Spinal cord injury

Dr. R. Muthu Kumar

 Definition

 SCI (spinal cord injury ) defined as disruption of

the normal spinal cord anatomy with neurological
deficit may be traumatic or non - traumatic
 Epidemiology

 More common in males (80%) average age 31.4 years

 10000 cases reported per year
 2.25 to 2.28 lakh people in US are living with paralysis
 Most commonly injured regions Cervical 4 to 6 (51%) and
thorocolumbar T12 to L1(34%)
 Fourth leading cause of death next to IHD, cancer and CVA
 Annual cost in for caring these patients was 7.73 billion $
 Etiology

 Motor vehicle accidents (40-56%)

 Falls (20-25%)
 Recreational and sports (10-15%)
 Violence eg -gun shot wounds (10-15%)


Other causes ( work related) [10-15%]
 Frequency of SCI according to level of injury

Level of injury Frequency in %

Cervical spine C 4-6 50-55

Thoracic spine 10-15

Thorocolumbar T 12 to L2 15 -20

lumbosacral 10

Sacral < 10

Multiple levels 20

Associated head injury (mild) 40 -50

severe 2-3
 Pathophysiology
 Primary SCI
 Caused by mechanical forces
 Direct neuronal disruption, petechial hemorrhages,
hematomyelia, vasospasm and ischemia
 Histologically extravasations of proteins into central grey horn
 Cord edema leading to necrosis and scar formation
 Pathophysiology
 Secondary SCI
 Complex cascade of events (biochemical, enzymatic and micro
vascular)
 Release of cytokinins and AA generates inflammatory cascade
 Leading to free radical formation, cellular edema and cellular
apoptosis
 Loss of vascular auto regulation
 Compounded by hypoxia, hypotension, and local cord edema
causing destruction of axons
 Anatomical correlates

 Flexion injuries causes anterior column and vertebral injury

 Hyperextension mostly whiplash and posterior column
 Vertical compression burst # and ligamentous rupture
 Rotational facetal and peduncle #
 Combined
 Stable or unstable potential for further injury and failure to heal
Mechanistic classification of cervical spinal
injuries

Allen and colleagues

 Clinical presentation of SCI
Clinical syndromes Key clinical features
Central cord syndrome
 Arm weakness in disproportion to legs

Anterior cord syndrome

 Sparing vibratory and position senses

Posterior cord syndrome

 Loss of fine vibration and positional senses

Brown -sequard syndrome

 Ipsilateral motor & touch and , contra lateral pain
and temperature loss

Cauda equina syndrome

 Flaccid areflexic parperesis or paraplegia

Conus medularis syndrome Deep tendon reflexes preserved. Areflexic bladder,



bowel, legs
Complete cord transection
 Complete loss of autonomic, sensory, and motor
functions below
General measures in acute SCI patients
airway Careful oxygenation with attention to spine mobility

breathing Nasotracheal intubation and avoidance of neck

extension
circulation Volume and vasopressors as needed

immobilization Hard collars with block , sand bags and strapping

transportation Immediate transport to SCI centers < 4 hrs

Clinical ASIA score

examination
Radiological X rays (5 views) CT and MRI
examination
 Immobilization and transportation
 Moved by log roll technique
 Soft collars- 96% flexion, 73% extension & full lateral rotation
 Rigid collars – (Philadelphia collar) 2 pieces- 30% flexion &
extension and 45% lateral rotation
 Easy to remove during intubation, easy to fix without lifting the head
 Sandbags and tapes -flexion & lateral rotation 5% , extension 35%
 Tong and Halo permits 4% flexion, 1% rotation and no extension So
intubation is only fibroptic
Immobilization

 A, Soft cervical collar

 B, Philadelphia-type
reinforced cervical
collar
 C, halo brace.
Comprehensive neurological examination
 Should be quick and efficient
 Assess consciousness and orientation
 Motor system assessment (grade 0-5) & Deep tendon reflexes
 Cerebellar function & cranial nerves examination in head injury
 Sensory system- light touch, pin prick, temperature, proprioception
and vibration
 Perirectal sensation , bulbo cavernous or anal cutaneous reflex
{sacral sparing} favorable prognosis
Comprehensive neurological examination
Classification Explanation

Complete ASIA (A)

 No motor or sensory function preserved in sacral
segments

Incomplete ASIA (B)

 Only sensory function is preserved below the
neurological level including sacral segments

incomplete ASIA (C)

 Motor function preserved below the lesion & 50%
and more of muscles have > grade 3 strength

Incomplete ASIA (D)

 Motor function preserved below the lesion & less than
50% of muscles have > grade 3 strength

Normal ASIA (E)

 Motor and sensory normal
 Radiological evaluation
 Five views of cervical spine X ray ( visualized till C7)
 Lateral - misses about 15 to 20% of CS #
 oblique
 Antero posterior 93% sensitivity
 Open mouth odontoid views
 Flexion & extension
 Radiological evaluation

