Acute Management of Spinal Cord Injury Dan Rutigliano, D.O Director of Inpatient Trauma Stony Brook Trauma Center No financial disclosures OVERVIEW • Spinal anatomy/classification • Evaluating a patient with suspected spinal injury • Broad management principles of spinal injury • Hypovolaemic vs neurogenic vs spinal shock SPINAL CORD INJURY: EPIDEMIOLOGY In the United States, the incidence of spinal cord injury in 2010 was approximately 40 per million persons per year, or approximately 12,400 annually • Causes in the United States are: - Motor vehicle accidents: 48 percent - Falls: 16 percent - Violence (especially gunshot wounds): 12 percent - Sports accidents: 10 percent - Other: 14 percent Prior to 2000, the most frequent occurrence was a young male with a median age of 22. Since that time, the average age has increased to 37 years in 2010, presumably as a reflection of the aging population. Males continue to make up 77 to 80 percent of cases. Alcohol plays a role in at least 25 percent of TSCI ANATOMY Location of Spinal Injuries 55% in cervical region (mobile and exposed) 15% in thoracic region (less mobile and protected) 15% in thoracolumbar region (fulcrum) 15% in lumbosacral region ANATOMY • Upper cervical region is wide from foramen magnum to lower part C3 - 1/3 die at scene from apnea - those that survive are usually neurologically intact when they reach the hospital ANATOMY • Below C3 the diameter of the spinal canal is smaller - vertebral column injuries are more likely to produce spinal cord injuries • Most thoracic spine fractures are wedge compression fractures without spinal cord injury - high association with a complete spinal cord injury because of narrow thoracic canal • Thoracolumbar junction is where the inflexible thoracic spine meets the strong lumbar spine making it an area vulnerable to injury ANATOMY • Multiple ascending and descending tracts in the spinal cord • 3 clinically relevant ones - lateral corticospinal tract - Controls motor functions on SAME side - spinothalamic tract - transmits pain and temp sensations from the OPPOSITE side - dorsal columns - transmits proprioception and vibration senses from the SAME side ANATOMY Dermatome- area of skin supplied by a single spinal nerve or cord segment Myotome- the muscle/s supplied by a single spinal nerve or cord segment SPINAL CORD INJURY: CLASSIFICATION • Injuries to the spinal cord can be categorized in numerous ways - Incomplete paraplegia (incomplete thoracic injury) - Incomplete quadriplegia (incomplete cervical injury) - Complete paraplegia - Complete quadriplegia SPINAL CORD INJURY: CLASSIFICATION Injuries may have complete or incomplete neurological symptoms • Complete injury patients demonstrate total and flaccid paralysis, total anesthesia/analgesia, and no tendon reflexes • Incomplete injury will demonstrate partial paralysis w/ altered sensation and preserved sacral function (sacral sparing) SPINAL CORD INJURY: CLASSIFICATIONS Different patterns of injury can result in various “syndromes” • Central Cord Syndrome • Anterior Cord Syndrome • Posterior Cord Syndrome • Brown-Sequard Syndrome • Cauda Equina Syndrome SPINAL CORD INJURY: CLASSIFICATION Spinal injuries can also be described as: • Fractures • Fracture-dislocations • Penetrating injury • Spinal Cord Injury without Radiographic Abnormalities (SCIWRA) SPINAL CORD INJURY: EVALUATION Signs and Symptoms: • Pain • Tingling, numbness and weakness in periphery • Loss of sensation or paralysis below the level of injury • Respiratory distress • Incontinence • Priapism SPINAL CORD INJURY: EVALUATION Evaluation and care starts with the ABCs of trauma • A=airway - Need to establish an airway while maintaining c- spine immobilization - Place a definitive airway early if respiratory compromise is suspected- typically with high cervical injury (C3/4/5) SPINAL CORD INJURY: EVALUATION Evaluation and care starts with the ABCs of trauma • B=breathing - evaluate for any associated symptoms to indicate underlying pulmonary trauma - monitor for accessory muscle use to indicate impending respiratory collapse - use supplemental oxygen to prevent hypoxia SPINAL CORD INJURY: EVALUATION Evaluation and care starts with the ABCs of trauma • C=circulation - identify and control any bleeding from injuries - Maintain a normal blood pressure to prevent secondary spinal injury - ? spinal shock- aggressive fluid resuscitation, pressers may be required SPINAL CORD INJURY: EVALUATION Evaluation and care starts with the ABCs of trauma • D=disability - Check patient’s GCS status - exam for equal and reactive pupils - evaluate all 4 extremities for signs of weakness or loss of sensation - perform a rectal exam to evaluate for sphincter tone - evaluate for priapism, bulbocavernosus reflex SPINAL CORD INJURY: