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Spinal Cord Injury Sarah Crosby June 2010.

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Presentation on theme: "Spinal Cord Injury Sarah Crosby June 2010."— Presentation transcript:

1 Spinal Cord Injury Sarah Crosby June 2010

2 C-Spine

3 Epidemiology C-spine injuries occur in % of blunt trauma patients Co-existing head injury increases the incidence of C-spine injury to 10% Injury to the cervical spinal cord in the absence of fracture occurs in % of trauma admissions Missed or delayed diagnosis of cervical spine injury occurs in 4-8% Results in 10 x the incidence of secondary neurologic deficit compared to early diagnosis Of the patients with missed or delayed diagnosis most have decreased GCS, hypotension or critical injuries Obtunded patients unable to assist in demonstrating neurology Lifetime healthcare and living costs for a quadriplegic patient $ million AUD Spinal injuries are very common in the polytrauma population Therefore a thorough examination of the spinal column should always be methodically performed Inadequate immobilisation and unprotected movement of the spine may lead to additional neural injury and may worsen the outcome. 2 peaks of spinal fractures young men Elderly women Associated non-spinal injuries in 38% Overall mortality 4% Patients with delayed diagnosis were more

4 EAST Guidelines (Eastern Association for the Surgery of Trauma)
1998 guidelines for evaluation of c-spine injury in trauma patients 2009 update CT largely replacing plain x-rays Clinical clearance remains standard in awake, alert patients with no neurologic deficit, distracting injury, neck pain or tenderness Cervical collars should be removed ASAP Controversy still exists regarding cervical spine clearance in the obtunded patient Who needs imaging What imaging How to exclude significant ligamentous injury EAST (Eastern Association for the Surgery of Trauma) initially established guidelines for evaluation of cervical spine injury in 1998 - a 2009 update (systematic review of 78 articles- 52 articles used to construct the guideline) showed a significant change in practice, with CT largely replacing plain x-rays. - Clinical clearance remains the standard in awake, alert trauma patients without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion - Cervical collars should be removed as soon as feasible - CONTROVERSY PERSISTS REGARDING CERVICAL SPINE CLEARANCE IN THE OBTUNDED PATIENT WITHOUT GROSS NEUROLOGICAL DEFICIT. - Issues of concern: o Who needs C-spine imaging? o What imaging? (CT/MRI/Flexion Extension views) o How to exclude significant ligamentous injury in the comatose patient

5 Removal of Cervical Collars
As soon as feasible (Level III) Early removal is associated with: Decreased collar related pressure ulcers Skin breakdown 6.8% after 24h Decreased ICP Fewer ventilator days Fewer ICU and hospital days Decreased incidence of delerium and pneumonia Removal of Cervical Collars - Early removal of cervical collars is associated with: o Decreased collar-related decubitus ulceration o Decreased ICP o Fewer ventilator days o Fewer ICU and hospital days o Decrease in the incidence of delirium and pneumonia - Skin breakdown in 6.8% of ICU patients who remained in a collar for more than 24 hours - 9 out of 10 head injured patients have a rise in ICP after application of cervical collar

6 Penetrating Brain Injury
Immobilisation is not indicated unless the trajectory suggests direct injury to the cervical spine

7 Clinical Clearance of the C-spine in the awake patient
In awake, alert trauma patients without neurologic deficit or distracting injury, who have no neck pain or tenderness with full range of motion of the cervical spine, imaging is not necessary and the collar can be removed (Level II) Meta-analysis of clinical clearance of the asymptomatic C-spine (2010) GCS 14-15 No posterior cervical tenderness No neurological deficit No dangerous mechanism No distracting Injury Normal range of motion without pain or neurology Sensitivity 98.1% NPV 99.8% Clinical examination can still miss injuries (Duane J. Trauma (2007) Compared clinical examination to CT c-spine 12 out of 52 missed C-spine fractures from clinical examination alone (7 out of 17 awake alert patients GCS 15) Sensitivity 76.9% NPV95.7%