 15 -20 % have to be evaluated with CT and MRI to rule

out whiplash and ligamentous injury
 SCIWORET- without radiological evidence
 SCIWBA- without bony injury (children)
 Widening of paravertibral space indicates unstable spine
and airway problems
Radiological evaluation
 1-anterior vertebral border
 2-posterior margins
 3-jn between lamina and spinous
processes
 4-Tips of spinous process
 2 & 3 – borders of spinal canal
 Lardotic alignment on 4
anatomical lines
 Airway management

 Urgency of airway intervention

 Associated facial, neck and soft tissue injuries
 Basilar skull fractures
 Awake or unconscious patient
 Skill of the operator
 Airway management

 Intubation worsens C –spine injuries

 polytrauma are considered to have C spine injury unless proved
 Jaw thrust causes 5mm widening of disc space (aprahamain et al)
 Single handed Cricoid pressure causes 9 mm posterior
displacement (Gabbot A .D et al )
 No evidence to prove the efficiency of posterior support
 I-LMA and LMA causes posterior displacement @ C2-3
Wood P.R et al
 Airway management

 MILS reduces neck movement during intubation

 Axial traction causes subluxation and distortion
 Laryngoscopy (curved/straight) 3-4 mm widening @ C5-6
 Maximal extension @ C1-2 & occipito-attlantal joint
 Bullard and glide-scope reduces movement @C2-5 <50%
 Blind nasal intubation -2 to 5mm subluxation @ C5-6
Hastings R.H et al
 Blind nasal intubation

Advantages Disadvantages
Minimal head movement Trauma to nasal passage and
infections
Can be done in spontaneously Longer time
breathing
Contraindicated in basal skull
# and facial injury
Needs expertise
 Awake fibroptic

Advantages Disadvantages
Least neck movement Need expertise only in non
emergency
Patient need not be Airway free of blood and
anesthetized and breathing aspirate
spontaneous
only in non emergent
situations
Patient should be cooperative
 Summary of airway control
 There is no evidence that any particular airway
management technique is either safe or dangerous in a
patient with an unstable cervical

 Several retrospective studies have failed to demonstrate a

higher incidence of neurologic injury in patients with
cervical instability after trauma associated with intubation

 The method for definitive airway control should be based

primarily on the operator’s skill and experience rather than
on the fear of inflicting cervical cord damage
Cotrell and Young
 Medical management of SCI
 Cardiovascular system
 Intense SNS activity immediately after injury
 Can cause MI, pulmonary edema, raised ICP
 Spinal shock – 4 phases

1. Hypo reflexive / flaccid paralysis / loss of DTR- 24 hrs

2. Denervation super sensitivity – return of initial reflexes

3. Initial hyper reflexia after a week – axonal growth

4. Final hyper reflexia after a month of phase 3 – soma growth

 Cardiovascular system
 Spinal shock ( neurogenic shock)- phase 1
 Loss of SNS more with lesions above T6
 Hypotension, vasodilatation, ventricular dysfunction and dysrhythmias
 Unopposed vagal tone with loss of T2 –T5 fibers
 Reflex bradycardia and asystole during airway manipulation
 Relative tachycardia indicates hypovolumia

 Treatment
 Isotonic fluids and vasopressors to maintain cord perfusion
 PA catheter / CVP guided volume loading to prevent PE
 Atropine and even TPI for severe bradycardia
 Autonomic dysreflexia (ADR)
 Occurs in 85% with SCI > T6 usually 1-3 weeks after injury
 Uninterrupted sympathetic over discharge in response to stimuli
 Increase in BP > 250/>150 ( 20mmhg > baseline)
 Bradycardia , throbbing occipital or bi-frontal headache
 sweating, pallor, flushing above the lesion
 Spasticity and muscle rigidity below the lesion
 Triggering factor occur usually below the level of lesion ( bladder,
bowel, uterus, rectal, lower limb)
 Autonomic dysreflexia (ADR)
 Treatment ( medical emergency)
 Remove the trigger
 Upright position
 Close monitoring of BP and HR
 Nefidepine, nitrates, SNP, ganglion blockers
 Urinary retention & fecal impaction should be relieved
 Manipulations done under anesthesia
 Can lead to seizures, MI, ICH if not treated aggressively
 Respiratory system
 monitored close as most common cause of morbidity and mortality
 Respiratory rate, O2 saturation, vital capacity recorded

 CXR obtained; ABG for CO2 levels

 C 1-3 level injury patient in apneic and intubation instantaneously
 Intubation criteria
 VC < 15 ml/kg ( PaCO2 >50 mmhg)
 RR > 35 breaths /min
 Fall in SpO2 (PaO2 < 60mmhg)

 Negative inspiratory force < 20 cmH 2O

 Pulmonary edema, aspiration
 Respiratory system
 Most frequent respiratory complications
 Atelectasis
 Pneumonia
 Pulmonary edema
 Respiratory failure

