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Traumatic Spinal Cord Injury Edgardo Tan, M.D.

)e&$ew: ?nter$or 1"$nal >ord : motor and sensor +oster$or 1"$nal >ord: &$brator

Epidemiology Comatose/Into icated Patients 75% of cases: male ?lwa s ass'me t%at t%e %a&e cran$al or s"$nal $n('r 'nt$l 60%: between 16-30 ears of age "ro&en ot%erw$se ! of "#s w$t% cer&$cal s"$ne tra'ma "resent w$t% 5# of >l'es to t%e "resence of s"$nal $n('r : ne'rolog$c $n('r /lacc$d arrefle#$a 5-10% of "#s w%o are 'nconsc$o's d'e to a fall or motor D$a"%ragmat$c breat%$ng@ can be "arado#$cal &e%$cle acc$dent w$ll %a&e cer&$cal s"$ne $n('r 4oss of gr$mace to "a$nf'l st$m'l$ below s"ec$f$c le&el 60% w$t% a cer&$cal s"$ne fract're w$ll %a&e at least 1 4oss of w$t%drawal res"onse below a s"ec$f$c le&el: ma(or assoc$ated $n('r el$c$t b "$nc%$ng t%e leg no res"onse b 5-15% w$t% cer&$cal s"$ne fract're w$ll %a&e a second w$t%draw$ng 1>7 &ertebral col'mn fract're 4oss of s"ontaneo's mo&ement below a s"ec$f$c le&el 4oss of s"%$ncter tone Definition of Terms +r$a"$sm )ad$c'lo"at% *root ner&e $n('r M elo"at% *s"$nal cord $n('r !hiplash"#ssociated Disorders $!#D% )otat$onal $n('r *transect$on of t%e cord +r$a"$sm*"ers$stent erect$on $n males ? tra'mat$c $n('r soft t$ss'e str'ct'res -cer&$cal m'scles, l$gaments, $nter&ertebral d$scs 5 facets. $n t%e reg$on of Mechanism of Spinal Cord Injury cer&$cal s"$ne d'e to: Motor &e%$cle cras%es*,5% -most common. 9 "errefle#$on /alls*00% 9 "ere#tens$on or rotat$onal $n('r to t%e nec; $n t%e 1"orts*1,% absence of fract'res, d$slocat$ons, or $nter&ertebral 2$olence*1,% d$s; %ern$at$on 3t%er ca'ses*5% D$slocat$on 7nter&ertebral d$sc %ern$at$on History & PE Clues to the Presence of SCI Most common non-fatal a'tomob$le $n('r @ ben$gn beca'se +a$n, n'mbness or d$ff$c'lt w$t% l$mb mo&ements can t%ere $s no com"ress$on, onl stretc%$ng of s"$nal root be: 1 m"toms: nec; "a$n, st$ffness 5 tenderness 1"$nal cord $n('r 1 m"toms ma be dela ed for se&eral %o'rs or da s 4$gamento's tear >er&$cal s"$ne 5 s"$nal cord A3T $n&ol&ed Tenderness o&er t%e s"$no's "rocesses, "aras"$nal Most of t%e t$me treatment $s s m"tomat$c swell$ng or a ga" between t%e s"$no's "rocesses +lace a collar to a&o$d f'rt%er $n('r $nd$cates r'"t're of $nters"$no's l$gament A1?7Ds +resence of ne'rolog$c "arado#$cal &ent$lat$on ?nalges$cs -abdomen $nflates '"on $ns"$rat$on*d'e to m'scle 8ed rest "aral s$s., b$lateral absence of l$mb refle#es $n flacc$d l$mbs, 'nres"ons$&eness to "a$nf'l st$m'l$ Complete Spinal Cord Injury +a$nless 'r$nar retent$on 56or "r$a"$sm d'e to cont$n'o's "aras m"at%et$c