8 NEXUS Study Validated 5 Criteria for Low Probability of C-Spine Injury
(No imaging required if meet all criteria) No posterior midline C-spine tenderness No evidence of intoxication Normal level of alertness No focal neurologic deficit No painful distracting injury Long bone fracture, visceral injury requiring surgical consultation, large laceration, degloving injury, crush injury, large burns NEXUS (National Emergency X-Radiography Utilisation Study) 2000 NEJM 34,069 patients after blunt trauma - missed 8 of 818 patients with a radiologically identified c-spine injury (only 2 clinically significant injuries were missed- only 1 of these required surgical treatment) Sensitivity 99% Negative Predictive Value 99.8% Specificity 12.9% Positive Predictive Value 2.7% controversially if they could move their neck, even if there was pain then no imaging required Hoffman et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM 2000;343:94-99.

9 Canadian Cervical Spine Rule Study
1. Are there any high risk factors present that require imaging GCS 15 YES NO 2. Are there any low risk factors present to allow for safe assessment by using active range of motion NO Image C-Spine NO Canadian C-Spine Rule (CCR) 8924 adults with blunt trauma and GCS 15 Sensitivity 100% Specificity 42.5% Radiography rate 58.2% 3 High risk factors (have to be absent) - Age >65 years - Dangerous mechanism o High speed MVA >35mph o Crash with death at scene o Fall from height >10 ft o Closed head injury o Pelvic or multiple extremity fractures o Drowning or diving accident o Rigid vertebral disease - Paraesthesia in extremities 5 Low risk factors (allow safe assessment of range of motion) - Simple rear rend MVA - Sitting position in ED - Ambulatory at time - Delayed onset of neck pain - Absent midline cervical tenderness Able to actively rotate neck 45コ left and right YES 3. Can the patient actively rotate the neck 45º left and right No imaging of C-spine needed YES Stiell, I. et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:

10 Canadian Cervical Spine Rule Study
High risk factors that require imaging Age ≥65 yo Dangerous mechanism of injury Fall from 1m (5 stairs) Axial load to the head (eg. Diving) MVA- high speed (>100kph, rollover, ejection) Motorised recreational vehicles Bicycle collision Paraesthesia in extremities 2. Low risk factors that allow safe assesment of range of motion Sitting position in the emergency department or Simple rear end MVA or Ambulatory at any one time or Delayed onset of neck pain or Absence of midline C-spine tenderness If the patient can actively rotate the head 45 left and right (regardless of any pain) then no imaging of the C-spine is required

11 Clinical Clearance of the C-Spine in the Awake Patient
NEXUS Sensitivity 90.7% Specificity 36.8% Radiography Rate 55.9% CCR Sensitivity 99.4% Specificity 45.1% Radiography Rate 66.6% NEJM 2003 compared NEXUS to CCR and found CCR to be more sensitive and specific than NEXUS. 2% of 8283 patients had clinically significant C-spine injuries and the NEXUS criterial would have missed 10% of these Excluded indeterminant cases Stiell IG, et al. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. NEJM 2003;349:

12 Radiographic Examination of the C-Spine
Plain C-spine X-Rays 3-view (lateral, AP, odontoid) Supplemented by swimmers views and CT for poorly visualised areas CT C-Spine Occiput to T1 with saggital and coronal reconstruction More time efficient and cost-effective in moderate and high risk cases More accurate Sensitivity 98% (vs c-spine x-ray 52%) Radiographic Examination of the C-Spine Indicated for patients with: - pain or tenderness - neurological deficit - altered mental status - distracting injury - obtunded patients CT - minimally increases total imaging time (<20min) - more expensive but cost can be justified Holmes and Akkinepalli J. Trauma (2005) CT vs plain radiography to screen for cervical spine injury: A meta-analysis - pooled sensitivity for plain c-spine x-ray was 52% vs CT c-spine 98% CT C-spine found to be more time efficient and more cost-effective in moderate and high risk patients. CT c-spine must include axial images from the occiput to TI with sagittal and coronal reconstructions - more accurate - more time effective - more cost effective If a CT c-spine demonstrates an injury or if there is a neurological deficit referable to a C-spine injury, a spine consultation should be obtained.

