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