st$m'lat$on*t%ese s'ggest Ao "reser&at$on of an motor and6or sensor f'nct$on "oor "rognos$s B3 segments below t%e le&el of $n('r 7f o' can "lace one breadt% of f$nger between t%e s"$ne 1'rg$cal o"erat$on w$ll not do an t%$ng@ $t w$ll ('st $n&$te more l$gament tear "roblem +lace a collar $n$t$all to a&o$d an mo&ements t%at co'ld Ma $nd'ce >1/ lea; $nfect$on men$ng$t$s )es'lts to "aral s$s "ert'rb t%e $n('r . 3bser&e@ treat med$call +a$n Transect$on of s"$nal cord 4ocal "a$n d'e to bone or soft t$ss'e $n('r )ad$c'lar "a$n d'e to ner&e root com"ress$on Incomplete Spinal Cord Injury ?n res$d'al motor or sensor f'nct$on B 3 segments below 2$tal s$gns t%e le&el of $n('r 8rad card$a d'e to loss of s m"at%et$c $n"'t to t%e %eart 4oo; for s$gns of "reser&ed long tract f'nct$on: from cer&$cal or %$g% t%orac$c les$on 1ensat$ons $ncl'd$ng "os$t$on sense or &ol'ntar 9 "otens$on d'e to loss of s m"at%et$c $n"'t to t%e mo&ement $n t%e lower e#trem$t$es s stem$c &asc'lat're -:s"$nal s%oc;<. 1acral s"ar$ng: sensat$on aro'nd t%e an's, &ol'ntar +ool$ng of blood flow % "otens$on brad card$a rectal s"%$ncter contract$on or toe e#tens$on. E#ternal Tenderness, br'$s$ng or swell$ng d'e to local soft t$ss'e damage +al"able ste"-off d'e to malal$gnment -w$dened $nters"$no's s"ace. +aras"$no's m'scle s"asm Tort$coll$s d'e to m'scle s"asm or 'nred'ced &ertebral d$slocat$on 9 "errefle#$a seen after 0,%rs =ea;ness +art$al &s. com"le# Motor le&el $s def$ned as t%e most ca'dal le&el w$t% grade 777 strengt% 1ensat$on Decreased &s. absent &s. % "erest%es$a 1ensor le&el $s def$ned as t%e most ca'dal dermatome w$t% normal sensat$on 1addle reg$on needs to be tested: ma be t%e onl reg$on of "reser&ed sensat$on -w%en absent, t%ere $s com"lete tra'ma to t%e 1> Categori&ation -7m"ortant for treatment dec$s$on 5 "rognos$s. >entral >ord 1 ndrome >entral s'bstance cord affected >ommon $n older "eo"le 8leed$ng $n t%e s'bstance of t%e s"$nal cord D$s"ro"ort$onatel greater motor def$c$t $n '""er e#trem$t t%an lower e#trem$t w$t% cer&$cal reg$on $n&ol&ement 1ensor def$c$t to "a$n 5 tem"erat're e#tends downwards $n ca"e-l$;e d$rect$on A'mbness $n s%o'lders, A3T on l$mbs +resence of sacral s"ar$ng beca'se sacral f$bers on t%e lateral s"$not%alam$c tract l$e "er$"%erall loss of "a$n "erce"t$on 9 "ere#tens$on $n('r d'e to osteo"% tes Treatment: >onser&at$&e -s%o'ld not e&ac'ate %ematoma. 4am$nectom *a&o$d com"ress$on of cord $ns$de 7nd$cat$ons for s'rger most common of t%e $ncom"lete 1>7Cs@ cont$n'o's com"ress$on of t%e s"$nal cord t%at correlates w$t% t%e le&el of def$c$t w$t% an of t%e follow$ng:

