1. Spinal cord injury assessment
Presenter‘s name Arial 24 pt
Meeting Arial 24 pt
Presenter‘s title Arial 20 pt
City, Month, Year Arial 20 pt

2. Learning outcomes
Assess neurological status of spinal injured patients using the ASIA scale
Describe the prognostic factors associated with spinal cord injury
Recognize complications associated with the presence of a significant spinal cord injury and understand the principles of their management
Apply and manage cervical traction

3. Spinal cord injury Most common in young men
50% due to motor vehicle accidents
Two thirds of patients are less than 30 years old
Most commonly involve cervicothoracic and thoracolumbar regions of the spine
Estimated cost of USD 2 billion annually in the USA

4. Types of injuries Spinal cord concussion:
Due to concussion of the spinal cord
No anatomical lesion evident
Temporary loss of function for 24 to 48 hours
No neuropathic changes are evident
Spinal cord contusion:
Bruising that includes bleeding, subsequent edema, and possible necrosis from the resulting compression

5. Types of injuries Spinal cord laceration: Partial injury
Cord continuity
Variable neurological compromise
Spinal cord compression:
Cord compression prevents normal vascularization
Edema, necrosis, and inflammatory process
Complete transection:
Complete discontinuity of the spinal cord
No recovery expected

6. Pathophysiology Hemorrhage
Injury to cord vascularization (anterior spinal artery)
Grey matter of spinal cord avascular
Secondary chain of events (ischemia, hypoxia, edema, hemorrhage)
Axon disintegration
Neuronal apoptosis
Fibrous scar tissue preventing further chance of neuroconduction

7. Expected outcome in spinal cord injury
Depends on:
Type of injury (concussion, contusion, laceration, transection)
Complete versus incomplete lesions
Level of injury
Associated injuries
Age
Does not depend on:
Timing of surgery in the absence of ongoing spinal cord compression
Kind of surgery
Methylprednisolone protocol

8. Immediate management
Treatment at the scene of the accident is critical
Inappropriate handling may cause further damage
Always suspect spinal injury until ruled out
Immobilize the spine
Prevent flexion, rotation, and extension of neck
Avoid twisting patient
Conscious patient will report pain and neurological compromise

9. Immediate management Prevent further injuries and protect spinal cord
Blood pressure
Adequate oxygenation
Aggressive fluids
Emergency treatment following ATLS protocol of A-B-C-D-E sequence

10. Neurological assessment
Motor function—voluntary contraction of muscles, graded
Unconscious involuntary movement to pain
Compare both sides of the body
Sensation—soft touch in all dermatomes
Autonomic function—bladder/bowel control, priapism, bulbocavernosis reflex

11. Clinical features of spinal cord injury
Neurogenic shock
Disruption of descending sympathetic pathways
Bradycardia, loss of smooth muscle tone leading to hypotension (fluid load: inotropes)
Spinal shock
Loss of all spinal cord function after injury causing flaccidity and loss of reflexes may last up to 48 hours
Abnormal breathing
Due to paralysis of intercostals with preservation of diaphragmatic innervation (C4)

12. ASIA score—assessment of neurological function
The ASIA spinal injury classification system has become a universal method for assessing SCI and monitoring recovery.

13. ASIA score—assessment of neurological function
Severity of Spinal Cord Injury (SCI)
Complete—no motor or sensory function is preserved in the sacral segments
Incomplete—sensory but not motor function is preserved below the neurological level and extends through the sacral segments
Incomplete—motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3
Incomplete—motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3
Normal—motor and sensory function is normal

14. Spinal cord anatomy

15. Spinal cord injury Incomplete neurological impairment syndromes
Brown-Séquard
syndrome:
90% recover
Central cord syndrome: 50% recover
Anterior cord syndrome: only 15% recover
Dorsal column syndrome

16. Assessment of motor power
Grade: 0 No muscle contraction evident 1 Visible contraction, but no function 2 Contraction and movement with gravity eliminated 3 Contraction against gravity, but not resistance 4 Contraction against resistance, but reduced 5 Normal power

17. Medical management The controversy of high-dose methylprednisolone
Not enough convincing evidence
Some benefit if administered within 6 hours of spinal cord injury
More evidence against its use
Usage dependent on the local criteria and personal belief
Always be aware of secondary complications
Important to maintain median arterial pressure and 100% oxygen saturation
Avoid hypotension and hypoxia!

18. Neurogenic shock May mask normal signs of hypovolaemia
Vasomotor tone below the injured level is lost, allowing hypotension due to vasodilation
Increased vagal tone produces bradycardia
The skin keeps warm and dry because of lack of compensatory shunts of blood from periphery to core
Treat aggressively
Fluid replacement (beware too much may cause heart failure!)
Vasoactive drugs for redistribution of blood flow and avoid overloading with fluids

19. Neuro-orthopedic management
As soon as possible and practical
Dependent on facilities, personnel, experience, and fitness of patient
Evidence for prompt stabilization of fractures and decompression of the cord reduces hospital stay and improves outcomes
Recent data suggest that early (less than 12 hours post-injury) decompression and stabilization, particularly in patients with incomplete neurological impairment, may result in better neurological recovery

20. Timing of surgical intervention
Strong biological rationale, based on experimental evidence in animal models, to support the concept that early decompression may improve outcome after acute spinal cord injury
There are Class III data to suggest a role for urgent decompression in:
Bilateral facet dislocation
Incomplete spinal cord injury with a neurologically deteriorating patient (option)
Reference:
Fehlings MG, Perrin RG (2006) The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine; 15;31(11 Suppl):S28-35.
Fehlings MG, Perrin RG (2006) The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine; 15;31(11 Suppl):S28-35.

21. Timing of surgical intervention
There is Class II evidence that early (less than 24 hours) surgery does not increase the complication rate after acute spinal cord injury (guideline)
Based on a comprehensive review of the available literature, decompressive surgery for spinal cord injury can overall only be recommended as a practice option (Class III evidence)
Reference:
Fehlings MG, Perrin RG (2006) The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine; 15;31(11 Suppl):S28-35.
Fehlings MG, Perrin RG (2006) The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine; 15;31(11 Suppl):S28-35.

22. Take-home messages Spinal cord injury tends to affect young men
Mainstays of treatment are the prevention of secondary spinal cord injury and rehabilitation
Recovery after spinal cord injury is more likely with incomplete injury
Most recovery occurs early but some improvement may be seen over 18 months to 2 years after injury

23. Excellence in Spine