhibit pituitary endorphin release, and attenuate the inflammatory response.

Timing of steroid therapy is critical in its ultimate efficacy (8-72

hrs

)

recommended for penetrating

SCI.

Slide35

SCI is followed by a series of detrimental hemodynamic and biochemical processes

that cannot be prevented by early and aggressive medical management

PREVENTION &TREATMENT OF COMPLICATIONS

Slide36

Cardiovascular picture following SCI:

Spinal shock - loss or depression of all or most spinal reflex activity below the level of the injury

Hypotension-

common in lower level of injury, caused by a withdrawal of sympathetic tone.

Neurogenic shock - The vasodilatation, hypotension, decreased peripheral vascular resistance (PVR), decreased preload, and bradycardia.

Slide37

Deep Venous Thrombosis: Prevention and Treatment

Causes:

Immobility

vascular dilatation and stasis

epithelial damage, and

an increase in the level of factor VIII and fibrinogen.

Slide38

Incidence

of DVT during acute inpatient stay: 13.6

%.

pneumatic

devices

are applied

to the lower extremities for the first 2 weeks after the

injury.

If

thromboprophylaxis

is delayed for more than 72

hours, venous doppler to screen for thrombi formation prior to application of above devices are usually not required

Slide39

Deep Venous Thrombosis: Prevention and Treatment

Anticoagulant prophylaxis with LMWH are initiated after 72 hours

It is continued until discharge in patients with incomplete injury.

for 8 weeks in patients with uncomplicated complete injury.

for 12 weeks or until discharge from rehabilitation in Complicated Complete injury.

Slide40

AUTONOMIC DYSREFLEXIA

Occurs at Neurological level-T6 and above

Characterized by

a

brupt onset of malignant hypertension &

bradycardia

Caused by any noxious stimulus

Only treatment possible is to give

Nifedipine

& nitrates

Treatment is to Identify & treat noxious stimulus

Slide41

Respiratory Management

Complete SCI with neurological level C4- ventilator dependent

C3 injuries- borderline

C2 and above- ventilator dependent

Primary Goal- Recruiting and maintaining aeration of alveoli thereby preventing atelectasis and pneumonia.

Slide42

Atelectasis & pneumonia:

Occur 40-70% of

tetraplegics

Most commonly occurs in the first 5 to 7 days

Often focused primarily in the left upper lobe

Chest percussions, postural drainage, assistive coughing, Intermittent positive pressure breathing, Bronchodilators & mucolytic agents(

guaifenesin

) are used for treatment

Slide43

Gastrointestinal Care

During spinal shock: gastric dilatation and paralytic ileus leads to distended stomach



vomiting and aspiration.

nasogastric tube is used for distended stomach

Stress ulcers are rare occurring in the acute phase following SCI

Prophylactic therapy with H2 blockers should be instituted for stress ulcers

Bowel management program should be established once normal bowel sounds and motility are restored.

Slide44

Bladder Care

During spinal shock: bladder distension leads to urinary reflux which can result in renal failure

A Foley’s catheter should be inserted at admission.

During

subacute

phase of injury, use of Clean Intermittent Catheterization (CIC) increases the risk of bacterial infections.

Slide45

The

most frequent secondary medical complication reported during the acute care of SCI patients is urinary tract

infection.

Symptomatic UTI should be treated with appropriate

antibiotics for 7 to 14 days.

Asymptomatic

bacteriuria

should

be treated routinely

Slide46

Skin Care

Pressure ulcers are a

devastatating

complication of SCI (40%)

Posture change is required every 2 hourly.

Specially designed foam/air mattresses can reduce the pressure over bony prominences, but will not obviate the need for turning.

Adequate nutrition is not important for pressure ulcer healing

Enteral

rather than

parenteral

nutrition

is preferred once

patient stabilized

Slide47

Ambulatory training

Slide48

Tilt Table

Slide49

Strengthening of UL & Trunk

Slide50

Standing balance

Slide51

Orthotic support

Slide52

Robotic-assisted Gait Training (

Lokomat

)

Slide53

Robotic-assisted Upper Limb Training (ARMEO)

Slide54

Virtual Reality-based Training (Nirvana)

Slide55

THANKS