13 Radiographic Examination of the C-Spine
Indicated for: Pain or tenderness in the neck Neurological deficit Altered mental status Distracting Injury The Primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions (Level II) Plain radiographs contribute no additional information and should not be obtained (Level II) If there is neurological deficit attributable to a c-spine injury an MRI should be obtained The primary screening modality is axial CT from occiput to T1 with sagittal and coronal reconstructions (Level II) Plain radiographs contribute no additional information and should not be obtained (Level II)

14 Neck Pain with negative CT in the neurologically intact patient
3 options (Level III) Continue collar Remove collar after negative MRI (<72h) Remove collar after negative and adequate flexion extension films Picks up c-spine instability in % of normal c-spine films Incidence of isolated ligamentous injury is rare (0.6% of traumatic c-spine injuries) Neck Pain with Negative CT C-Spine Options: 1. Can continue collar 2. Can remove collar after negative MRI (preferably within 72h of injury) 3. Can remove collar after negative and adequate flexion extension films. a. Need range of flexion and extension to be greater than 30コ from the neutral position to be adequate b. Ligamentous instability is confirmed if there is >3.5mm of intervertebral body motion or more than 11コ of relative angulation c. Abnormal F/E films pick up c-spine instability in % of patients with normal C-spine films d. NEXUS concluded that F/E imaging adds little to the acute evaluation of patients with blunt trauma e. Incidence of isolated ligamentous injury is rare (0.6% of traumatic c-spine injuries) f. Pre-vertebral soft tissue swelling on plain films or CT implies ligamentous injury

15 C-spine Clearance in the Obtunded Trauma Patient with a Negative CT C-Spine and no Gross Neurological Deficit EAST Recommendations 2009 Flexion/Extension radiographs should NOT be performed (Level II) The risk/benefit ratio of obtaining an MRI in addition to CT is not clear (individualise to each institution) (Level III) Options are: Continue cervical collar immobilisation until a clinical examination can be performed Remove the cervical collar on the basis of CT alone Obtain an MRI and if negative the collar can be safely removed (Level II) o For the obtunded patient with a negative CT and gross motor function of extremities: ァ Flexion/Extension radiographs should NOT be performed (Level II) ァ The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its use must be individualised to each institution (Level III). Options are: キ Continue cervical collar immobilisation until a clinical exam can be performed キ Remove the cervical collar on the basis of CT alone キ Obtain a MRI and if negative the collar can be safely removed (Level II)

16 ? MRI in addition to CT? Incidence of ligamentous injury with negative CT c-spine is very low (<5%) Incidence of clinically significant injury is even lower (<1%) Expensive Difficult in the intubated patient Limited availability More sensitive for identification of soft tissue injuries (Gold standard for spinal cord injury) Not reliable for identifying bony injury - incidence of ligamentous injury in the setting of a negative CT is very low (<5%) - incidence of clinically significant injury is even lower (<1%) - MRI is expensive - MRI is difficult in the intubated ICU patient - MRI is more sensitive for the identification of soft injuries than CT C-spine and is considered the gold standard in identifying injuries to the spinal cord and cervical spine soft tissue injuries, but it is not clear if all the injuries identified by MRI are clinically significant - MRI is NOT reliable for identifying bony injury (missed up to 45% of fractures in one study) - MRI should be obtained within 72 hours of injury if it is to be performed, but this is rarely possible. Ghanta 2002 (51 obtunded patients with normal CT) - 22% of patients with normal CT c-spine had abnormal MRI (11% unstable) Stassen 2006 (52 obtunded blunt trauma patients) - 30% of patients with normal CT c-spine had abnormal MRI (none required surgery, ?stability) Sarani 2007 (46 obtunded patients with normal CT) - 11% had abnormal MRI (4 ligament, 1 herniated disc) Hogan 2005 (366 obtunded patients with negative CT c-spine) - 7 (1.9%) showed cervical cord contusion - 4 (1.1%) showed ligamentous injury - 3 (0.8%) showed intervertebral disc oedema - 1 (0.3%) had cord contusion + ligamentous injury +intervertebral disc injury - CT c-spine had negative predictive value of 98.9% for ligamentous injury and 100% for unstable c-spine injury Como 2007 (115 obtunded blunt trauma patients with negative CT) - 6 (5%) missed injuries (none required immobilisation)