Lala 3C-Med-09

"ers$stent s$gn$f$cant motor def$c$t follow$ng a &ar $ng "er$od of reco&er deter$orat$on of f'nct$on cont$n'ed s$gn$f$cant d sest%et$c "a$n $nstab$l$t of t%e s"$ne

9alo tract$on: wa$t for 0 mont%s before f's$on -to stab$l$Ge.

+oster$or >ol'mn 1 ndrome Aot commonl seen@ $n acc$dents, tra'ma 5 bon fract're +oster$or sense lost below t%e les$on Motor f'nct$on 5 "a$n "erce"t$on "reser&ed /ract're of lam$na b$laterall @ some "arts dr$&en $ns$de 5 com"ress on col'mns Edema w$ll later on $ncl'de ot%er tract ?nter$or >ord 1 ndrome ?rter damaged b bones or s"$c'les -anter$or s"$nal arter * s'""l$es anter$or 063 of t%e cord. >om"ress$on fract're $n('r 8$lateral loss of motor f'nct$on 5 "a$n and tem"erat're sensat$on below $n('red segment +os$t$on sense, 0-"t d$scr$m$nat$on 5 dee" "ress're sensat$on "reser&ed Dastr$c s'rger can ca'se t%$s cond$t$on -gastrectom . 7n('r to t%e gastr$c &essel w%$c% d$rectl comes from t%e s"$nal arter 8rown 1eE'ard >ommon $n stab wo'nds 1"$nal cord %em$sect$on 's'all d'e to "enetrat$ng tra'ma 4oss of motor f'nct$on -d'e to cort$cos"$nal tract les$on. 5 "os$t$on sense -"ro"$oce"t$on 5 &$brator sense. on t%e same s$de and "a$n 5 tem"erat're -lateral s"$not%alam$c tract. sensat$on on t%e o""os$te s$de 7"s$lateral loss of motor 5 "os$t$on sense >ontralateral loss of "a$n 5 tem"erat're >on's Med'llar$s 5 >a'da EE'$na 4ow bac; "a$n6sc$at$ca >om"ressed fract're d'e to osteo"oros$s -T10-T10. Motor wea;ness $n&ol&ed more t%an a s$ngle root 1addle anest%es$a: most common sensor def$c$t Fr$nar retent$on: most cons$stent f$nd$ng 8'rn$ng sensat$on ? med$cal emergenc : remo&e bon fragment at once >lass$c man$festat$on: se&ere "a$n Pediatric SCI'SCI (/o )adiographic #*normality" SCI!+)# ?ge 1.5-16 ears old >lass$c f$nd$ngs: =ea;ness +aral s$s6n'mbness Ao $n('r on t%e rad$ogra"% D'e to l$gamento's la#$t toget%er w$t% $mmat'r$t of "aras"$nal m'scles 5 'nderde&elo"ed 'nc$nate "rocesses, cer&$cal -,0%. most common 1"$nal cord ma 'ndergo cont's$on, $nfarct, transect$on, stretc% $n('r$es6men$ngeal r'"t're M)7 s%o'ld be done@ +ET scan ma &$s'al$Ge t%e $n('r 4am$nectom no benef$t@ Treatment $s conser&at$&e w$t% $mmob$l$Gat$on of t%e nec; for 3 mont%s

