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SPINAL CORD INJURIES SURGERY ON THE CERVICAL SPINE Dr. Umakanth Dr. Prabhu Moderator : Prof. Rajeshwari.

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Presentation on theme: "SPINAL CORD INJURIES SURGERY ON THE CERVICAL SPINE Dr. Umakanth Dr. Prabhu Moderator : Prof. Rajeshwari."— Presentation transcript:

1 SPINAL CORD INJURIES SURGERY ON THE CERVICAL SPINE Dr. Umakanth Dr. Prabhu Moderator : Prof. Rajeshwari

2 Introduction Anaesthesiologist  Resuscitation + management of trauma victims High index of suspicion Evaluation of C-spine Understanding the pathophysiology of SCI Evaluating the risks and benefts of various airway appliances


4 Epidemiology Age 15-35 years and >65 years (peak incidence) C.spine injuries- 1.8% of all trauma cases 20% more than one cervical spine fracture 20-70% unstable 30-70% associated neurological injury 3-25% of SCI are iatrogenic i.e. during field stabilization, transit or early management

5 Causes Motor vehicle accidents50% Fall20% Sports15% Acts of violence15% Waters et al, spinal cord 1996

6 Mechanisms Hyper flexion Hyperextension Compression Rotation Combined

7 Hyper flexion Compression, subluxation or fracture dislocation Disruption of posterior longitudinal ligament (PLL)

8 Hyperextension Result from frontal / facial trauma Most common in cervical region Reduce AP diameter of spinal canal Disruption of anterior longitudinal ligament (ALL) Damage to vertebral arteries

9 Compression Result from forces containing axial load Wedge compression and burst fracture Serious damage due to retropulsion of bone Most common in thoracolumbar region

10 Rotation All parts of vertebral body and disc ‘Locked facets’- due to flexion rotation Most often seen in C5-C7

11 Combined Mainly cervical region Whiplash injury –Rapid acceleration – decelaration forces  extreme extension followed by flexion

12 Pathophysiology Primary insult : direct injury Secondary insult: inflammation, edema, microhemorrhages,and diminished capillary blood flow to spinal cord at risk. -free radicals -vascular mechanism -apoptosis

13 Pathophysiology

14 Management of SCI Goals - To suspect C-spine injury -To look for clinical pointers –Protect spinal cord from further injury –Indicators for securing airway –Ensure hemodynamic stability –Neuroprotection –Attention to other injuries (thoracic, faciomaxillary )

15 NEXUS criteria No midline cervical tenderness. No focal neurological deficit Normal alertness. No intoxication. No painful distracting injury.

16 Maintain immobilisation and proceed with cervical x rays Films adequate Not adequate (C1 –T1 Visible) Consider repeating exam with swimmers and oblique view or CT Scan Normal Abnormality C-spine cleared Maintain cervical immobiolisation and get CT Scan

17 Immobilization method No gold standard Soft collar Hard collar Short boards MILS

18 Soft collar Allows 96% of flexion, 73% of extension

19 Hard collar Allows 72-73% of normal flexion and extension

20 Short boards Reduce movement in all planes Good results if combined with hard collar in prehospital settings


22 Method C-spine motion Intubation difficulty Time required Rigid collar0  - MILS  0-  Axial traction  --

23 Radiological assessment Normal C-spine anatomy Choice –Lateral, AP, open mouth- C-spine X-rays –Combined plain film + CT 99% to 100% sensitivity –MRI very sensitive for soft tissue and spinal cord

24 Normal lateral C-spine

25 Alignment


27 Predental space

28 Prevertebral soft tissue


30 AP view


32 Odontoid view


34 SUMMARY Adequacy- C1 to T1 visible Pseudosubluxation? Look for any widening of spaces and indices Spinal cord injury without radiographic abnormality: “SCIWORA”

35 Airway management Indication for securing airway –? Apnoea –? GCS <9/sustained seizure activity –? Unstable midface trauma –? Airway injuries –? Large flail segment or respiratory failure –? High aspiration risk –? Inability to otherwise maintain an airway or oxygenation


37 Clinical Predictors of Difficult Airway

38 Airway management (contd…) Goal: Tracheal intubation without causing further injury to spinal cord Method depends on –Patient’s condition –Level of cooperation –Skill of anaesthesiologist

39 Airway management (contd…) Effect of immobilization technique on DL –“We cannot stabilize the neck without impairing the laryngeal view”

40 ASA (2003) algorithm for C-spine injury

41 Failed intubation:Alternative techniques LMA Combitube Cricothyroidectomy

42 FOB Technique of choice in awake cooperative patient Some authors recommend FOB even as initial intubation choice with 100% success rate. Some emphasize its limitations -technical difficulty -success rate only 73% in ED. Bullard laryngosope vs FOB

