Download MBBS Physical Medicine and Rehabilitation Presentations 1 Acute Spinal Cord Injury Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Physical Medicine and Rehabilitation 1 Acute Spinal Cord Injury PPT-Powerpoint Presentations and lecture notes


Acute Spinal Cord Injury

? Every slide has 4 to 5 statements.
? Out of these 1 statement is false
? Identify it
1. SCI is a devastating life threatening event.

2. Currently 2,25000-2,28000 individuals living

in U.S. with sequelae of SCI including

permanent paralysis.

3. Male: female- 1:4

4. Age: 16-30 yrs majority

Leading causes-

1. motor vehicle accidents- 47.5%
2. sports-22.9%
3. violance-13.8%
4. Falls- 8.9%
1. Acute SCI: complex, multifaceted .

2. Mechanical trauma cause direct neuronal

damage

3. However a smal no. of axons are lost as a

result of secondary pathophysiological events

- hypo perfusion, ischemia, and

biochemical and inflammatory changes

4. Salvaging as little as 10% of adult axons can

makes walking a potential goal.

Common Injuries


C-Spine Flexion Injury

1. Occurs during Cervical flexion with axial

loading

2. C5- least commonly injured
3. Anterior wedging +/-
4. retropulsion of bony fragments
into spinal canal is present

Cervical - Facet dislocations

? Unilateral
1. Occurs in Flexion/rotation injury, C5-C6 is

most common

2. More likely to be complete
? Bilateral
1. Occurs in Flexion injury, C5-C6 is most

common

2. More likely to be complete


Cervical hyperextension injury

1. Occurs in Acceleration-deceleration injury
2. Due to Falls, MVCs
3. C4-C5 most common involvement
4. Do not Often results in a central
cord syndrome

Jefferson Fracture

1. It is C1 burst fracture
2. Usually UNSTABLE with no neuro findings
3. Due to Axial loading of atlas
4. Common in contact sports


Hangman Fracture

1. C1 burst fracture
2. Bilateral fracture from deceleration injury
3. Common in Head hitting windshield
4. Mostly stable

Chance Fracture

1. It is T12-L2 transverse fracture through

posterior elements and vertebral body

2. Common in lap belt injury
3. Caused by Hyperextension
of thorax
4. Degree of injury depends on
movement of bony elements
Management at Injury Site

Critical factors in recovery:

1. Late pre hospital recognition of injury
2. Prompt resuscitation
3. Stabilization of injury
4. Avoidance of additional neurological injury

and medical complications.
Prehospital management

- 3 to 25 percent of SCIs occur after the initial

traumatic insult, either during transit or early in

the course of treatment.

- Four responsibilities of prehospital(infield) care

are:

1. initial evaluation

2. adequate resuscitation

3. mobilization of the suspected fractured area

4. safe extrication, and transportation

Initial Evaluation

Steps of Trauma PRIMARY SURVEY are:

1. Airway maintenance with cervical spine control;

2. Breathing and ventilation management;

3. Circulation with hemorrhage control;

4. Disability (neurological status) limitation

5. Exposure/Environmental control (covering the

patient while preventing hyper- or hypothermia)
Evaluation

? Secondary survey includes:

1. a detailed Head to toe evaluation

2. Quick motor examination : grip strength & a foot

dorsiflexion evaluation

3. Gross sensory examination.

4. Signs of incontinence, urinary retention, priapism, or loss

of anal sphincter tone are usually not found in SCI.

1. All evaluations must take place in full spinal

immobilization

2. In an unconscious patient assume that cervical spine is

injured until radiography of its entire length prove

otherwise.

3. Even in the absence of any of the clinical findings, the

patient must be placed in a rigid collar and backboard

and immobilize for transport.

4. Resuscitation begins after the secondary survey
IMMOBILIZATION

1. All major trauma victims must be immobilized

2. Patients complaining of neck pain or

neurological symptoms must be immobilized

3. Any patient with altered mental status of

uncertain cause must be immobilized.

4. Flexed position of spine is critical to prevent any

further damage to the cord.

Immobilization

1. Secure the neck first by

a cervical collar.

2. When removing a

patient from a seated

position, a cervical

collar is first placed on

the patient.

3. Immobilize the entire

spine using a soft board.


Extrication and Transportation

1. After proper immobilization, a safest

method of extrication and transportation

should be adopted.

2. After proper immobilization, a fastest

method of extrication and transportation

should be adopted.

3. Minimum Three persons are required

during extrication

4. Scoop stretcher & Kendric extrication

devices(KED) are used for extrication


Scoop stretcher & KED

Patient on vacuumed mattresses
Goals of Medical Management in a

hospital:

1. Normalize vital signs.
2. Minimizing the neurological damage caused

during the primary injury

3. Prevent aspiration
4. Preventing further cord injury secondary to

hypo perfusion, ischemia, and biochemical

and inflammatory changes

Management in Hospital
Spinal Stability- neurological and

mechanical:

? Neurologic stability denotes a state in

which, under the stresses that are

imposed, no further neural damage is

caused.

? Mechanical stability refers to the relative

motion of vertebral segments under the

physiologic loads of everyday activity.

Spinal Stability

1. To assess mechanical

stability: Dennis' 3 column

theory used.

2. A column can be disrupted

by either fracture or

ligamentous disruption.

3. Disruption of three or more

columns imparts instability.

4. Flexion & Extension X-ray

films are done in conscious

patients with no neurological

deficits.


Imaging:

? Computerized tomography (CT):

1. provides highly detailed axial images of each

vertebral segment

2. inferior to MRI for delineating fractures.

