Spinal cord injury

Revision as of 14:05, 22 February 2020 by Rossdonaldson1 (talk | contribs) (See Also)

Background

  • Penetrating injury
    • GSW
      • Most are stable injuries and only require supportive orthosis, analgesia
      • Bullet removal does not improve neuro status for stable cervical and thoracic lesions
      • Bullet removal may improve neuro status for thoracolumbar region injury (T11-L2)
    • Stabbing
      • Vertebral instability is generally not an issue
      • Delayed deficits are rare
        • If do occur related to retained fragment of blade within spinal canal

Anatomy

Spinal cord tracts
  • Dorsal columns
    • Proprioception, vibration
    • Decussation at medulla
  • Corticospinal Tract
    • Voluntary motor
      • Upper extremity fibers more central, lower extremity fibers more lateral
    • Decussation at medulla
  • Spinothalamic
    • Crude touch, pressure, pain, temperature
    • Decussates 1-2 levels above entry point to spinal cord

Peds

  • In patients <10yr spinal injury occurs mainly in upper cervical vertebrae
  • In patients >10yr majority of injuries occur in lower cervical spine, similar to adults
  • Odontoid fractures are among most common cervical spine injuries in children
    • Do not confuse with normal anatomic variations in odontoid seen in children up to 7yr old
  • SCIWORA
    • Spinal cord injury without radiologic abnormality
    • MRI has shown significant pathology in many of these patients
    • Symptoms
  • Transient quadriparesis ("stinger")
    • Occurs most often in boys after sports injuries
    • Paresthesias or weakness of extremities lasting from seconds to minutes
      • Complete recovery within 48hr

Types

Spinal Cord Syndromes

Differential Diagnosis

Neck Trauma

Evaluation

Management

Acute Management of Spinal Cord Injury

  • Neurogenic shock management
  • Consider intubation injuries at C5 or above
    • Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization[1][2]
    • Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
    • Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension[3]
    • Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
  • Consider surgical intervention for:
  • Steroids are no longer recommended
    • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is NOT approved by the FDA for this indication. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.[6]
    • See EBQ:High Dose Steroids in Cord Injury for further discussion

Disposition

  • Admit

See Also

References

  1. The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.
  2. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.
  3. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.
  4. Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.
  5. Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.
  6. Hurlbert RJ et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 http://www.ncbi.nlm.nih.gov/pubmed/23417182