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

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? Identify it
1. SCI is a devastating life threatening event.

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

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in U.S. with sequelae of SCI including

permanent paralysis.

3. Male: female- 1:4

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4. Age: 16-30 yrs majority

Leading causes-

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

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2. Mechanical trauma cause direct neuronal

damage

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

result of secondary pathophysiological events

- hypo perfusion, ischemia, and

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biochemical and inflammatory changes

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

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makes walking a potential goal.

Common Injuries

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C-Spine Flexion Injury

1. Occurs during Cervical flexion with axial

loading

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

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Cervical - Facet dislocations

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

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most common

2. More likely to be complete
? Bilateral

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1. Occurs in Flexion injury, C5-C6 is most

common

2. More likely to be complete

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Cervical hyperextension injury

1. Occurs in Acceleration-deceleration injury

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

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Jefferson Fracture

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

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4. Common in contact sports


Hangman Fracture

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

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Chance Fracture

1. It is T12-L2 transverse fracture through

posterior elements and vertebral body

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2. Common in lap belt injury
3. Caused by Hyperextension
of thorax
4. Degree of injury depends on

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movement of bony elements
Management at Injury Site

Critical factors in recovery:

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

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and medical complications.
Prehospital management

- 3 to 25 percent of SCIs occur after the initial

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traumatic insult, either during transit or early in

the course of treatment.

- Four responsibilities of prehospital(infield) care

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are:

1. initial evaluation

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2. adequate resuscitation

3. mobilization of the suspected fractured area

4. safe extrication, and transportation

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Initial Evaluation

Steps of Trauma PRIMARY SURVEY are:

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1. Airway maintenance with cervical spine control;

2. Breathing and ventilation management;

3. Circulation with hemorrhage control;

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4. Disability (neurological status) limitation

5. Exposure/Environmental control (covering the

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patient while preventing hyper- or hypothermia)
Evaluation

? Secondary survey includes:

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1. a detailed Head to toe evaluation

2. Quick motor examination : grip strength & a foot

dorsiflexion evaluation

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3. Gross sensory examination.

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

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of anal sphincter tone are usually not found in SCI.

1. All evaluations must take place in full spinal

immobilization

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2. In an unconscious patient assume that cervical spine is

injured until radiography of its entire length prove

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otherwise.

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

patient must be placed in a rigid collar and backboard

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and immobilize for transport.

4. Resuscitation begins after the secondary survey
IMMOBILIZATION

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1. All major trauma victims must be immobilized

2. Patients complaining of neck pain or

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neurological symptoms must be immobilized

3. Any patient with altered mental status of

uncertain cause must be immobilized.

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4. Flexed position of spine is critical to prevent any

further damage to the cord.

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Immobilization

1. Secure the neck first by

a cervical collar.

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2. When removing a

patient from a seated

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position, a cervical

collar is first placed on

the patient.

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3. Immobilize the entire

spine using a soft board.

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Extrication and Transportation

1. After proper immobilization, a safest

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method of extrication and transportation

should be adopted.

2. After proper immobilization, a fastest

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method of extrication and transportation

should be adopted.

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3. Minimum Three persons are required

during extrication

4. Scoop stretcher & Kendric extrication

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devices(KED) are used for extrication


Scoop stretcher & KED

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Patient on vacuumed mattresses
Goals of Medical Management in a

hospital:

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

during the primary injury

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

hypo perfusion, ischemia, and biochemical

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and inflammatory changes

Management in Hospital
Spinal Stability- neurological and

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mechanical:

? Neurologic stability denotes a state in

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which, under the stresses that are

imposed, no further neural damage is

caused.

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? Mechanical stability refers to the relative

motion of vertebral segments under the

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physiologic loads of everyday activity.

Spinal Stability

1. To assess mechanical

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stability: Dennis' 3 column

theory used.

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2. A column can be disrupted

by either fracture or

ligamentous disruption.

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3. Disruption of three or more

columns imparts instability.

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4. Flexion & Extension X-ray

films are done in conscious

patients with no neurological

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deficits.


Imaging:

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? Computerized tomography (CT):

1. provides highly detailed axial images of each

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vertebral segment

2. inferior to MRI for delineating fractures.

3. can demonstrate nondisplaced fractures not

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discernible on plain x-ray.

4. an excellent method for evaluating and

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quantifying the degree of spinal canal

compromise.

Imaging

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? MRI:

1. Modality of choice for

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evaluating the spinal cord

and neural elements.

2. Can reveal edematous soft

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tissues, in either the

anterior or posterior

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cervical spine.

