Presentation on theme: "SPINAL CORD INJURIES SURGERY ON THE CERVICAL SPINE Dr. Umakanth Dr. Prabhu Moderator : Prof. Rajeshwari."— Presentation transcript:
SPINAL CORD INJURIES SURGERY ON THE CERVICAL SPINE Dr. Umakanth Dr. Prabhu Moderator : Prof. Rajeshwari
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
Epidemiology Age 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
Causes Motor vehicle accidents50% Fall20% Sports15% Acts of violence15% Waters et al, spinal cord 1996
Hyper flexion Compression, subluxation or fracture dislocation Disruption of posterior longitudinal ligament (PLL)
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
Compression Result from forces containing axial load Wedge compression and burst fracture Serious damage due to retropulsion of bone Most common in thoracolumbar region
Rotation All parts of vertebral body and disc ‘Locked facets’- due to flexion rotation Most often seen in C5-C7
Combined Mainly cervical region Whiplash injury –Rapid acceleration – decelaration forces extreme extension followed by flexion
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
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 )
NEXUS criteria No midline cervical tenderness. No focal neurological deficit Normal alertness. No intoxication. No painful distracting injury.
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
Immobilization method No gold standard Soft collar Hard collar Short boards MILS
Soft collar Allows 96% of flexion, 73% of extension
Hard collar Allows 72-73% of normal flexion and extension
Short boards Reduce movement in all planes Good results if combined with hard collar in prehospital settings
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
Airway management techniques and their effect on C-spine
Acute phase (4-6 weeks) Spinal shock Flaccid paralysis of muscles Loss of sympathetic tone Hypo reflexia Urinary retention
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
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
Supersensitivity Denervation Cholinergic receptor proliferation beyond the motor end plate Muscle contracts for a minimal Ach (10 -4 to ) 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
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