17 Albrecht et al. Evaluation of cervical spine in intensive care patients following blunt trauma. World J Surg 2001 150 Patients (150 obtunded) Retrospective study of blunt trauma ICU patients. 25% of patients with negative x-rays or CT C-spine had extradural soft tissue or ligamentous injury on MRI (only 1 required operative stabilisation) Ghanta et al. An analysis of Eastern Association for the Surgery of Trauma Practice guidelines for cervical spine evaluation in a series of patients with multiple imaging techniques. Am Surg. 2002 124 patients (51 obtunded) Retrospective study of trauma patients. All had plain C-spine x-ray, CT and MRI. 19% of patients had injuries only evident on MRI Horn et al. Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients J. Neurosurg Spine 314 patients (22 obtunded) Retrospective study of c-spine MRI patients. 42% of patients with no injury detected on CT or C-ray had abnormality detected on MRI. No cervical instability detected on MRI that wasn’t evident on CT or flexion/extension Holmes et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma 2002 688 patients Prospective multicentre study of blunt trauma patients. MRI superior to CT for detection of cervical spine ligamentous and cord injuries. CT was superior for skeletal and facet joint injuries.

18 Significant Cord Injury without obvious radiological abnormality
SCIWORA Significant Cord Injury without obvious radiological abnormality Incidence 3-5% (x-ray/CT) Higher incidence in paediatric population (34.8%) The relatively large size of the head inherent skeletal mobility cord vulnerable to damage Higher incidence above 60 yo Posterior vertebral spurs due to spondylosis Ligamentum flavum bulging due to loss of disc height Risk of central cord syndrome after hyperextension injury SCIWORA (Significant Cord Injury without obvious radiological abnormality) In up to 3.5% of spinal injuries, isolated cervical cord injury may occur without fractures or subluxations (usually due to established spondylosis) Even minor hyperextension in spondylotic cervical spines may cause injury due to osteophytes narrowing the spinal canal, without there being fractures or obvious cord abnormality on initial MRI. In children, the relatively large size of the head and inherent skeletal mobility leads the cord vulnerable to damage, with no radiographical abnormality.

19 Thoracolumbar Spine Trauma
4.4% of trauma patients have TLS fracture 19-50% of these fractures are associated with spinal cord damage Higher incidence of neurologic deficit when fracture identification was delayed (10.5% vs 1.4%)

20 EAST Recommendations (2007)
Level II Guidelines Trauma patients should be examined by a qualified attending physician Trauma surgeons, emergency physicians or spine surgeons (neurosurgery or orthopaedics) Trauma patients who are awake, without any evidence of intoxication, with normal mental status, neurologic and physical examinations may be cleared clinically Absence of symptoms does not exclude TLS injury Only 60% of trauma patients with confirmed TLS fractures were symptomatic In series of 110 trauma patients with GCS 13-15, 31% of patients had fractures of TLS despite no pain or tenderness Non-spinal injuries are associated with TLS fractures Marker of mechanism of severity Phenomenon of multilevel, non-contiguous spinal fractures - presence of one fracture indicates the need to image entire spine

21 EAST Recommendations (2007)
Radiographic Examination is required for: High energy mechanism of injury Falls from >10 feet MVA/MBA crash with or without ejection Pedestrians struck Assault, Sport or Crush injury Bicycle injury Concomitant cervical spine fracture Altered mental status, intoxication Distracting injuries Neurologic deficits Spine pain or tenderness on palpation