3. can demonstrate nondisplaced fractures not

discernible on plain x-ray.

4. an excellent method for evaluating and

quantifying the degree of spinal canal

compromise.

Imaging

? MRI:

1. Modality of choice for

evaluating the spinal cord

and neural elements.

2. Can reveal edematous soft

tissues, in either the

anterior or posterior

cervical spine.

3. Do not offer information

regarding the integrity of

the ligamentous structures

4. Can detect presence of

herniated disc material in

the spinal canal or

foramina
Closed Reduction and Immobilization

1. Most mechanically stable thoracolumbar

injuries without neurologic deficit can be

treated nonoperatively

2. Nonoperative treatment should not be

considered in stable injury patterns with

limited potential for progressive deformity and

neurologic compromise.

Operative Treatment

? The indications for surgical intervention of

spinal cord injuries depend on

1. pattern of injury.
2. alignment and stability of the vertebral

fracture.

3. neurologic status of the patient.
4. overall medical condition of the patient do

not affect decision


SURGICAL Management:

1. decompress the neural elements by

anterior decompression or Posterior

decompression

T

2. spine stabilized by instrumentation.
3. spinal orthosis- for 1 month.

TREATMENT MODALITIES

METHYLPREDNISOLONE-

1. stabilize membranes, inhibit lipid peroxidation,

suppress vasogenic edema by restoring the blood-

central nervous system (CNS) barrier

2. enhance the spinal cord blood flow, inhibit

pituitary endorphin release, and attenuate the

inflammatory response.

3. Timing of steroid therapy is critical in its ultimate

efficacy (8-72 hrs)

4. recommended for penetrating SCI.
PREVENTION &TREATMENT OF

COMPLICATIONS

1. SCI is followed by a series of detrimental

hemodynamic and biochemical processes

2. that cannot be prevented by early and

aggressive medical management

Cardiovascular picture following SCI:

1. Spinal shock - loss or depression of all or most

spinal reflex activity below the level of the

injury

2. Hypotension- common in lower level of injury,

caused by a withdrawal of sympathetic tone.

3. Neurogenic shock - The vasodilatation,

hypotension, decreased peripheral vascular

resistance (PVR), decreased preload, and

bradycardia.
Deep Venous Thrombosis: Prevention and

Treatment

? Causes:
1. Immobility
2. vascular dilatation and stasis
3. epithelial damage, and
4. an increase in the level of factor VI I and

fibrinogen.

1. Incidence of DVT during acute inpatient stay:

13.6 %.

2. pneumatic devices are applied to the lower

extremities for the first 2 weeks after the

injury.

3. If thromboprophylaxis is delayed for more

than 72 hours, venous doppler to screen for

thrombi formation prior to application of

above devices are usually not required
Deep Venous Thrombosis: Prevention and

Treatment

1. Anticoagulant prophylaxis with LMWH are

initiated after 72 hours

2. It is continued until discharge in patients with

incomplete injury.

3. for 8 weeks in patients with uncomplicated

complete injury.

4. for 12 weeks or until discharge from

rehabilitation in Complicated Complete injury.

AUTONOMIC DYSREFLEXIA

1. Occurs at Neurological level-T6 and above
2. Characterized by abrupt onset of malignant

hypertension & bradycardia

3. Caused by any noxious stimulus
4. Only treatment possible is to give Nifedipine

& nitrates

5. Treatment is to Identify & treat noxious

stimulus
Respiratory Management

1. Complete SCI with neurological level C4- ventilator

dependent

2. C3 injuries- borderline

3. C2 and above- ventilator dependent

4. Primary Goal- Recruiting and maintaining aeration of

alveoli thereby preventing atelectasis and pneumonia.

Atelectasis & pneumonia:

1. Occur 40-70% of tetraplegics
2. Most commonly occurs in the first 5 to 7 days
3. Often focused primarily in the left upper lobe
4. Chest percussions, postural drainage, assistive

coughing, Intermittent positive pressure

breathing, Bronchodilators & mucolytic

agents(guaifenesin) are used for treatment
Gastrointestinal Care

1. During spinal shock: gastric dilatation and paralytic

ileus leads to distended stomach vomiting and

aspiration.

2. nasogastric tube is used for distended stomach

3. Stress ulcers are rare occurring in the acute phase

following SCI

4. Prophylactic therapy with H2 blockers should be

instituted for stress ulcers

5. Bowel management program should be established

once normal bowel sounds and motility are restored.

Bladder Care

1. During spinal shock: bladder distension leads to

urinary reflux which can result in renal failure

2. A Foley's catheter should be inserted at admission.
3. During subacute phase of injury, use of Clean

Intermittent Catheterization (CIC) increases the risk of

bacterial infections.
1. The most frequent secondary medical complication

reported during the acute care of SCI patients is

urinary tract infection.

2. Symptomatic UTI should be treated with

appropriate antibiotics for 7 to 14 days.

3. Asymptomatic bacteriuria should be treated

routinely

Skin Care

1. Pressure ulcers are a devastatating

complication of SCI (40%)

2. Posture change is required every 2 hourly.

3. Special y designed foam/air mattresses can

reduce the pressure over bony prominences,

but wil not obviate the need for turning.

4. Adequate nutrition is not important for

pressure ulcer healing

5. Enteral rather than parenteral nutrition is

preferred once patient stabilized
Ambulatory training

Tilt Table
Strengthening of UL & Trunk

Standing balance
Orthotic support

Robotic-assisted Gait Training

(Lokomat)
Robotic-assisted Upper Limb

Training (ARMEO)

THANKS

This post was last modified on 08 April 2022