SPINAL CORD-SPINE INJURY N.İREM ABDULHAYOĞLU

Spinal cord injury (SCI)  Insult to the spinal cord resulting in a change; temporary or permanent Patients with SCI usually have permanent and often devastating neurologic deficits and disability After a suspected SCI diagnosis initiate treatment Prevent further neurologic injury from 1)mechanical instability secondary to injury 2)effects of cardiovascular instability or respiratory insufficiency

terminology Tetraplegia (quadriplegia): -injury to the spinal cord in the cervical region -loss of muscle strength in all 4 extremities Paraplegia: -injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

EPIDEMIOLOGY Incidence: approximately 40 cases per million Males are 4 times more likely than females 50% of SCI 16-30 years 3.5% 15 years and younger 11.5% older than 60 years(greater mortality)

TYPES Cervical 55 % The most common neurologic level of injury is C5. In paraplegia,T12 and L1 are the most common level. Incomplete tetraplegia: 29.5% Complete paraplegia: 27.9% Incomplete paraplegia: 21.3% Complete tetraplegia: 18.5%

PATHOPHYSIOLOGY SCI can be sustained through different mechanisms; leading to tissue damage: 1)Destruction from direct trauma 2)Compression by bone fragments, hematoma, or disk material 3)Ischemia from damage or impingement on the spinal arteries The primary injury refers to the immediate effect of trauma which includes forces of compression, contusion, and shear injury to the spinal cord. This is followed by the delayed onset of a secondary injury phase involving vascular dysfunction, edema, ischemia, excitotoxicity, electrolyte shifts, free radical production, inflammation, and delayed apoptotic cell death. 

SPINAL STABILITY- 3 COLUMN MODEL OF DENIS Unstable=If two or more columns are involved or if the middle column alone is involved.

Completeness of lesion Complete lesion: No preservation of any motor and/or sensory function more than 3 segments below the level of the injury in the absence of spinal shock. In the acute stage, reflexes are absent, there is no response to plantar stimulation, and muscle tone is flaccid. A male with a complete SCI may have priapism. The bulbocavernosus reflex is usually absent. Urinary retention and bladder distension occur. 

Incomplete lesion: any residual motor or sensory function more than 3 segments below the level of the injury. Usually sensation is preserved to a greater extent than motor function because the sensory tracts are located in more peripheral. The bulbocavernosus reflex and anal sensation are often present.

Levels of Injury High-Cervical Nerves (C1 – C4): - Most severe of the spinal cord injury levels - Paralysis in arms, hands, trunk and legs - Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements. (diaphragm is innervated by C3-C5 levels)

Low-Cervical Nerves (C5 – C8): - C5 injury: Person can raise his or her arms and bend elbows. Can speak and use diaphragm, but breathing will be weakened. - C6 injury: Person can use both of the elbow and the wrist. Can speak and use diaphragm, but breathing will be weakened. - C7 injury: Person can extend the elbow and can do finger extension. Most can straighten their arm and have normal movement of their shoulders. - C8 injury: Person can flex their fingers, allowing them a better grip on objects. 

Thoracic Paraplegia: People with T1-T12 paraplegia have nerve sensation and function of all their upper extremities. - Paraparesis or paraplegia Lumbosacral Nerves (L1 – S5): Injuries generally result in some loss of function in the hips and legs.

Incomplete Injury Anterior spinal cord syndrome: -Lesions affecting the anterior or ventral two-thirds of the spinal cord -Sparing the dorsal columns -Usually reflect injury to the anterior spinal artery -Often represents a direct injury to the anterior spinal cord by retropulsed disc or bone fragments

Central Cord Syndrome: -In small central cord lesions, damage to spinothalamic fibers crossing the ventral commissures causes bilateral regions of suspended sensory loss to pain and temperature. -With larger central cord lesions, the anterior horn cells are damaged, producing lower motor neuron deficits at the level of the lesion.In addition, the corticospinal tracts are affected, causing upper motor neuron signs, and the posterior columns may be involved.

Posterior Cord Syndrome -Dorsal column symptoms include gait ataxia and paresthesias -Causes of a dorsal cord syndrome include multiple sclerosis, tabes dorsalis, Friedreich ataxia, subacute combined degeneration, vascular malformations, epidural and intradural extramedullary tumors, cervical spondylotic myelopathy, and atlantoaxial subluxation

Brown Sequard Syndrome -A lateral hemisection syndrome -involves the dorsal column, corticospinal tract, and spinothalamic tract unilaterally -Unilateral involvement of descending autonomic fibers does not produce bladder symptoms -Knife or bullet injuries and demyelination are the most common causes.

Conus Medullaris Syndrome: -Lesions at vertebral level L2 -saddle anaesthesia -loss of bladder reflex: urinary retention -loss of bowel reflex: incontinence  -lower limb motor weakness, paraesthesia and numbness -chronic lower backache -Causes include disc herniation, spinal fracture, and tumors 

Cauda Equina Syndrome: -injury to the lumbosacral nerve roots in the spinal canal. -Perianal and "saddle" paraesthesia. -Bowel, bladder and/or sexual dysfunction -This syndrome is a nerve root injury rather than a true spinal cord injury, the affected limbs are areflexic -Caused by a central lumbar disk herniation

Neurogenic Shock Due to interruption of the sympathetic input from hypothalamus to the cardiovascular centers Hypotension (due to vasodilation, due to loss of sympathetic tonic input) and bradycardia No real blood loss but blood is pooled in periphery

Spinal shock Temporary loss or depression of all or most spinal reflex activity below the level of the injury. Flaccid paralysis Loss anal tone, reflexes, autonomic control

Initial Management ABC Shock (Hemorrhagic or neurogenic?) Immobilisation and prevention of further injury Transportation

Systematic treatment in spinal trauma Airway management-modified jaw thrust and insertion of an oral airway, intubation may be required Hypotension, hemorrhage, and shock-Blood transfusion ,dopamin, adrenaline, opiate antagonists Steroid Therapy-should be initiated within 8 hours of injury ; methylprednisolone 30 mg/kg bolus over 15 minutes and an infusion of methylprednisolone at 5.4 mg/kg/h for 23 hours beginning 45 minutes after the bolus.  Head injuries and neurologic evaluation Ileus- Placement of a nasogastric (NG) tube Urine output should be more than 30 mL/h; placement of a Foley catheter

Specific Treatmet Spinal cord treatment: - Prevention of secondary injury - Antiedema tx - Decompressive surgery - Regeneration strategies: stem cell, growth factors, gene tx Spine treatment: -Stabilisation -Decompression

Indications of Emergency Surgery Progressive neurological deficit Open wounds Penetrating wounds Spinal cord compression Instability

Prognosis Complete spinal cord injury (SCI) have a less than 5% chance of recovery. If complete paralysis persists at 72 hours after injury, recovery is essentially zero. The prognosis is much better for the incomplete cord syndromes. Approximately 10-20% of patients who have sustained a spinal cord injury do not survive to reach acute hospitalization, whereas about 3% of patients die during acute hospitalization. The leading causes of death are pneumonia, pulmonary embolism, or septicemia.

references Handbook of Neurosurgery 8th Edition http://emedicine.medscape.com/article/793582- overview https://radiopaedia.org/articles/cauda-equina- syndrome https://www.ncbi.nlm.nih.gov/pubmed/10646440 THANK YOU..