Ma$nta$n 8+: 18+ H I0mm9g 9 "otens$on -s"$nal s%oc;. ca'sed b : 7nterr'"t$on of s m"at%et$cs J loss of &asc'lar tone )elat$&el 'no""osed "aras m"at%et$cs J brad card$a 4oss of s;eletal m'scle tone d'e to "aral s$s 8lood loss from assoc$ated wo'nds, $f "resent Trans$ent loss of all ne'rolog$c f'nct$ons below le&el of 1>7: flacc$d "aral s$s and arrefle#$a +ressors $f necessar : Do"am$ne*commonl g$&en E"$ne"%r$ne >aref'l % drat$on %emod nam$cs: "'lmonar edema M?1T -m$l$tar ant$-s%oc; tro'sers. $mmob$l$Ges lower s"$ne, com"ensates for lost of m'scle tone -"re&ent &eno's "ool$ng of blood. ?tro"$ne for brad card$a 3#$dat$on -adeE'ate /730 5 &ent$lat$on. Es"ec$all needed $f t%ere $s %$g% cer&$cal cord $n('r Aasal cat%eter or face mas; >a't$on w$t% $nt'bat$on w$t% 'ncleared >-s"$ne Aasotrac%eal $nt'bat$on: for com"rom$sed a$rwa and % "o"nea secondar to "aral Ged $ntercostal m'scles6"aral Ged d$a"%ragm or from de"ressed sensor$'m Aasogastr$c T'be 1'ct$on 8eca'se somet$mes "# ma not be able to swallow To "re&ent &om$t$ng 5 as"$rat$on Dastr$c s"%$ncter la#$t reg'rg$tat$on as"$rat$on To decom"ress t%e abdomen w%$c% can $nterfere w$t% res"$rat$ons $f d$stented 7ndwell$ng /ole >at%eter /or $n"'t and o't"'t Fno""osed "aras m"at%et$c st$m'lat$on lead$ng to brad card$a arrest To "re&ent d$stent$on from t%e 'r$nar retent$on Tem"erat're reg'lat$on 2asomotor "aral s$s ma "rod'ce "o$;$lot%erm -loss of tem"erat're control. and s%o'ld be treated as needed w$t% cool$ng blan;ets Electrol tes, % "o&olem$a 5 % "otens$on ca'se $ncreased "lasma aldosterone % "o;alem$a ,ran-el .eurological Performance Scale Fsed to ga'ge e#tent of s"$nal $n('r Scale Manifestation ? -1. >om"lete motor and sensor "aral s$s below les$on 8 -0. >om"lete motor "aral s$s w$t% some res$d'al sensor "erce"t$on below les$on > -3. )es$d'al motor f'nct$on b't of no 's D -,. Fsef'l b't s'bnormal motor f'nct$on below les$on E -5. Aormal Comprehensi/e & Serial .eurological E/aluation 9$stor : ;now %ow t%e acc$dent or mec%an$sm of $n('r +% s$cal e#am$nat$on Motor le&el 1ensor le&el 1 m"toms of ?A1 d sf'nct$on: "ers"$rat$on, bladder6bowel "r$a"$sm

Management of Traumatic Spinal Cord Injury #SI# Impairment Scale -%el" determ$ne le&el of $n('r cl$n$call . 7mmob$l$Ge: $ncl'de >1-T1 Most $m"ortant es"ec$all $f t%ere $s cer&$cal s"$ne 1ensor >%art $n&ol&ement 1ensor le&el 's'all 1 or 0 le&els %$g%er )$g$d cer&$cal collar, s;'ll tract, %alo brace, etc. >, J to" of acrom$ocla&$c'lar (o$nt 1andbags on bot% s$des of %ead w$t% 3< str$" of >5 J lateral s$de of antec'b$tal fossa ad%es$&e ta"e from 1 s$de to ot%er s$de across fore%ead >6 J t%'mb +lace "# on bac;board >7 J3rd f$nger or m$ddle f$nger 4og roll: "# to t'rn %ead, nec;, bac;, s%o'lder 5 t%ese >K J 5t% f$nger or small f$nger s%o'ld all mo&e toget%er T1 J med$al s$de of antec'b$tal fossa 7mmob$l$Gat$on s%o'ld start "r$or to and d'r$ng T, J n$""le l$ne e#tr$cat$on from s$te of acc$dent 5 d'r$ng trans"ort to T5-TI J $ntercostal s"aces "re&ent act$&e or "ass$&e mo&ements of t%e s"$ne T10 J 'mb$l$c's