43 Airway management techniques and their effect on C-spine

44 Acute phase (4-6 weeks) Spinal shock Flaccid paralysis of muscles Loss of sympathetic tone Hypo reflexia Urinary retention

45 Acute phase (4-6 weeks) Management Treat associated life threatening conditions –Tension pneumothorax –Chest / pelvic/ orthopedic injuries Treatment of hypotension Pharmacological neuroprotection

46 Steroids Suspected/ known blunt injury of spinal cord Methyl prednisolone. Dose: 30mg/kg over 15 min followed by infusion of 5.4mg/kg/hr for 24 – 48 hrs. Started within 8 hrs of injury. Contra indications: -penetrating injury -cauda equina syndrome

47 Patient coming in chronic phase After recovery from spinal shock Concerns –Autonomic hyperreflexia –Supersensitivity of cholinergic receptors Autonomic hyper-reflexia –Chronic spinal cord lesion above T6 –85% of patients have this at some time during the course of living –Uncontrolled reflex arc below the level of lesion

48 Supersensitivity Denervation Cholinergic receptor proliferation beyond the motor end plate Muscle contracts for a minimal Ach (10 -4 to 10 -5 ) K+ released suddenly along entire length of muscle fibre Sch –4 to 10 meq/L increase in K+ –Duration of supersensitivity: From 1 week upto 6 months to 2 years So Sch is safe in the first days of paraplegia, avoid it after 3 rd or 4 th day

49 References 1.Rogers LF. Fractures and dislocations of the spine. In: Garfin’s Spine Trauma? Jefferson’s Series, 2006. 2.Jefferson G. Discussion on spinal injuries. Proc R Soc Med 1927;21:625–628. 3.Lali HS, Sehko MB, Fehlings MG. Epidemiology, demographics,and pathophysiology of acute spinal cord injury.Spine 2001; 26:S2–S12.

50 4. Vale, FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess merits of aggressive medical resusitation and blood pressure measurement. J Neurosurg1997; 87:239–246. 5.Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343:94–99[Erratum, N Engl J Med 2001; 344:464]

51 6. A.U.Ghafoor et al,Caring for the patients with cervical spine injuries: what we have learned? Jounal of clin anesthesia (2005) 17, 640-649. 7. Grande CM, Stene JK. Anesthesia for trauma. In: Miller RD, ed.Anesthesia. Philadelphia, Churchill Livingstone. 1994:2164. 8. Wilson WC. Trauma: airway management. ASA Difficult Airway Algorithm Modified for Trauma—and Five Common Trauma Intubation Scenarios. ASA Newsletter 2005; 69(11):10.

52 9. ASA Task Force: Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2003; 98(5):1269–1277. 10. Segal JL, Brunnemann SR.Clinical pharmacokinetics in patients with spinal cord injuries.Clin pharmacokinet: 17:109-29. 1989 11. Konishi A, Sakai T, Nishiyama T etal.Cervical spine movement during orotracheal intubation using McCoy laryngoscope compared with the Macintosh and Miller Laryngoscope.Masui 46:124-7, 1997.

53 12. Hasting RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology 80:825-831, 1994. 13. Fitzgerald RD etal.Excursion of the cervical spine during tracheal intubation: blind oral intubation compared with direct laryngoscopy.Anesthesia 49:111- 115,1994 14.Cohn AI, Zornow MH: Awake endotracheal intubation in patients with cervical spine disease: a comparison of the Bullard laryngoscope and fiberoptic bronchoscope.Anesth Analg 81:1283-1286, 1995.

54 15. Crosby Et, Lui A: The adult cervical Spine: implication for airway management.Can J Anaesth 37:77-93, 1990. 16. Saha AK et al: Comarision of awake endotracheal intubation in patients with cervical spine disease: The lighted intubating stylet vs.Fibreoptic bronchoscope.Anesth Analg 87:477-479,1998. 17. Hastings RH et al.Cervical spine movement during laryngoscopy with the Bullard, Macintosh, and Miller laryngoscope. Anesthesiology 82:859-869, 1995.

55 18.Wangeman BU, Jantzen JP. Fibreoptic intubation of neurosurgical patients. Neurochirurgia (Stuttg) 1993;36:117-22. 19.Ovassapian A, Dykes M. The role of fibreoptic endoscopy in airway management. Semin Anesth 1987;6:93-104. 20.Mlinek EJ et al. Fiberoptic intubation in emergency department. Ann Emerg Med 1990;19:359-62.

56 21. Afialo M et al. Fiberoptic intubation in the emergency department: A case series. J Emerg Med 1993;11:387-91.

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