Management of spinal cord injury

(SCI)BY

ADEAGBO, CALEB A.adewummy007@yahoo.com

04/11/2023 2

Case scenario47 y/o male involved in RTA 4/12 ago.Admitted via A&E in LUTH and

transferred to National Hospital for further mgt.

Sensation intact on both ULs & LLs.Muscle power 0/5 below the Umbilicus. No bladder / bowel control.Diagnosed of C-spine injury and

presenting now with paraplegia LLs and paraparesis ULs

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Outline

Overview Key terms Anatomy Causes Type Pathophysiology Clinical syndromes

Diagnosis Neurological

assessment and classification

Management References

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Overview

SCI is damage to the spinal cord that results in loss of functions such as mobility or feeling.

The fourth leading cause of death in the US.

Spinal Cord (SC) is the major bundle of nerves that carry impulses to/from the brain to the rest of the body.

Spinal Cord is surrounded by rings of bone-vertebra and function to protect the spinal cord.

Most common vertebrae involved are C5, C6, C7, T12, and L1 because they have the greatest ROM

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Key terms used in SCISCI is insult to spinal cord resulting in a

change in the normal motor, sensory or autonomic function. This change is either temporary or permanent.

Tetraplegia The impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal.

Paraplegia The impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord due to damage of neural elements within the spinal canal.

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Key terms used in SCIDermatome The area of skin innervated

by one sensory nerve root.Myotome The collection of muscles

innervated by one motor nerve root.Neurological Level of Injury The most

caudal segment of the spinal cord with normal motor and sensory function on both sides.

Skeletal Level The radiographic level of greatest vertebral damage.

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Key terms used in SCI Motor level The most caudal key muscle

group that is graded 3/5 or greater with the segments cephalad to that level graded normal (5/5) strength.

Sensory level The most caudal dermatome to have normal sensation for both pinprick and light touch on both sides.

Complete injury The absence of sensory and motor function in the lowest sacral segments.

Incomplete injury Preservation of motor or sensory function below the neurologic level of injury that includes the lowest sacral segments.

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Key terms used in SCISacral sparing Presence of motor

function (voluntary external anal sphincter contraction) or sensory function (light touch, pinprick at S4/5 dermatome, or anal sensation on rectal examination) in the lowest sacral segments.

Zone of partial preservation All segments below the neurologic level of injury that have preserved motor or sensory findings; used only in complete SCI.

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AnatomySpinal cord: foramen magnum 1st/2nd lumbar

vertebrae. Gray matter: central (cell bodies)White matter: peripheral (ascending and

descending tracts)On the surface : Deep anterior median fissure Shallower posterior median sulcusSpinal cord segment : Section of the cord from which a pair of spinal

nerves are given off31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5

lumbar, 5 sacral, 1 coccygeal

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Anatomy

Dorsal root – sensory fibres

Ventral root – motor fibres

Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve

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Longitudinal section of SC

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Tracts of SC

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Clinically important ascending tracts and where they decusate

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Clinically important descending tracts and where they decusate

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Causes of SCI

RTA Falls Gunshot Injuries Blunt Assault Diving Accidents Stab Wounds Sport Injuries Vascular disorders

Tumors Infectious

conditions Spondylosis Vertebral fractures

secondary to osteoporosis

Development disorders

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Type of SCI Transient concussion - is due to extreme

vibration of the cord and may cause temporary loss of function lasting 24 to 48 hours. No neuropathologic changes are present.

Contusion - is a bruising that includes bleeding, subsequent edema, and possible necrosis from the edematous compression. The neurological involvement depends on the severity of contusion and necrosis

Laceration Compression of cord substance Complete transection of the cord

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Pathophysiology Hemorrhage: Blood flows into the

extradural, subdural, or subarachnoid spaces of the spinal cord

Injury to spinal cord vasculature causes nerve fibers to swell and disintegrate

Blood circulation to the gray matter of the spinal cord is impaired

Secondary chain of events: Ischemia, hypoxia, edema, and hemorrhagic lesions

These secondary events result in destruction of myelin and axons.

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Pathophysiology These secondary reactions, are believed

to be the principal causes of spinal cord degeneration .

The damage may be reversible within the first 4 to 6 hours after the injury.

The consequence of spinal cord injury depends on

The type of SCI injuryThe neurologic level (lowest level at which sensory and motor functions are normal)

Clinical Syndromes Central Cord Syndrome: Cervical injury with sacral

sparing and greater weakness in the arms than the legs.

Brown-Sequard Syndrome: An injury that causes greater ipsilateral weakness and proprioceptive loss and contralateral pain and temperature loss.

Anterior Cord Syndrome: Injury to the spinal cord causing loss of pain and temperature sensation with preserved proprioception.

Posterior Cord Syndrome: Injury to the spinal cord causing loss of proprioception with preserved pain and temperature sensation.