Lala 3C-Med-09

41 J $ng'$nal l$gament 40 J m$ddle of t%$g% 4, J med$al calf 45 J lateral calf 10 J "oster$or t%$g% 1,, 15 J "er$ne'm Motor >%art +lantar fle#$on J 11 Dors$fle#$on J 45 E#tend leg J 43, 4, /le# leg at %$" J 41, 40 1"read f$ngers J T1 =r$st fle#$on J >K E#tend forearm J tr$ce"s >7 /le# forearm J b$ce"s >6 )a$sed elbow J delto$d >5 )efle# >%art 8$ce"s J >5->6 Tr$ce"s J >6->7 +atella J 4, ?c%$lles J 11 )adiologic E/aluation 1"$nal L-ra >-s"$ne: antero"oster$or, lateral M >7-T1, obl$E'e fle#$on-e#tens$on, o"en mo't% T%oracol'mbosacral s"$ne: ?+ 5 lateral &$ews >6, >7, and T1 can be co&ered b s%o'lder area $n #ra @ rec%ec;N M)7 scan ?ssess soft t$ss'e and 1>7 &er well Does not s%ow bon fract'res 9owe&er, res'lts are dela ed >T scan or >T m elogra"% ?ssess bon anatom $n deta$l 7f w$t% $ntrat%ecal contrast, ma also del$neate an ne'ral $m"$ngement Medical Management Met% l"redn$solone treatment: 8enef$c$al -motor 5 sensor . effects at 6w;s, 6 mont%s, and 1 r w%en adm$n$stered w$t%$n K%rs of $n('r -b't &er e#"ens$&e. 2er e#"ens$&e Ao role $n 9E?D $n('r 9el"f'l $n cont's$ons b't A3T transect$on E#cl's$on cr$ter$a: >a'da eE'$na s ndrome D'ns%ot wo'nds O13 6o +regnanc 4$fe-t%reaten$ng morb$d$t Aarcot$c add$ct$on +# on ma$ntenance stero$ds 7n(ect$on: 30mg6;g, $n$t$al 72 bol's o&er 15m$ns followed b a ,5m$n "a'se, t%en ma$ntenance $nf'se at 5.,mg6;g w$t% cont$n'o's $nf's$on 3t%er dr'gs: Aalo#one, 4aGaro$d, Tr$laGad Den$to'r$nar $n&ol&ement 7ndwell$ng cat%eter $s mandator $n bowel6bladder $ncont$nence after t%e $n('r +lacement of an $ndwell$ng 'r$nar cat%eter $s mandator $n t%e se&erel $n('red "at$ent for mon$tor$ng of 'r$ne o't"'t &ol'me ?lso "re&ents t%e com"l$cat$on of bladder r'"t're d'e to o&erd$stent$on )es"$rator Ma$ntenance of adeE'ate a$rwa and breat%$ng rema$ns t%e f$rst "r$or$t 7f endotrac%eal $nt'bat$on $s needed, ma$ntenance of s"$nal al$gnment $s cr$t$cal d'r$ng $nt'bat$on >ard$ac ?deE'ate "erf's$on m'st be ass'red and % "otens$on "re&ented Indications for Decompressi/e Surgery T%e most com"ell$ng $nd$cat$on $s t%e "resence of an $ncom"lete ne'rolog$c $n('r w$t% "ers$stent ne'ral com"ress$on at t%e s$te of $n('r Most cl$n$c$ans agree t%at s'rger s%o'ld be done emergentl $n t%e "resence of a ra"$dl decl$n$ng ne'rolog$c e#am$nat$on

T%e goal of decom"ress$&e s'rger $s restorat$on of a normal s"$nal canal w$t%o't add$t$onal $n('r to t%e ne'ral elements 1tab$l$Gat$on "roced're e$t%er o"erat$&e f$#at$on or $mmob$l$Gat$on b 9alo braces, s;'ll tract$on

Surgical Management Specific to SCI $only for incomplete SCI0s% Decom"ress$on lam$nectom comb$ned w$t% a stab$l$Gat$on "roced're Mod$f$ed recommendat$ons of 1c%ne$der for $ncom"lete 1>7 w$t% e#tr$ns$c com"ress$on, w%o follow$ng ma#$mal "oss$ble red'ct$on of s'bl'#at$on s%ow: +rogress$on of ne'rolog$cal s$gns E&$dence of com"lete s'barac%no$d bloc; E&$dence of bones, soft t$ss'e elements, /8 $ns$de t%e s"$nal canal ca's$ng s"$nal cord com"ress$on Aecess$t for decom"ress$on of a &$tal cer&$cal root com"o'nd fract're or "enetrat$ng tra'ma ?c'te anter$or cord s ndrome Aon-red'c$ble fract're d$slocat$ons from loc;ed facets ca's$ng s"$nal cord com"ress$on