EVALUATION Evaluation and care starts with the ABCs of trauma • E=exposure - remove all clothes to fully evaluate for injuries - carefully log roll the pt to palpate the spine and paraspinal regions ‣ identify all areas of pain with palpation - patients with high spinal injuries may be vasodilated and unable to regulate temperature ‣ Cover patients with warm blankets SPINAL INJURY: EVALUATION Adjuncts to primary survey • Done after completion of ABCs • Patient should be on continuous monitoring of vitals • CXR and pelvic x-rays typically performed • FAST exam- bedside ultrasound to evaluate for bleeding in the abdomen as a source of hypotension • Placement of Foley catheter, OGT • Obtain a full medical history- important to ask about use of anticoagulants! SPINAL CORD INJURY: EVALUATION Spinal Imaging • X-rays- not done as first line, provided limited information, can be difficult to obtain needed views • CT scan- gold standard for defining bony injuries, typically done as 1st line imaging as part of the trauma “pan scan” • MRI- useful to identify ligamentous injury or contusions/compression of the spinal cord SPINAL CORD INJURY: EVALUATION Identify the level of spinal cord injury • Make note of both sensory and motor deficit levels ANATOMY Dermatome- area of skin supplied by a single spinal nerve or cord segment Myotome- the muscle/s supplied by a single spinal nerve or cord segment SPINAL CORD INJURY: EVALUATION Identify the level of spinal cord injury • Make note of both sensory and motor deficit levels SPINAL CORD INJURY: EVALUATION American Spinal Injury Association (ASIA) Classification • Allows for standardized classification of spinal cord • Based on • severity of neurological deficit- A=complete to E=normal • the neurological level- identify the most caudal segment with normal function SPINAL CORD INJURY: EVALUATION SPINAL CORD INJURY: MANAGEMENT Phases of injury • Primary spinal cord injury- injury to spinal cord directly related to fractures, dislocations, compression, bleeding • Secondary spinal injury- resulting from prolong mechanical instability or subsequent episodes of hypotension, hypoxia, infections SPINAL CORD INJURY: MANAGEMENT Management principles: Stabilize the primary source of injury; prevent any secondary injury from occurring • Immobilization • IV fluid resuscitation • Medications • Surgery SPINAL CORD INJURY: MANAGEMENT Strict immobilization • 5% of patients with existing injury experience a worsening or new onset of symptoms after arriving to the ED- poor immobilization techniques • use a cervical collar • if a pt needs intubation must maintain inline cervical stabilization • These are potentially difficult intubations • maintain patients flat and on bedrest until appropriate bracing is in place if appropriate SPINAL CORD INJURY: MANAGEMENT SPINAL CORD INJURY: MANAGEMENT IV fluid resuscitation • maintain SBP > 90mm Hg • Normal saline bolus • If blood pressure is refractory to fluid resuscitation consider neurogenic shock SPINAL CORD INJURY: MANAGEMENT Hypovolemic Shock vs Neurogenic SPINAL CORD INJURY: MANAGEMENT Neurogenic Shock: • Mechanism- impairment of descending sympathetic pathways in the cervical or upper thorax (usually above T6) - Leads to a loss of vascular sympathetic motor tone ‣ Results in peripheral vasodilation, pooling of blood and hypotension - Loss of sympathetic stimulus to the heart (injury above T1) ‣ Results in bradycardia and lack of reflexive tachycardia response to hypotension SPINAL CORD INJURY: MANAGEMENT Neurogenic Shock vs Spinal shock SPINAL CORD INJURY: MANAGEMENT Spinal Shock: • Mechanism- transient loss of voluntary and reflexive neurologic function below the level of injury - Spinal cord dysfunction maybe transient but can last days to months - flaccid paralysis, bowel and bladder incontinence, priapism - first reflexes to return are bulbocavernosus and babinski SPINAL CORD INJURY: MANAGEMENT Neurogenic Shock • Management - Hypotension: ‣ Bolus of crystalloid fluids- may require large amounts but beware of fluid overload and pulmonary edema ‣ Vasopressors- typically a pure alpha-blocking agent such as phenylephrine ‣ Goal is to maintain end organ perfusion- warm extremities, MAP >65mm Hg, UO >0.5cc/kr/hr - Bradycardia: treatment only needed if persistent hypotension ‣ Atropine given for acute therapy ‣ Pacemaker can be needed rarely in refractory cases ‣ Avoid over-zealous vagal stimulation such as NT suctioning, ETT manipulation, carotid massage SPINAL CORD INJURY: MANAGEMENT Medical therapy: • Corticosteroids- Aimed at reducing the extent of secondary spinal damage - Most trials have used high dose methylprednisolone ‣ to be given within 8 hrs from time of injury ‣ bolus first given followed by IV infusion for 24-48hrs - Insufficient evidence to