22 Mode of Imaging of TLS Multidetector CT with axial reconstruction is superior to plain films for screening of TLS for bony injury (II) CT scout films can be used for spine assessment (II) CT scan may be associated with less overall radiation exposure than plain films (III) Plain films are adequate for the examination of the TLS if the patient does not require CT scan for any other reason (III) (Not if they have a major trauma mechanism) MRI is indicated for patients with neurologic deficits, abnormal CT scans or clinical suspicion despite normal radiographic evaluation suggesting an unstable injury (III) Early decompression of traumatic lesions improves outcome

23 Plain Film vs CT of TLS Ballock et al. (1992)
plain radiography of the thoracolumbar spine would have missed 25% of fractures Gestring et al. (2002)- CT protocol for examining TLS Anterior, posterior and lateral scout films and axial images 100% sensitivity and specificity Hauser et al. (2003)-prospective study 222 patients Plain radiography of the TL spine vs Helical CT (5mm images) CT scan accuracy 99% vs plain radiographs 87% CT could also differentiate acute vs old # Sheridan et al. (2003) Reformatted helical T (2.5mm images) vs plain x-ray Sensitivity for Thoracic #- CT 97% vs x-ray 62% Sensitivity for Lumbar #- CT 95% vs x-ray 86%

24 “Clearing” the Spine The ultimate evaluation of all radiographic studies is the responsibility of the attending radiologist. Other persons qualified to interpret TLS radiographs Trauma surgeon Emergency medicine physician Neurosurgeons Orthopaedic spine surgeons These may clear the spine after interpretation of the images and clinical evaluation of the patient

25 Obtunded Patient No level I evidence Level II Level III
Multidetector CT with axial reconstruction is superior to plain films for screening of the TLS for bony injury Level III The obtunded patient (intoxicated or head injury) presenting to a centre without CT scan capability should be transferred to the nearest available trauma centre

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27 Primary Management A - Airway control with C-spine immobilisation
B- Avoid hypoxaemia- will further worson the prognosis of an injured spinal cord - Injury above C5 will cause respiratory insufficiency - 50% of C3 tetraplegics need permanent ventilation C- Need to minimise secondary ischaemic injury to the cord - Aim MAP > 100mmHg - SCI above C6 associated with loss of cardiac sympathetic supply leading to hypotension & bradycardia - Loss of sympathetic vasoconstriction leads to vasodilation & venodilation - relative hypovolaemia needing plasma volume expansion and vasoconstrictors

28 Secondary Survey of Spine
Assessment of the cervical soft tissue for swelling Log roll and palpation of the spinous processes of the entire spinal column Neuro exam Motor, sensory and reflexes Perianal sensation, rectal sphincter tone and sacral reflexes Absence of the bulbocavernosus reflex indicates spinal shock Signs of SCI in unconscious patient Response to pain above but not below a level Flaccid areflexia in arms/legs Elbow flexion with the inability to extend (cervical SCI) Paradoxical breathing Inappropriate vasodilation Unexplained bradycardia, hypotension Priapism Loss of anal tone and reflexes Complete SCI muscle paralysis somatic and visceral sensory loss below a discrete segment Spinal shock Additional features of Muscle flaccidity Absence of tendon reflexes Vaso and venodilation Loss of bladder function Paralytic ileus Due to temporary loss of somatic and autonomic reflex activity below the neurological level of the injury Lasts 1-3 weeks

29 Spinal Cord Injury Complete SCI Spinal shock muscle paralysis
somatic and visceral sensory loss below a discrete segment Spinal shock Additional features of Muscle flaccidity Absence of tendon reflexes Vaso and venodilation Loss of bladder function Paralytic ileus Due to temporary loss of somatic and autonomic reflex activity below the neurological level of the injury Lasts 1-3 weeks

