1. Spinal Cord Disorder Michael H. Wilhelm, CRNA, APRN

2. Acute Spinal Cord Injury Trauma is the leading cause of injury 1.5% to 3.0% cervical spine injury in major trauma 4% to 5% have injury to upper cervical spine C1-C3 Injury can also occur at thoracic and lumbar spinal area

3. Clinical Manifestation Depend on the extent and level of the injury Initially Flaccid Paralysis Loss of Sensation below level of injury Classified by the terms of the American Spinal Injury Association

4. ASIA Classification System

5. Physiological Effects Depends on Level of Injury More severe at cervical level and less sever caudally Reduction of blood pressure Loss of sympathetic nervous system activity and a decrease in systemic vascular resistance Bradycardia resulting from loss of T1-T4 sympathetic innervation to the heart Can be seen in Thoracic or Lumbar Injury but more common with Cervical Injury Another Term for these findings is spinal shock Lasts 1-3 weeks

6. With Cervical and Thoracic Injury Major cause or morbdity Alveolar hypoventilation Inability to clear secretions More respiratory muscle impairment with cervical injury Aspiration of gastric contents Pneumonia Pulmonary Embolism

7. Do we always need an x-ray? Well Stoelting talks about how x-rays are over used, pt can be evaluated on the following five criteria No midline cervical spine tenderness No focal neurologic deficits Normal sensory No intoxication No painful distracting injury

8. Anesthesia Managment Airway Management Special Care with Direct Laryngoscopy Neck movement minimized If collar in place have another provider maintain C-Spine immobillization with their hands, document appropriately If no collor on trauma pt, ensure clearance from trauma team is noted in the chart Avoid Hypotension Maintain Spinal Cord Perfusion

9. More Airway Tips Other options to Direct Laryngoscopy Glidescope Awake Fiberoptic Laryngoscopy Pt must be cooperative Can have visualization problems with blood, secretions and anatomic deformities Coughing can be detrimental to the pt Awake Tracheotomy Only used as a last resort and for the most challenging airways (i.e. facial fractures, deformities) No matter what method you use always have manual in line stabilization in place

10. Systemic Systems Absence of compensatory sympathetic nervous system Drastic drop in blood pressure can be noted Changes in body position, blood loss, or positive pressure ventilation Liberal Intravenous Infusion of crystalloid solution Fill the intravascular spaces Acute blood loss should be treated rapidly

11. EKG changes are common especially with a cervical spine injury Breathing best managed by ventilator Loss of accessory muscles Body Temperature should be maintained and monitored Pts become poikilothermic below level of injury

12. GA can be done with anesthetic gases or TIVA Caution with Nitrous Oxide as it can expand gas in closed spaces Especially in Basilar Skull Fractire of Rib Fractire Can worsen a pneumocephalus or a pneumothroax Arterial hypoxemia is common Monitor Pulse Oximetry and Oxygen Supplementation

13. Muscle Relaxation? Base decision on location of operative site and the level of spinal injury Pancuromium Sympathomimetic effects Succyncholine No excess potassium release seen with an initial spinal cord injury after a few hours

14. Chronic Spinal Cord Injury Anesthesia Focus should be to prevent Autonomic Hyperreflexia Non-Depolarizing Muscle Relaxant Drugs are the drug of choice Depolarizing Muscle Relaxants will provoke hyperkalemia Particularly for the initial 6 months after the injury Do not use after 24 hours of injury May see varying of heart rate and blood pressures Chronic immobile patients should always have a high suspicion of pulmonary thromboemolism Intercostal Muscle impairment can lead to difficulty in extubation Impaired Cough and Excessive Secretions Continue Baclofen and Benzodiazepines to prevent withdrawal symptoms

15. Autonomic Hyperreflexia Autonomic Hyperreflexia Syndrome Associated with the body’s resolution of the effects of spinal shock Commonly associated with injuries at or above T-6 Presentation Sudden hypertension Bradycardia Pounding headache Blurred vision Sweating and flushing of skin above the point of injury

16. How do we treat it? Patients at risk should be treated to prevent stimulation below the lesion, even though no prior history all spinal cord patients are at risk. Prior to intiating a surgical stimulus General Neuraxial Regional Use short acting vasodilators to treat hypertention

17. Autonomic Hyperreflexia

18. Spinal Cord Tumors Anesthesia Management Area of tumor and size with resulting neurological compromise can vary the treatment needed Airway Management Cervical Tumors may obstruct the view of the airway Severe movement can cause further damage Avoid hypotension and anemia Supplemental Oxygen Maintain spinal cord perfusion and oxygenation Caution in use of depolarizing muscle relaxants

19. Intervertebral Disc Disease Cervical Disc Disease Lumbar Disc Disease

20. Questions