Sta*ili&ation Procedure E$t%er o"erat$&e f$#at$on or $mmob$l$Gat$on b 9alo brace or s;'ll tract$on 7f "# cont$n'es to be 'nstable, $n('r ma f'rt%er be com"o'nded $f def$n$t$&e s'rger $s done "r$or to stab$l$Gat$on Contraindications to Emergent +peration >om"lete 1>7 H 0,%rs and w$t% no motor6sensor f'nct$on below le&el of les$on Med$call 'nstable "# -not 'nstable s"$ne. >entral cord s ndrome Spinal Sta*ility =%$te 5 +an(ab$: ab$l$t 'nder "% s$olog$c loads to l$m$t d$s"lacement so as to "re&ent $n('r or l$m$tat$on of s"$nal cord and ner&e roots and to "re&ent $nca"ac$tated deform$t or "a$n d'e to str'ct'ral c%anges Management Principles in Spinal Insta*ility Aeed for decom"ress$on of ne'ral elements Aeed to mob$l$Ge t%e "at$ent as soon as "oss$ble Earl s'rg$cal stab$l$Gat$on of t%e 'nstable s"$ne ma %el" to "re&ent atelectas$s, "ne'mon$a, D2T, and dec'b$t$ red'c$ng t%e com"l$cat$ons of (o$nt contract're and decond$t$on$ng, as well as "otent$all red'c$ng t$me off wor; Aeed to stab$l$Ge t%e s"$ne w%$c% $s not l$;el to %eal w$t%o't s'rg$cal $nter&ent$on 7n general, $n('r$es t%at are not l$;el to %eal $ncl'de t%ose w$t% w$del d$s"laced fract'res, 'nred'ced or red'c$ble d$slocat$ons, se&ere deform$t or se&ere l$gamento's $n('r : also $n('r$es w%$c% %a&e been treated w$t% "rolonged bed rest or brac$ng w%$c% %a&e not %ealed correctl 1'rg$cal 1tab$l$Gat$on /'s$on -art%rodes$s. J goal $s to $nd'ce ad(acent &ertebra abo&e 5 below $n('r to %eal toget%er $nto a sol$d bloc; of bone, el$m$nat$ng an "otent$al mo&ement between t%em 7nternal f$#at$on -$nstr'mental$Gat$on. J t%$s "ro&$des $mmed$ate strengt% and ma$nta$n anatom$c al$gnment d'r$ng t%e t$me $t ta;es for f's$on to occ'r@ $t 's'all $n&ol&es t%e $m"lantat$on of some comb$nat$on of w$re, %oo;s screws and6or rods@ $t $s A3T a s'bst$t'te for f's$on Med$cal >om"l$cat$ons ?ssoc$ated w$t% 1>7 1;$n )$s; of s;$n brea;down d'e to $nab$l$t to sense "a$n 5 "rolonged "er$ods of bed rest -dec'b$t's 'lcer. 0-%o'rl log roll$ng 8ladder

4MA bladder w$t% o&erflow $ncont$nence and 'r$nar retent$on or FMA bladder "resent$ng

Lala 3C-Med-09

w$t% $ncont$nence and red'ced bladder ca"ac$t Doals of t#: f'nct$onal lower 'r$nar tract free of $nfect$on 5 "reser&at$on of renal f'nct$on

8owel mo&ement Doals of management are for t%e "# to be free of $ncont$nence and to de&elo" a "red$ctable bowel ro't$ne w$t%o't fecal $m"act$on ?deE'ate da$l fl'$ds 5 f$ber $nta;e, man'al remo&al of feces or da$l d$g$tal rectal st$m'lat$on )es"$rator 1'sce"t$ble to atelectas$s and "ne'mon$a d'r$ng ac'te "%ase 1%o'ld be started on $ncent$&e s"$rometr as well as e#erc$se "rograms to $ncrease strengt% $n rema$n$ng m'scles of $ns"$rat$on +ro"% lact$c clear$ng of secret$ons s%o'ld be enco'raged 4$mb 7ntens$&e "% s$cal t%era" to %el" "re&ent fle#$on contract'res

D2T

Lala 3C-Med-09