30 Early Surgical Management of Spine Injuries
Cervical Spine Injuries Acute stabilisation with a halo ring allows further diagnostic evaluation and treatment of other injuries without further neurologic deterioration Thoracolumbar Spine Fractures McLain & Benson compared urgent spinal stabilisation (+/- decompression within 24h) vs early treatment (24-72h) No statistical difference in outcomes the urgent group had a non-statistical better neurological recovery Kerwin et al. Early stabilisation (<3 days) shortens ICU and hospital LOS but increased number of perioperative deaths and pneumonia Spinal cord compression with neurologic involvement as a result of spinal malalignment should be remedied as soon as possible (esp facet subluxations or dislocation)

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33 Medical Management of Acute Spinal Cord Injury
Primary Injury Primary cell death that occurs at time of injury Due to direct mechanical forces causing structural disruption of neuronal, glial and vascular structures Secondary Injury (days to weeks) (10% of injury) Variety of chemical pathways including hypoxia, ischaemia, ionic shifts, lipid peroxidation, free radical production, excitotoxicity, eicosanoid production, protease activation, prostaglandin production and apoptosis Medical strategies for treatment of SCI are directed at minimising the degree of secondary injury

34 Spinal Cord Perfusion Pressure
Most important medical management of spinal cord injury is to maintain arterial oxygenation and blood pressure support Class III evidence to suggest optimising spinal cord perfusion improves clinical outcome Maintain SBP between 85-90mmHg for first week

35 Steroids NASCIS II (1992) NASCIS III
Prospective randomised double blind controlled multicentre trial (487 patients) High dose Methylprednisolone vs Naloxone Vs Placebo given within 24h of SCI No difference in neurologic outcome between the 3 groups Post hoc analysis showed patients treated with Methylpred within 8h had statistically significant improvement in motor and sensory scores at 6 months, but only improved motor scores at 1 year Steroid group had increased pulmonary emboli, wound infections (non-significant), myopathy NASCIS III 48h Methylprednisolone was associated with severe pneumonia, severe sepsis. 2 other Class I clinical trials prospectively assessed steroids (less power than NASCIS) neither showed a difference in primary outcome measures The AANS/CNS Joint Section on Disorders of the Spine and Peripheral nerves guidelines committee reviewed all the literature and concluded that “Methylprednisolone for either 24 or 48 hours is an option in the treatment of patients with acute spinal cord injuries that should be undertaken only with the knowledge that the evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit.

36 GM-1 Ganglioside Compound normally found in cell membranes of CNS tissue in mammals Antiexcitotoxic activity Promotes neuritic sprouting Potentiates the effects of nerve growth factor Prevents apoptosis Initial promising results, not reproduced in long term follow-up Not used in clinical practice

37 Future Directives Stem cell transplantation
Electric Field gradients to influence nerve growth after injury Neuroprotective strategies Monoclonal antibodies Minocycline Rho inhibitor Macrophage injection

38 References Ackland, H. et al. Magnetic Resonance Imaging for clearing the cervical spine in unconscious intensive care trauma patients. J. Trauma 2006;60: Practice Management Guidelines for identification of cervical spine injuries following trauma- update from the Eastern Association for the Surgery of Trauma Practice Managament Guidelines Committee. J.Como, J.Diaz, M Dunham J Diaz et al. Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture. J Trauma 2007;63: Harris, M. et al. The initial assessment and management of the Multiple-Trauma patient with an associated spine injury. Spine 2006;31:S9-S15 Hurlbert, R. Strategies of Medical Intervention in the Management of Acute Spinal Cord Injury. Spine 2006;31:S16-S21 Rechtine G. Nonoperative Management and Treatment of Spinal Injuries. Spine 2006;31:S22-S27 Stiell IG, et al. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. NEJM 2003;349: Stiell, I. et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286: Hoffman et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM 2000;343:94-99. Richards, P. Cervical Spine Clearance: a review. Injury, Int. J. Care Injured. 2005;36: Ed Bersten, A. Soni, N. Oh’s Intensive Care Manual, 5th Edition.2003. Ed Wilson W.et al Trauma- Emergency Resuscitation, Perioperative Anaesthesia, Surgical Management. Vol


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