3. Do not offer information

regarding the integrity of

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the ligamentous structures

4. Can detect presence of

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herniated disc material in

the spinal canal or

foramina

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Closed Reduction and Immobilization

1. Most mechanically stable thoracolumbar

injuries without neurologic deficit can be

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treated nonoperatively

2. Nonoperative treatment should not be

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considered in stable injury patterns with

limited potential for progressive deformity and

neurologic compromise.

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Operative Treatment

? The indications for surgical intervention of

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spinal cord injuries depend on

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

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fracture.

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

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not affect decision


SURGICAL Management:

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1. decompress the neural elements by

anterior decompression or Posterior

decompression

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T

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

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TREATMENT MODALITIES

METHYLPREDNISOLONE-

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1. stabilize membranes, inhibit lipid peroxidation,

suppress vasogenic edema by restoring the blood-

central nervous system (CNS) barrier

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2. enhance the spinal cord blood flow, inhibit

pituitary endorphin release, and attenuate the

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inflammatory response.

3. Timing of steroid therapy is critical in its ultimate

efficacy (8-72 hrs)

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4. recommended for penetrating SCI.
PREVENTION &TREATMENT OF

COMPLICATIONS

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1. SCI is followed by a series of detrimental

hemodynamic and biochemical processes

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2. that cannot be prevented by early and

aggressive medical management

Cardiovascular picture following SCI:

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

spinal reflex activity below the level of the

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injury

2. Hypotension- common in lower level of injury,

caused by a withdrawal of sympathetic tone.

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3. Neurogenic shock - The vasodilatation,

hypotension, decreased peripheral vascular

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resistance (PVR), decreased preload, and

bradycardia.
Deep Venous Thrombosis: Prevention and

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Treatment

? Causes:
1. Immobility
2. vascular dilatation and stasis

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3. epithelial damage, and
4. an increase in the level of factor VI I and

fibrinogen.

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1. Incidence of DVT during acute inpatient stay:

13.6 %.

2. pneumatic devices are applied to the lower

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extremities for the first 2 weeks after the

injury.

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3. If thromboprophylaxis is delayed for more

than 72 hours, venous doppler to screen for

thrombi formation prior to application of

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

Treatment

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1. Anticoagulant prophylaxis with LMWH are

initiated after 72 hours

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2. It is continued until discharge in patients with

incomplete injury.

3. for 8 weeks in patients with uncomplicated

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complete injury.

4. for 12 weeks or until discharge from

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rehabilitation in Complicated Complete injury.

AUTONOMIC DYSREFLEXIA

1. Occurs at Neurological level-T6 and above

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2. Characterized by abrupt onset of malignant

hypertension & bradycardia

3. Caused by any noxious stimulus

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4. Only treatment possible is to give Nifedipine

& nitrates

5. Treatment is to Identify & treat noxious

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stimulus
Respiratory Management

1. Complete SCI with neurological level C4- ventilator

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dependent

2. C3 injuries- borderline

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3. C2 and above- ventilator dependent

4. Primary Goal- Recruiting and maintaining aeration of

alveoli thereby preventing atelectasis and pneumonia.

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Atelectasis & pneumonia:

1. Occur 40-70% of tetraplegics
2. Most commonly occurs in the first 5 to 7 days

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3. Often focused primarily in the left upper lobe
4. Chest percussions, postural drainage, assistive

coughing, Intermittent positive pressure

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breathing, Bronchodilators & mucolytic

agents(guaifenesin) are used for treatment
Gastrointestinal Care

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1. During spinal shock: gastric dilatation and paralytic

ileus leads to distended stomach vomiting and

aspiration.

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2. nasogastric tube is used for distended stomach

3. Stress ulcers are rare occurring in the acute phase

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following SCI

4. Prophylactic therapy with H2 blockers should be

instituted for stress ulcers

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5. Bowel management program should be established

once normal bowel sounds and motility are restored.

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Bladder Care

1. During spinal shock: bladder distension leads to

urinary reflux which can result in renal failure

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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

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bacterial infections.
1. The most frequent secondary medical complication

reported during the acute care of SCI patients is

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urinary tract infection.

2. Symptomatic UTI should be treated with

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appropriate antibiotics for 7 to 14 days.

3. Asymptomatic bacteriuria should be treated

routinely

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Skin Care

1. Pressure ulcers are a devastatating

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complication of SCI (40%)

2. Posture change is required every 2 hourly.

3. Special y designed foam/air mattresses can

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reduce the pressure over bony prominences,

but wil not obviate the need for turning.

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4. Adequate nutrition is not important for

pressure ulcer healing

5. Enteral rather than parenteral nutrition is

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preferred once patient stabilized
Ambulatory training

Tilt Table

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Strengthening of UL & Trunk

Standing balance
Orthotic support

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Robotic-assisted Gait Training

(Lokomat)
Robotic-assisted Upper Limb

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Training (ARMEO)

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