1. Avoiding Spinal Cord Disasters The Key is Early Recognition J. Stephen Huff, MD, FACEP University of Virginia Departments of Emergency Medicine and Neurology June 25 - 27, 2009

2. Spinal Cord Disasters The Key is Early Recognition Injury patterns Differential diagnosis Cases Pitfalls Pearls

3. Spine or Spinal Cord?

4. Spinal Cord Syndromes and Injury Patterns Complete Incomplete –Anterior –Posterior –Central Cord –Brown-Sequard –Cauda equina lesion –Conus medullaris lesion

5. Spinal Cord Syndromes and Injury Patterns Complete –Transverse sensory pattern –Transverse motor pattern What’s the level?

6. Motor levels C4 level – quadriplegia C5 level + deltoid, biceps C6 level + wrist extensors, brachioradialis C7 level + triceps T1 level + finger abductors

7. Motor levels T2 – T12 paraplegic L1 intact – Iliopsoas (hip flexion) L2 + hip adductors L3 + quadriceps L4 + tibialis anterior (dorsiflexion) L5 + hamstrings S1 + gastrocs (plantarflexioin)

8. Motor Weakness –Sudden or progressive Fatigability Clumsiness Atrophy / fasciculations

9. Patterns of sensory loss Bilateral segmental loss Pinprick loss alternating with position & vibration loss Sacral sparing Sacral loss

10. Reflexes Reflex assessment may be unreliable in acute lesions Autonomic reflexes “Spinal Shock”

11. Pitfalls Time constraints Incomplete history Incomplete examination Unusual presentations

12. “Levels” Vertebral Cord Disability Function => say what you mean…

13. Imaging Plain radiography CT MRI Myelography

14. Case 1 - multiple trauma Unrestrained driver Head injury Intubated at scene Immobilized / IV’s

15. Case 1 - arrival Intubated / unresponsive Hypotensive Stable chest Rigid abdomen

16. Case 1 - Management Airway verified Resuscitation continued Examination Ancillary tests

17. Case 1 - Pressure problems Hypotensive… No fractures on early xrays –CXR –Pelvis Peritoneal lavage negative ? Why hypotensive?

18. Neurogenic Shock “Vasogenic shock” –Diagnosis of exclusion –Fluids –Pressors Not “spinal shock”

19. Pitfalls – complete lesions Failed recognition ABCD Attributing hypotension to the spinal cord injury erroneously Steroid stumble

20. Case 2 - football player Tackling injury Ambulatory after accident Immobilized Helmet on….

21. Case 2 - football player Awake, alert Strength exam normal Severe pain upper extremities Grip good

22. Central Cord Syndrome Upper extremity symptoms Lower extremities intact Variable sensory findings Variable bladder dysfunction

23. Central Cord Syndrome “Burning Hands” in football players with spinal cord injuries…. Cord at risk Narrow canal – etiology? Advanced imaging Restriction of play?

24. Case 3 – chest pain 53 year-old man with chest pain and upper back pain Left-sided, sharp, + movement Hx COPD, sarcoidosis, CHF, pulmonary embolism, diabetes On prednisone, metformin, diuretic Wheelchair at times, active

25. Case 3 – chest pain Afebrile CXR, CT-PA obtained WBC 23,000

26. Case 3 – chest pain Leukocytosis attributed to steroids Pain medications, discharged

27. Case 3 – Clinical course Returned 48 hours with leg weakness Blood cultures + Staph aureus MRI- epidural fluid collection

28. Sensory Paresthesias-positive Negative symptoms Pain –Local pain –Radicular pain –Diffuse burning/aching

29. Compressive lesions –Spinal epidural hematoma –Spinal epidural abscess –Disciitis –Disc –Neoplasm –Metastatic tumors –Primary CNS tumor

30. Spinal Epidural Abscess Acute, sub-acute, and chronic Thoracic location more common Extends 4-5 levels Triad –Back pain –Fevers –Progressive neurologic dysfunction

31. Spinal Epidural Abscess Risk factors –Intravenous drug abuse –Diabetes –Chronic renal failure –Alcoholism –Immunosuppression –Instrumentation

32. Spinal Epidural Abscess diagnosis MRI diagnostic test of choice ESR elevated LP relatively contraindicated

33. Spinal Epidural Abscess Therapy Surgical decompression Antibiotics* –Staph coverage –MRSA Prognosis related to pre-op state

34. Compressive lesions –Treatment generally similar… –Diagnosis… Exclude remedial causes… –Steroids … –Decompression… –XRT for tumors… “the only XRT emergency….”

35. Case 4 – crack in neck Awakened with severe neck pain Became weak on way to ED Right-sided weakness –No facial droop –No speech difficulty

36. Case 4 – crack in neck At arrival, weak right arm and leg –4/5 –Left side normal Additional history –Strong family history of stroke –No medical history other than mild hypertension

37. Spinal Epidural Hematoma Sudden, severe back pain Radicular component Progressive neurologic deficits

38. Spinal Epidural Hematoma Anticoagulant use Thrombocytopenia Liver disease / alcoholism Instrumentation MRI imaging modality of choice

39. Case 5 16 year old Abrupt inability to walk

40. Case 5 Awake, alert Sitting on side of bed Lifting legs with arms Sensory level at umbilicus

41. Case 5 Normal tone Normal reflexes “Don’t worry about me…”

42. “Hysterical paraplegia” Untenable patterns –Sensory loss –Motor loss Normal muscle tone Normal reflexes No bladder dysfunction

43. “Hysterical paraplegia” Beware diagnosis Positive findings… Ask for help… Lumbar puncture?

44. “Stable” vs. “unstable” Mechanical Deficit General condition

45. Low lesions C onus medullaris lesion Cauda equina lesion –Overlap / coexist –Sphincter involvement –UMN vs. LMN –Bilateral vs. unilateral

46. Nontraumatic etiologies of spinal cord dysfunction Demyelination –Multiple sclerosis / Transverse myelitis –Stroke AVM / SAH –Syringomyelia –Traumatic –Tumor Idiopathic spastic paraparesis –HIV myelopathy –Other myelopathies Compressive lesions

47. THINK REVERSIBLE

48. Avoiding Spinal Cord Disasters The Key is Early Recognition J. Stephen Huff, MD, FACEP University of Virginia jshuff@virginia.edu