Conus Medullaris Syndrome: Injury of the sacral conus and lumbar nerve roots

Cauda Equina Syndrome: Injury to the lumbosacral nerve roots within the neural canal.

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Diagnosis

X-rays of cervical spine to establish level and extent of vertebral injury

CT scan and MRI: changes in vertebrae, spinal cord, tissues around cord

Arterial blood gases to establish baseline

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Neurological assessment and classification

The most widely tool for classifying SCI is “the American Spinal Injury Association (ASIA) classification,” this assessment requires manual muscle testing of 10 key muscles bilaterally, sensory testing for light touch and sharp/dull discrimination in all dermatomes, and a rectal exam for sensation and presence of voluntary anal contraction. These tests are used to classify injury levels and ASIA Impairment Scale (AIS) grade

ASIA Sensory Testing

Sensory Testing:0 = Absent1 = Impaired2 = NormalNT = Not testable

ASIA Dermatones

C2-Occipital Protruberance C3 –Supraclavicular fossa C4 – A.C. Joint C5 – Lateral antecubital fossa C6 – Thumb C7 – Middle finger C8 – Little finger T1 – Medial antecubital fossa T2 – Apex of the axilla T4 – Nipple line

T6 – Xyphoid T10 – Umbilicus T12 – Inguinal ligament L2 – Mid thigh L3 – Medial femoral condyle L4 – Medial Malleolus L5 – 3rd MTP joint S1 – Lateral heel S2 – Mid popliteal fossa S3 – Ischial tuberosity S4-5 – Perianal area

ASIA Motor Testing

0 = No movement

1 = Trace contraction

2 = Full AROM gravity eliminated .

3 = Full AROM against gravity

4 = Full AROM against gravity with resistance

5 = Normal power

ASIA Myotomes

C5 – Elbow flexorsC6 – Wrist extensorsC7 – Elbow extensorsC8 – Finger flexorsT1 – 5th digit

abductors

L2 – Hip flexorsL3 – Knee extensorsL4 – Ankle dorsiflexorsL5 – Long toe extensorsS1 – Ankle plantar

flexors

ASIA Impairment Scale A = Complete: No motor or sensory function

in the lowest sacral segment. B = Incomplete: Sensory but no motor

function is preserved in the lowest sacral segment.

C = Incomplete: Less than ½ of the key muscles below the (single) neurological level have a grade 3 or better.

D = Incomplete: At least ½ of the key muscles below the (single) neurological level have a grade 3 or better.

E = Sensory and motor function are normal.

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Management Immediate

management at the scene is critical.

Improper handling can cause further damage and loss of functioning

Always assume there is a spinal cord injury until it is ruled out Immobilize Prevent flexion, rotation

or extension of neck Avoid twisting patient

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Management

Management consists of emergency treatment following an A-B-C-D-E sequence.

AirwayBreathingCirculationDisabilityExpose

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Medical managementHigh dose corticosteroids

(Methylprednisolone) - improves the prognosis and decreases disability if initiated within 8 hours of injury. Patient receives a loading dose and then a continuous drip.

High dose steroids, Mannitol, DextranNeurological/orthopedic management

includes methods a surgeon may use to treat unstable spinal cord injuries: ReductionFixationFusion

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Reduction

With reduction, the spine is realigned through the application of a skeletal traction devise (such as Gardner-Wells tongs, Minerva vest, Halo traction) or Soft and hard collars.

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Gardner-Wells tongs

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Minerva vest and halo-vest

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Soft and hard collars

Fixation and Fusion

Fixation involves stabilizing vertebral fractures with wires, plates, and other types of hardware.

Fusion involves attaching injured vertebrae to uninjured vertebrae with bone grafts, and steel rods to help maintain structural integrity.

Physiotherapy GoalsRelieve painMaintain optimal level of wellnessMaintain optimal functioningMinimal or no complications of immobilityLearn new skills, self careReturn to home Integrate back into community

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Physiotherapy techniques

Therapeutic exercises: Passive movement, Free active exercises, Auto assisted exercises, Assisted resisted exercises, Resisted exercises

Soft tissue manipulationPositioning

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Physiotherapist teaches

MobilitySelf careFunctional activities

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Mobilitybed mobility (i.e. turning from side to

side, moving from supine to sitting).sitting balance.wheelchair transfers (i.e. from

wheelchair to bed, wheelchair to car, and wheelchair to floor).

standing balance. ambulation (wheelchair or walking).

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Self careAlong with increasing mobility,

minimizing the need for assistance in self-care is a major step toward independence for those with SCI.

Self-care includes feeding, bathing, dressing, grooming, and toileting. Those with motor-complete injuries at the C-7 level or below can usually achieve independence in all of these activities.

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Functional activities

Living skills (e.g. meal preparation, shopping, cheque writing, housekeeping, etc) are necessary tasks of everyday life and must be relearned and adapted to a patient’s needs. These skills are often reacquired with the help of occupational therapists.

…….THANK YOU