Management of
spinal cord injury
(SCI)
Dr FUAD HANIF SpS M Kes
Outline
Overview Diagnosis
Causes Neurological
Type assessment and
classification
Pathophysiology
Management
Key terms
Clinical References
syndromes
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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.
Most common vertebrae
involved are C5, C6, C7, T12,
and L1 because they have the
greatest ROM
Epidemiology
Spinal Cord Injury
• Incidence: 10000-12000/ yr
• 80-85% males (usually 16-30 y/o), 15-
20% female
• 50% of SCI’s are complete
• 50-60% of SCI’s are cervical
• Immediate mortality for complete
cervical SCI ~ 50%
Mechanism of Injury
• High energy trauma such as an MVA or fall from a
height or a horse.
MVC : Motor vehicular crashes
GSW : Gunshot wound
– MVA: 40-55%
– Falls: 20-30%
– Sports: 6-12%
– Others: 12-21%
• Low energy trauma in a high risk patient (ie a patient
with known spinal canal compromise such as ankylosing
spondylitis, Osteoporosis or metatstatic vertebral lesions)
• Penetrating trauma from gunshot or knives.
Spinal Cord Injury
epidemiology
– Cause
• MVC 42% – Level of Education
• Fall 20% • To 8th Grade: 10%
• GSW 16% • 9th to 11th: 26%
– Gender • High School: 48%
• Male 81% • College: 16%
• Female 19%
MVC : Motor vehicular crashes
GSW : Gunshot wound
Etiology of SCI by Age
Vehicular kendaraan lalu lintas
Violence kekerasan
Fall jatuh
Source: National Spinal Cord Injury Statistical Center,
University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
Employment Status
Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004 employed karyawan
Percent Employed
Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
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.
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.
Key terms used in SCI
• Dermatome The area sensory nerve
root.
• Myotome muscles motor nerve root.
Neurological Level of Injury segment
of the spinal cord with normal motor
and sensory function on both sides.
Skeletal Level The radiographic level
Key terms used in SCI
Sacral sparing
• motor function (voluntary
external anal sphincter
contraction)
• sensory function (light touch,
pinprick at S4/5 dermatome, or
anal sensation on rectal
examination)
Definitions
Spinal shock:
• transient flaccid paralysis
• areflexia (including bulbocavernosus reflex)
• while present (usually <48 h), unable to predict
potential for neurological recovery.
Neurogenic Shock:
• Loss of sympathetic tone, vasomotor and
cardiac regulation.
• Hypotension with relative bradycardia.
Classification
Complete
• absence of sensory & motor function in lowest
sacral segment after resolution of spinal shock
Incomplete
• presence of sensory & motor function in lowest
sacral segment (indicates preserved function
below the defined neurological level)
Classification
Incomplete SCI syndromes
Central Cord Syndrome
• Motor loss UE>LE
• Hands affected
• Common in elderly w/
pre-existing spondylosis
and cervical stenosis.
• Substantial recovery can
be expected.
Classification
Incomplete SCI syndromes
Brown Sequard
• Ipsilateral motor,
proprioception loss.
• Contralateral pain,
temperature loss.
• Penetrating injuries.
• Good prognosis for
ambulation.
Classification
Incomplete SCI syndromes
Anterior Cord Syndrome
• Motor loss
• Vibration/position
spared
• Flexion injuries
• Poor prognosis for
recovery
Classification
Incomplete SCI syndromes
Posterior Cord
Syndrome
• Profound sensory
loss.
• Pain/temperature less
affected.
• Rare.
Classification
Other SCI syndromes
Conus Medullaris Syndrome
• Loss of bowel or bladder function
• Saddle anaesthesia
• Looks like cauda equina
• Skeletal injuries T11-L2
Level of Cord Injury
determines level of function
Prognosis for Recovery
of spinal Cord Injury:
Poor prognosis for recovery if:
-pt arrives in shock
-pt cannot breath
-pt has a complete injury
Neurologic Examination
• American Spinal Injury Association (ASIA)
– A = Complete – No Sacral Motor / Sensory
– B = Incomplete – Sacral sensory sparing
– C = Incomplete – Motor Sparing (<3)
– D = Incomplete – Motor Sparing (>3)
– E = Normal Motor & Sensory
ASIA Sensory Exam
– 28 sensory “points” (within dermatomes)
– Test light touch & pin-prick pain
**Importance of sacral pin testing**
– 3 point scale (0,1,2)
– “optional”: proprioception & deep pressure to
index and great toe (“present vs absent”)
– deep anal sensation recorded “present vs absent”
Motor Examination
• 10 “key” muscles (5 upper & 5 lower extremity)
C5-elbow flexion L2-hip flexion
C6-wrist extension L3-knee extension
C7-elbow extension L4-ankle dorsiflexion
C8-finger flexion L5-toe extension
T1-finger abduction S1-ankle PF
– Sacral exam: voluntary anal contraction (present/absent)
Motor Grading Scale
• 6 point scale (0-5) …..(avoid +/-’s)
– 0 = no active movement
– 1 = muscle contraction
– 2 = active movement without gravity
– 3 = movement thru ROM against gravity
– 4 = movement against some resistance
– 5 = movement against full resistance
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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Management
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.
Airway
Breathing
Circulation
Disability
Expose
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Medical management
High 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.
Neurological/orthopedic management
includes methods a surgeon may use to
treat unstable spinal cord injuries:
Reduction
Fixation
Fusion
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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
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National Acute Spinal Cord
Injury Studies
NASCIS II NASCIS III
• 10 hospitals, 487 patients • 16 hospitals, 499 patients
• Compared: • 3 treatment arms (all got MPSS
MPSS (30 mg/kg bolus + 5.4 mg/kg x bolus)
23°) MPSS 5.4 mg/kg 24 hrs
Naloxone (5.4 mg/kg bolus + MPSS 5.4 mg/kg 48 hrs
4.5mg/kg x 23°) Tirilazad 2.5 mg/kg Q6 hr for 48 hrs
Placebo • 48 hr protocol better than 24 hr
• 8 hours, steroids neurologic protocol (if treated between 3 and 8
improvement hours)
• Infections, PE but not • 2x incidence of pneumonia, sepsis in
48 hr group (NS)
significant
Bracken, N Engl J Med, 1990 Bracken, JAMA, 1997
Bracken, N Engl J Med, 1992 Bracken, J Neurosurg, 1998
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