 Treatment & prevention

 Aggressive pulmonary toileting
 IPPV
 Intrapulmonary percussion
 Cough stimulation
 Postural drainage

 Early tracheostomy
 Genitourinary system
 Acute SCI causes atonic bladder , intermittent catheterization
 Ach like oxybutin or propantheline added to lower the pressure
 Complications
 UTI
 Pyelonephritis
 Nephrolithiasis
 Renal failure

 Chronic bacteruria leads to urosepsis prevented by

 Good hydration
 Chronic low dose antibiotic
 Intravesical instillation

 Surgical options
 Gastrointestinal system
 GERD , delayed gastric emptying,
 Increased transit time , severe constipation
 Abdominal distension & hemorrhoids
 Ileus ( complete lesions)
 Treatment
 Adequate diet and fluid intake
 Fibre diet and stool softener
 Contact irritants and prokinetic agents
 Ryles tube
 Hypo Cl- metabolic alkalosis due to gastric suctioning
 DVT prophylaxis
 Incidence of 60% even with prophylaxis
 Included as a part of therapeutic regimen from admission
 Combination is better than either alone
 Low dose UF heparin or LMWH if no contraindication
 Sequential compression devices ( SCD)
 Gradient elastic stockings

 Continued for 3 months and during rehabilitation

 INR of 2 -3 to be maintained
 Temperature & pressure sore control
 Loss of thermoregulatory ability below the level of lesion
 Injury > T6 become poikilothermic (temp of surroundings)
 Arrhythmias common
 Delayed awakening during anesthesia
 Temperature monitoring and warming efforts needed
 Skin care and treatment of pressure sores is vital
 Prevention is better
 Surgical modalities of treatment
 Neuro protective strategies
 Spine immobilisation
 Surgical decompression
 Physiological therapy
 Avoid hyperthermia, hypotension, hyperglycemia

 Pharmacological therapy
 NASCIS- II inj MP 30 mg/kg for 15 min followed by 5.4 mg/kg /hr for 23 hrs
 Treatment started within 8 hrs of injury had significant improvement
 NASCIS –III ; 24 hr regimen for patients < 3 hrs of injury
 Continued for 48 hrs for patients presenting 3 -8 hrs

 Use of high dose steroids remain controversial

Anesthesia for SCI
patients
 Preoperative evaluation

 Multiple medical complications

 Airway evaluation
 Neurologic evaluation
 Counseling about awake intubation and wake up test
 Investigations

 Complete blood count

 Renal function
 LFT
 Electrolytes
 ECG ,CXR
 ABG
 PFT if needed
 Premedication

 Minimal sedation
 Anti-sialogogue
 Prokinetic for gastric emptying
 DVT prophylaxis if not contrandicated
 Intraoperative monitoring
 Invasive arterial BP in shock patients
 NIBP
 CVP or PA catheter for monitoring volume status
 SpO2, ECG, ETCO2, temperature
 SSEP
 ICP monitoring if head injury is associated
 Urinary catheter
 Induction agent

 Induced after securing the airway in lesion < C6

 Nerve block preferred over sedation for awake intubation
 Sometimes positioned before anesthesia or paralysis
 Flexometallic armored tube fixed and secured
 Ketamine is the drug of choice in spinal shock
 Avoid scoline if injury < 24 hrs ( hyperkalemia)
 Positioning
 Head and neck in neutral position
 Adequate padding at pressure points ( eyes, nose, extremities)
 Avoid excessive neck extension and flexion
 Avoid sudden change of position
 Pressure points changed every 15 minutes under anesthesia
 Abdomen free of compression
 Prevent peripheral nerve injuries , blindness, pressure necrosis
Positioning
 A, Kneeling prone
 B, Wilson Frame Pad
 C, Georgia prone;
 D, Relton - Hall frame
 E, Seated prone.
 Fluid management

 Preoperative deficit and intra-operative loss replaced

 Cardiopulmonary status of high cervical lesion
 High propensity for pulmonary edema with < T6
 Avoid glucose containing solutions( RBS <150mg%)
 Crystalloid VS colloid debatable
 Temperature management

 Warm blankets and warm enviroment

 Humidification of gases
 Warm fluids
 Avoid hyperthermia
 Postoperative care
 Extubation

 Cautious in deciding in high cervical and thoracic injuries

 Patients with preoperative pulmonary impairment
 Metabolic derangement and persistent muscle weakness
 Excessive facial or pharyngeal edema in prolong surgery
 Cuff leak test to confirm reduction of edema
 Ability to generate cough
 Minimal secretion and stable cardiac function
 Absence of pulmonary infection
 Postoperative care
 Analgesia
 Intermittent iv or im opioid
 Continuous infusion of low dose opioids
 PCA ; epidural and intravenous with opioid
 PCEA with opioid +LA or only LA
 Intercostal nerve block
 Paravertibral blocks
 Wound infiltration
 Non-opioid analgesics