DR SHOLA AARON DR SANI ABDULLAHI DR ABOKI YAKUBU DR SANUSI ABDULLAHI PURPLE TEAM NATIONAL ORTHOPAEDIC HOSPITAL DALA 11 th February 2022 OUTLINE CASE PRESENTATION INTRODUCTION COMPONENTS OF CARE ID: 1012680
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1. CARE OF THE QUADRIPLEGIC PATIENTDR. SHOLA AARONDR. SANI ABDULLAHIDR. ABOKI YAKUBUDR. SANUSI ABDULLAHIPURPLE TEAMNATIONAL ORTHOPAEDIC HOSPITALDALA11th February, 2022
2. OUTLINECASE PRESENTATIONINTRODUCTIONCOMPONENTS OF CAREPRE-HOSPITAL CARERESUSCITATIONHISTORY AND EXAMINATIONINVESTIGATIONSTREATMENT CONSERVATIVESURGICALCOMPLICATIONSREHABILITATIONFOLLOW-UPCONCLUSION
3. CASE PRESENTATIONCASE 1.AA is a 24yr old male trader who was referred from AKTH o/a of; Neck pain and inability to use both upper and lower limbs 6/7 ff RTAStable vital signsNeurological examination showed; power (R) C5 was 5 while C6-S1=0, (L) C5 was 3 while C6-S1=0 DTR sensation C7, no sacral sparing, BCR present.( briefly demonstrate)
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6. Patient was optimized and prepared for ACDF. He was mobilized on wheelchair and discharged a week postop.
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8. CASE 2MT is a 34yr old Okada rider with a week hx of inability to use both upper and lower limb ff RTA.Stable vital signs.Neurology; both R&L C5-C6 =5 C7=2, C8-T1=0. L2-S1=0, sensationT6 with sacral sparing. BCR present.Post-traumatic incomplete C-spine injury
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11. He was optimized and had ACDF , discharged home 5/7 post op, presently on regular follow up visitsThe sensation is intact now, there is improvement in the motor function
12. IntroductionSpinal cord injury(SCI) is the insult to the spinal cord resulting in a change in the normal motor, sensory and autonomic function. This change is either temporary or permanentA major cause of morbidity and mortality worldwide.Other associated injuries – head injury, abdominal, pelvic, limb fracturesPatient with incomplete injury can become complete from pre-hospital mal-handling and delay in presentationEarly diagnosis and prompt treatment are key to successful management.
13. EpidemiologySpine injuries are common in our environmentCervical spine – 42%, thoracic – 31%, lumbar 27%NOHD Dala – at least 3 new cases /weekIn the US, about 50,000 cases are recorded per yearMales more affected
14. Relevant anatomyThe Spinal cord extends from the foramen magnum where it is continuous with the medulla to the level of L1(or L2) vertebra(conus medullaris). Below the conus, spinal nerves continues as bundles of nerves called cauda equinaTwo consecutive nerve roots emerge on each side. The nerve roots join distally on each side to form 31 pairs of spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1coccygeal)
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17. Causes of InjuryRoad traffic accident, RTA – 41.3%Fall from height 27.3%Others Gunshot injuriesSport injuriesViolence Birth injuries
18. Mechanism of InjuryMechanism of injury include:HyperflexionRotationalHyperextensionVertical loadingFlexion rotationShearing
19. Pathophysiology Primary injury :Concussive or compressive force to the spinal cord can lead to immediate death of neural cell bodies in the local central grey matterCan be by direct shearing of nerve tissuesSecondary injury: damage to the spinal cord is initiated by inflammatory response via arachidonic acid cascade;There is release of Excitatory amino acids(Glutamate, Aspartate), and lipid peroxidation of cell membrane by oxygen free radicals
20. Patho..Oedema and inflammatory mediators result in changes in local blood flow thereby leading to cord ischaemiaThere is initiation of apoptotic changes in the neurones and glial cellsDepending on the severity of trauma, contusion, infarction, laceration, transection, dural disruption, vertebral artery injury and total anatomic discontinuity can occur
21. Classification Complete SCI – complete absence of sensation and voluntary motor activity below the level of injury after spinal shock is overIncomplete SCI- there is residual sensory or motor function below the level of injury Sacral sparing- intact perianal sensation, voluntary sphincteric/anal contraction, or great toe activity.
