1. SPINAL CORD INJURY USAF CSTARS Baltimore University of Maryland Medical Center R A Cowley Shock Trauma Center

2. OBJECTIVES Review spinal cord anatomy and neural pathways Identify and treat neurogenic shock, spinal shock, and specific patterns of cord injury Describe initial evaluation and management principles of the trauma patient with spinal cord injury Recognize specific radiographic findings of spinal cord injury

3. EPIDEMIOLOGY Incidence (all trauma patients) –Cervical: 4.3% –Thoracolumbar: 6.3% Males: 70% (M:F ratio = 4:1) Mechanism (Most to least common) –MVC –Fall –Act of Violence –Sport Activity

4. INJURY LOCATION Cervical: 55% –High (Oc-C2): 25% –Subaxial (C3-C7): 75% Thoracic: 30% Lumbar: 15% –Most common at thoracolumbar junction –L1 accounts for 16% of all injuries

5. ANATOMY Vertebral Column –Cervical: 7 –Thoracic: 12 –Lumbar: 5 –Sacral: 5 (fused) –Coccygeal: 3 – 5 (fused)

6. DERMATOMES

7. NEURAL PATHWAYS CORTICOSPINAL TRACT Ipsilateral Motor Control

8. NEURAL PATHWAYS SPINOTHALAMIC TRACT Contralateral Pain & Temperature

9. NEURAL PATHWAYS DORSAL COLUMNS Ipsilateral Proprioception & Vibration

10. MECHANISM OF ACUTE INJURY Direct Space Occupying Lesion: Focal injury at site of impact Direct Non-Space Occupying Lesion: Stretch, shear, compressive forces Secondary Injury: Due to compromise of blood supply

11. SHOCK Neurogenic –Systemic phenomenon –Hypotension, Bradycardia, Hypothermia Spinal Shock –Temporary loss of reflex activity below injury –Flaccid paralysis –May last up to 48 hours Management –Assume hypovolemic –Volume, followed by pressors

12. NEUROLOGIC INJURY PATTERNS Classification –Complete: No motor or sensory function caudal to level –Incomplete: Not complete –Spinal cord must have recovered from spinal shock prior to classification

13. NEUROLOGIC INJURY PATTERNS Anterior Cord Syndrome –Injury to anterior 2/3 –Loss of motor, pain, temperature below level of injury –Preservation of proprioception and vibration –Prognosis is poorest of all cord syndromes

14. NEUROLOGIC INJURY PATTERNS Central Cord Syndrome –Upper extremity deficit > lower extremity deficit –Loss of arm and hand function –Less impairment of leg movement –Prognosis varies

15. NEUROLOGIC INJURY PATTERNS Brown-Sequard Syndrome –Damage to one side of spinal cord –Loss of ipsilateral motor –Loss of contralateral pain and temperature –Prognosis varies

16. EVALUATION & MANAGEMENT ABCs –Presume spinal cord injury is present –Immobilization: Cervical collar, backboard –Definitive airway –Maintenance of blood pressure –Spine precautions: Immobilization and log- rolling

17. EVALUATION & MANAGEMENT Secondary Survey –Examination may be altered; loss of sensation –Presence of other life-threatening injuries –Oxygenation/ventilation difficulty with cervical injuries –Thorough radiographic evaluation during/following resuscitation

18. EVALUATION & MANAGEMENT Cervical Spine Clearance – Clinical –Awake, alert, oriented –No intoxication –No midline tenderness –No focal neurologic injury –No distracting injury

19. EVALUATION & MANAGEMENT Pharmacologic Prophylaxis –Initiate for: Neurologic symptoms attributable to SCI Blunt mechanism Less than 8 hours from injury –Protocol Methylprednisolone (30 mg/kg) bolus followed by infusion at 5.4 mg/kg/hr for 23 hours If injury is 3 - 8 hours out, continue infusion for 48 hours –Outcome (Class II) Better recovery of neurologic function at 6 weeks, 6 months, and 1 year No difference in mortality and morbidity

20. EVALUATION & MANAGEMENT Thoracolumbar Spine –Characteristics Stabilizing effect of ribs and chest wall Injury is usually compressive Deficit usually due to: –Lack of space for spinal cord –Tenuous arterial blood supply –Energy required to inflict injury

21. EVALUATION & MANAGEMENT Thoracolumbar Spine –Clinical Manifestations Lower extremity paralysis Loss of sensation Bowel & bladder dysfunction –Evaluation Physical Exam Radiographic: AP & Lateral films, CT spine

22. EVALUATION & MANAGEMENT Penetrating Spinal Cord Injury –12% of traumatic SCIs –Initial management focuses on life- threatening issues –Surgical Intervention Deferred until stable patient Goals are debridement, decompression, removal of fragments, & dural closure Rarely indicated in complete injuries

23. RADIOGRAPHIC ASSESSMENT Cervical Spine –Adequacy requires base, C1-C7 and T1 –Lateral C-Spine Film: May miss 15% of injuries and requires additional views (AP, Odontoid, or CT scan) –Assessment Soft tissue swelling Contour and Alignment AP canal diameter Fracture lines, step offs, displacement

24. RADIOGRAPHIC ASSESSMENT Cervical Spine –Soft Tissue Guidelines Less than 6 mm at C2 Less than 22 mm at C6 –Instability Displacement of > 3mm adjacent vertebrae Angulation difference > 11 mm adjacent vertebrae (implies ligamentous injury)

25. RADIOGRAPHIC ASSESSMENT Thoracolumbar Spine –Spinous process alignment –Pedicle widening/symmetry –Vertebral and disc height –Vertebral body contour

26. SPECIFIC INJURIES C-1 Fracture –Rarely involves neurologic deficit –Posterior arch is most common –Jefferson Fracture (4- part fracture) –Others: Lateral mass, anterior arch of C1, transverse process fracture

27. SPECIFIC INJURIES Atlantoaxial Joint Injury –Etiology: Transverse ligament disruption –Extremely unstable –High risk for neurologic deficit

28. SPECIFIC INJURIES C-2 Fracture –Type I: Tip of Dens –Type II Junction of Dens & Body Most common –Type III: Through body at base of C-2

29. SPECIFIC INJURIES Lower Cervical: C3 – C7 Thoracolumbar Fractures

30. SUMMARY Spinal cord anatomy and syndromes Identification of “spinal cord related” shock and treatment ABCs & spinal cord injury evaluation and management Radiographic findings in spinal cord injury

31. QUESTIONS ?