Presentation on theme: "Staff Neurosurgeon, Touro Infirmary and West Jefferson Medical Center"— Presentation transcript:
1Staff Neurosurgeon, Touro Infirmary and West Jefferson Medical Center Spinal Cord InjuriesGabriel C. Tender, MDAssistant Professor of Clinical Neurosurgery, Louisiana State University in New OrleansStaff Neurosurgeon, Touro Infirmary and West Jefferson Medical Center
3What is the anatomy of the spinal cord on cross section? On cross section; ascending (conveying information to the brain) and descending (conveying information from the brain) tracts.
4What is the anatomy of the spinal cord on cross section? On cross section; breathing and voiding.
5From a surgeon’s perspective, the layers to get to the spinal cord.
6From a surgeon’s perspective, the layers to get to the spinal cord.
7What are the clinically important ascending tracts and where do they cross over? Explain Brown Sequard if somebody stabs you in the Right hemicord: pain is abolished in the left leg (pin prick), fine touch is abolished in the right leg (light touch).
8What are the clinically important descending tracts and where do they cross over? Paralysis on the same side in Brown Sequard example (right leg)
9At what level does the spinal cord end and why is it important? Can a cauda equina syndrome give you complete paralysis of the legs? Only if it is at L2!
10What are the differences between UMN and LMN. (e. g. , cauda equina vs What are the differences between UMN and LMN? (e.g., cauda equina vs. myelopathy)
12Acute vs. chronic injuries; complete vs. incomplete injuries “Acute”=sudden onset of symptoms“Complete” ?
13What is a complete spinal cord injury? “Complete” = absence of sensory and motor function in the perianal area (S4-S5)
14Terminology Plegia = complete lesion Paresis = some muscle strength is preservedTetraplegia (or quadriplegia)Injury of the cervical spinal cordPatient can usually still move his arms using the segments above the injury (e.g., in a C7 injury, the patient can still flex his forearms, using the C5 segment)ParaplegiaInjury of the thoracic or lumbo-sacral cord, or cauda equinaHemiplegiaParalysis of one half of the bodyUsually in brain injuries (e.g., stroke)
18What are the important vegetative functions and when are they affected?
19Reflexes Deep Tendon Reflexes Pathological reflexes Arm Leg Bicipital: C5Styloradial: C6Tricipital: C7LegPatellar: L3, some L4Achilles: S1Pathological reflexesBabinski (UMN lesion)Hoffman (UMN lesion at or above cervical spinal cord)Clonus (plantar or patellar) (long standing UMN lesion)
20What is and how do you determine the level of injury? Motor level = the last level with at least 3/5 (against gravity) functionNB: this is the most important for clinical purposesSensory level = the last level with preserved sensationRadiographic level = the level of fracture on plain XRays / CT scan / MRINB: spine level does not correspond to spinal cord level below the cervical region
21Case scenario 25 y/o white male Fell off the roof (20 feet) Had to be intubated at the scene by EMSConsciousness regained shortly thereafterCould not move arms or legsCould close and open eyes to commandNot able to breathe by himself–totally dependent on mechanical ventilation
22High cervical injuries (C3 and above) Motor and sensory deficits involve the entire arms and legsDependent on mechanical ventilation for breathing (diaphragm is innervated by C3-C5 levels)
23Case scenario 19 y/o white male Diving accident (shallow water) No loss of consciousnessCould not understand why he could not move his legs, forearms and hands (he could shrug shoulders and elevate arms)BP 75/40, HR 54/’Had difficulties breathing and required intubation a few hours after the accident
24Midcervical injuries (C3-C5) Varying degrees of diaphragm dysfunctionUsually need ventilatory assistance in the acute phaseShock
25What is the difference between spinal shock and neurogenic shock? Spinal shock is mainly a loss of reflexes (flaccid paralysis)Neurogenic shock is mainly hypotension and bradycardia due to loss of sympathetic tone