22. Incomplete SCIThere are 4 syndromes seen:Central cord syndromeBrowne- sequard syndromeAnterior cord syndromePosterior cord syndrome
23. …SCIAnterior cord syndrome: Due to damage to the anterior part of the spinal cordPosterior cord syndrome: Due to damage to the posterior cord, which is rareCentral cord syndrome: Due to damage around the spinal canal by direct trauma, haematoma, fluid collection, ischaemia
24. …SCIBrown-sequard syndrome: Due to hemisection of the cord, with loss of motor function on same side, loss of pain and temperature on the contralateral sideSpinal shock: Transient loss of all neurologic function below the level of injury leading to flaccid paralysis and areflexia lasting varying period(usually 1-2 weeks)
25. Pre-hospital CareGOAL – to prevent further injury and neurologic deficitConsider all trauma pt as spinal injured until it is ruled out, especially unconsciousFocuses on :Patient handling - extrication and transport to hospital – use of sandbags, spine boardsAirway protection & cervical stabilization – cervical collarSupine position or left lateral with neck immobilizationLog-rolling and carried in one pieceRemoved from hard board immediately after radiological studies – prevent bed sores
26. Resuscitation MOST patients present late in this environment. ATLS protocol Primary survey and resuscitation (ABCDE)Secondary survey Definitive managementTertiary surveyEarly intubation and supplemental oxygen especially for high cervical injurySpine should be immobilized with rigid cervical collarRadiological investigations to determine the type and level of injury
27. Evaluation Comprehensive history and examinationHistory to: Establish mechanism of injury, energy transmitted, Direction of impactAssociated injury Medical and social history
28. Physical ExaminationInspection and palpation Occiput to coccyxSoft tissue swelling and bruisingPoint of spinal tendernessGap or step offSpasm of associated musclesNeurological assessmentMotor , sensation, and reflexesRectal examination
29. RightgradeSegmentMuscleAction to testLeftgrade0-5C5Deltoid or bicepsShoulder abduction or elbow flexion0-50-5C6Wrist extensorsCock up wrist0-50-5C7TricepsElbow extension0-50-5C8Flexor digitorum profundusSqueeze hand0-50-5T1Hand intrinsicsAbduct little finger0-50-5L2IliopsoasFlex hip0-50-5L3QuadricepsStraighten knee0-50-5L4Tibialis anteriorDorsiflex foot0-50-5L5Extensor halllusis longusDorsiflex big toe0-50-5S1GastrocnemiusPlantar flex foot0-550¬ Total possible points ®50Grand total: 100
30. LevelDermatomeC4ShouldersC6ThumbC7Middle fingerC8Little fingerT4NipplesT6XiphoidT10UmbilicusL3Just above patellaL4Medial malleolusL5Great toeS1Lateral malleolusS4 - 5Peri-analKey sensory landmarksWACS UPDATE, JOS 2015
31. Investigations Cervical Xray (craniocervical junction to C7/T1 junction) (AP, lateral, oblique, swimmers view) Open mouth view for suspected odontoid process fractureThoracolumbar spine X-raysCT scan with reconstructionMRIBaseline investigations
32. Treatment After resuscitation, treatment of patient with complete injury is aimed at preventing the 3 major complications; pressure sores, UTI, contracture/deformities of limbIn those with incomplete injury, the aim is stabilization until spontaneous recovery occurs
33. Treatment High dose methyl prednisolone given within 8hours of injury has been found to have both sensory and motor benefits in patients
34. Mode of treatmentConservative Surgical treatment
35. Conservative treatmentCervical collarSkull tractionGarner well’sCrutchfield’s tongsOrthosis Guilford brace; Ring brace around the occiput and chinYale brace; an extended Philadelphia collar bracing against flexion/extension & rotationHalo vest brace; Immobilize upper or lower cervical spine
36. Philadelphia neck collar
37. WACS UPDATE, JOS 2015Skull Traction
38. Guilford BraceMinerva Orthosis
39. Yale BraceHalo Brace
40. Surgical ManagementIndications Neurologic Deterioration Unstable fractureEpidural Hematoma Narrowing of spinal canal
41. Surgical TreatmentIncomplete SCI:Patients with incomplete injury and instability or canal compromise that do not improve on conservative management should undergo surgical decompression and stabilization. This may facilitate some return of neurological function.
