Spinal Cord Injury Management

Epidemiology

 

RTA 50%

Falls 20%

Sport 20%

 

Unconscious after MVA or fall

- 10% chance cervical spine injury

- Cervical > Thoracic > Lumbar

- cervical spine is mobile & not protected

- quadriplegia more common than paraplegics

- assume cervical spine injury till cleared 

 

Permanent paralysis 10%

- incomplete > complete deficit

 

Natural History

 

Death in first year secondary to CRF and Infection

- 20% of Quadriplegics

- 10% of Paraplegics

 

Useful recovery

- complete lesions < 10% chance

- incomplete ~ 75% chance

 

Quadriplegics

- inpatient stay ~ 9/12

- OT doesn't decrease this

- life expectancy decreased by 10 years

 

Paraplegics

- inpatient stay ~ 4/12

- OT does decrease this 

- life expectancy normal

 

Mechanism of injury

 

Primary response / Mechanical

- Contusion (No.1) / Compression / Stretch / Laceration

 

Secondary response

- Ischaemia / Vascular Injury / Vasoactive Substance / Inflammation

 

Definition

 

Neurological level

- lowest level at which motor and sensory function is normal

 

Complete lesion / no sacral sparing

- absence of sensory and motor function in the lowest sacral segment

- no sacral sparing

 

Incomplete lesion / sacral sparing

- presence of sacral and motor function in the lowest sacral segment

- indicates preserved function below the defined neurological level

 

Complete Cord lesion

 

NHx

 

90% recovery of one & 20% recovery two root levels

- if motor grade at level is 2/5 at one week, will gain functional recovery

- if pinprick spared in dermatome, will likely recovery functional > 3/5 strength

- this may be significant i.e. diaphragm, elbow extension C7

- may be increased with surgical decompression

- majority recovery in first 6 - 9 months

 

Function

 

C1-3

- portable ventilation

 

C4

- need CPAP at night

- mouth controlled wheelchairs

 

C5

- active elbow flexion

- dependant for transfer and bed position

 

C6

- shoulder stability (RC)

- wrist extension

- can give them tenodesis grip

 

C7

- triceps

- can roll over and transfer

- eat independently

 

C8-T1

- independent

 

Walking

- > grade 3 hip flexion on one side

- > grade 3 knee extension on other side

 

Neurogenic Shock

 

Cause

 

2° unopposed parasympathetic vagal tone

- sympathetic tone lost

- loss of vasomotor tone with marked vasodilatation

- result is hypotension + bradycardia

 

Diagnosis

- hypotensive + bradycardia + warm periphery 

 

Management

 

Response to fluids moderate (CVP)

- trendelenburg position

- Atropine (0.6 mg push)

- may require inotropic support / Dopamine

 

Pharyngeal suction & intubation stimulate vagus

- may produce bradycardia & cardiac arrest

 

Respiration

 

Midcervical lesion

- C3/4/5

- phrenic nerve defunctioned

- paralysis of diaphragm

 

Low cervical / high thoracic lesion

- paralysis of intercostal muscles

 

Accessory muscles & abdominal respiration used in both circumstances

 

At The Scene

 

Unconscious  Patient

 

Assume spinal fracture secondary to force that caused unconsciousness

- place neck in neutral

- stabilise with gentle longitudinal traction

- hard collar + sandbags

 

Conscious Patient

 

Spinal injury assumed if

- complaining of sensory abnormality / weakness / paralysis

- back or neck pain

 

Immobilisation

- as above

 

Transportation

 

Spinal care / log roll

- monitor airway & O2 saturations

- beware overhydration

- keep patient warm

 

Initial Hospital Management

 

History

- Mechanism of injury

- any neurological deterioration / improvement since injury

 

ATLS

- paraesthesia masks abdominal & leg injuries

 

Vertebral assessment

- log-roll to allow visualisation

- palpate for tenderness / step

- perform PR (saddle anaesthesia / anal tone)

 

Features cord injury

- flaccid areflexia

- lax anal tone

- diaphragmatic breathing

- pain > clavicle only

- hypotensive & bradycardic

- priapism

 

Neurological Assessment / SMART

 

Sensation

- spinothalamic tracts (Pin prick)

- posterior column (Fine touch, Proprioception)

Motor - Corticospinal Tracts

Autonomic ~ Priapism

Reflexes - DTR / Abdominal / Anal / BCR

Tone

 

X-ray

 

Lateral film  

- must see C7/T1

- swimmer's view may be necessary

- pick up 85-90%

 

Cervical trauma series

- AP + Peg / Ondontoid View + Lateral

- up to 95%

 

CT / MRI

 

Early Management

 

1.  Stabilise Spine

 

Cervical

- unstable - Gardner Wells Tongs 4 kg initially

- stable - bed rest, hard collar

 

Thoracolumbar

- patient lies supine

- no flexion

 

2.  Respiratory

 

Worse if chest trauma 

- monitor ABG's

- physiotherapy

- incentive spirometry / triflow

- if respiratory function deteriorates may require intubation

 

3.  CVS

 

Avoid hypotension

- maintain SBP > 90 mmHg

- CVP monitor

- IDC monitor urine output

 

4.  Urinary

 

Bladder usually acontractile

- initial retention

- stretching of Detrusor muscle may delay return of function

- initial IDC followed by intermittent catheterisation

- high incidence UTI & calculi 

 

5. GIT

 

Paralytic Ileus 

 

Usually occurs

- NBM 48/24

- NGT 

 

Abdominal distension splints diaphragm

- vomit & aspiration may occur

- monitor electrolytes & supplement K+

 

Constipation 

- problem after a few days

- microlax & laxatives

 

Gastric ulceration

- can be masked

- ranitidine

 

6.  Skin & Position

 

Turn every 2 hours & inspect skin

- 4 Person lifts

- Edgerton Tilt bed

- Stryker frame

 

7.  Joints & Limbs

 

Daily Passive ROM

- foot drop splints

- hand splints 

 

Spasm 

- Baclofen, Dantrolene

 

HO common

- especially with head injury

- presents as hot red swelling

 

8.  Medication

 

Anticoagulants

- high risk of DVT & PE 

- anticoagulation indicated if no contra-indications i.e. surgical stabilisation

- subcutaneous Heparin & TEDS

 

Steroids

- controversial

- main reason why spinal injuries progress is lipid peroxidation

- bolus dose of Methylprednisolone could inhibit peroxidation

 

Antibiotics

- prophylaxis not indicated

- treat infection only

 

9.  Autonomic Dysreflexia

 

Occurs > T5

- usually with cervical spine injuries

- splanchnic nerves / sympathetic exit at T8 and are interrupted

 

Distended viscus / bladder or bowel

- efferent sympathetic outflow from cord

- vasoconstriction causes HTN

- HTN stimulates carotid body

- centrally mediated vagal response

- bradycardia & vasodilation

 

Presentation

- 80% within the first year

 

Signs

- severe HTN / systolic BP > 200

- headache / facial flushing / bradycardia

 

May result in

- cerebral hemorrhage

- seizures

- pulmonary oedema

 

Managment

- decompress organ - IDC / fecal disimpaction

- sublingual nifedipine

- IV Hydralazine