26Neurogenic shock Seen in cervical injuries Due to interruption of the sympathetic input from hypothalamus to the cardiovascular centersHallmark: hypotension (due to vasodilation, due to loss of sympathetic tonic input) is associated with bradycardia (not tachycardia, the usual response), due to inability to convey the information to the vasomotor centers in the spinal cord
27Low cervical injuries (C6-T1) Usually able to breathe, although occasionally cord swelling can lead to temporary C3-C5 involvement (need mechanical ventilation)The level can be determined by physical exam
28So what do you expect with a cervical lesion? Quadriplegia or quadriparesisBowel/bladder retention (spastic)Various degrees of breathing difficultiesNeurogenic and/or spinal shock
29Case scenario 22 y/o Hispanic female Motor vehicle accident (hit a pole at 60mph)+ for ETOH and THCShort term loss of consciousness (10’)Not able to move or feel her legsDTRs 2+ in BUE, 0 in BLENo bladder / bowel control or sensationSensory level at the umbilicus
30Thoracic injuries (T2-L1) Paraparesis or paraplegiaUMN (upper motor neuron) signs
31Case scenario 22 y/o African-American female Motor vehicle accident Not able to move or feel her legs below the kneeCould flex thighs against gravityDTRs 2+ in BUE, 0 in BLENo bladder / bowel control or sensationSensory level above the knee on L, below the knee on R
32Cauda equina injuries (L2 or below) Paraparesis or paraplegiaLMN (lower motor neuron) signsThigh flexion is almost always preserved to some degree
33What is the difference between cauda equina and conus medullaris syndrome?
35What is the central cord syndrome? Cervical spinal cord involvement with arms more affected than legsMay occur with trauma, tumors, infections, etcTraumatic lesions tend to improve in 1-2 weeksSurgical decompression may be indicated if there is spinal stenosis
37Initial Management Immobilization Prevent hypotension Rigid collarSandbags and strapsSpine boardLog-roll to turnPrevent hypotensionPressors: Dopamine, not NeosynephrineFluids to replace losses; do not overhydrateMaintain oxygenationO2 per nasal canulaIf intubation is needed, do NOT move the neck
38Management in the hospital NGT to suctionPrevents aspirationDecompresses the abdomen (paralytic ileus is common in the first days)FoleyUrinary retention is commonMethylprednisolone (Solu-Medrol)Only if started within 8 hours of injuryExclusion criteriaCauda equina syndromeGSWPregnancyAge <13 yearsPatient on maintenance steroids
39CT scan Good in acute situations Shows bone very well Sagittal reconstruction is mandatorySoft tissues (discs, spinal cord) are poorly visualizedDo NOT give contrast in trauma patients (contrast is bright, mimicking blood)
40MRI Almost never an emergency Exception: cauda equina syndromeShows tumors and soft tissues (e.g., herniated discs) much better than CT scanMay be used to clear c-spine in comatose patients
41Lumbar Puncture Sedate the patient and make your life easier Measure opening pressure with legs straightAlways get head CT prior to LP to r/o increased ICP or brain tumor
42Cervical Spine Clearance Occiput to T1 need to be clearedER, Neurosurgery or Orthopedics physicianIf the patientIs awake and orientedHas no distracting injuriesHas no drugs on boardHas no neck painIs neurologically intactthen the c-spine can be cleared clinically, without any need for XRaysCT and/or MRI is necessary if the patient is comatose or has neck painSubluxation >3.5mm is usually unstable
43Cervical Traction Gardner-Wells tongs Provides temporary stability of the cervical spineContraindicated in unstable hyperextension injuriesWeight depends on the level (usually 5lb/level, start with 3lb/level, do not exceed 10lb/level)Cervical collar can be removed while patient is in tractionPin care: clean q shift with appropriate solution, then apply povidone-iodine ointmentTake XRays at regular intervals and after every move from bed
45Surgical Decompression and/or Fusion IndicationsDecompression of the neural elements (spinal cord/nerves)Stabilization of the bony elements (spine)TimingEmergentIncomplete lesions with progressive neurologic deficitElectiveComplete lesions (3-7 days post injury)Central cord syndrome (2-3 weeks post injury)