42. Surgical TreatmentComplete SCIThe goal of surgical treatment in complete lesion include;Spinal stabilization before spontaneous fusion takes place in about 8-12 weeksReduce risk of kyphotic angulation
43. WACS UPDATE, JOS 2015
44. WACS UPDATE, JOS 2015
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46. ComplicationsDepression, suicidal ideations, low self esteemPulmonary tract infection, Aspiration PneumonitisGI ulcerationFeacal incontinence, constipationUTIs, Neurogenic bladderOrthostatic hypotension, DVT, PEPressure ulcer,Contractures
47. RehabilitationSum of all activities aimed at Prevention of secondary complications Maximization of physical functioning Reintegration into the communityAchieved via a multi-disciplinary team approachFor each patientSpecific goalsDesign appropriate plan for patients condition
48. Rehab…PHASES OF REHABILITATIONAcute and Subacute phasePrevent complicationsPsychological supportPrevent contracturesChronic Rehabilitation periodEnsuring the maximum independence related to the level of the patient’s injuryReintegration into the society
49. Rehab…PREVENTION OF SECONDARY COMPLICATIONHallmark of rehabilitationCommenced once patient becomes stablePsychological support Passive exercises, proper joint positioning, electrical stimulation.Air/water mattress, 2-3hrs position change,Breathing exercises, early mobilization, prophylactic antibioticsDVT prophylaxisAvoid prolonged lying flat on bedChange of indwelling catheters, Urine alkalinisation
50. Rehab…Maximization of physical functioningIs an active processOften carried out in a proper rehab. Center. Short and long term functional targets are determined by the calculation of the patients’ ASIA scale, level of injury and taking into consideration medical and social status and the individualized rehabilitation plan
51. Rehab…Chronic RehabilitationIndependent MobilizationAge, weight, level of injury, general health status, spasticity and MOTIVATIONProvision of wheelchairs, crutches, walkers, orthoses Robotic training
52. Rehab…Chronic RehabilitationRe-integration into societyHouse modificationDoor width should be 86.5cmDoor HandlesElectric switchesCarpets Kitchen apparatusEducationEmploymentFamily and sexual lifeSocial life
53. Follow upsMonitor improvement in neurology and social integration Majority of patients with complete injury make no improvement with or without surgeryMajority of patients with incomplete injury will make some improvement with or without surgery, although some may deteriorate
54. Peculiarities in our EnvironmentLate presentationPoor Pre-hospital care systemProblem of TBSFewer specialist centerLack of awarenessHigh cost of care Lack of rehabilitation centers/staffPaucity of records/data
55. ConclusionSystematic and effective management of patients with SCI can improve the overall outcomeMultidisciplinary approach to management can lead to prevention of complications associated with SCI
56. Next Hospital Clinical Presentations, Year 2022Next Week (18th February, 2022):PHYSIOTHERAPY DEPT.Topic:…Fortnight (25th February, 2022):NEURO-SPINETopic:…….Thank You & Have a Nice Day