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CASE REFLECTION

SPINAL CORD INJURY

Arfian Deny Prakoso


1410029049

Spinal Cord Injury


Definition : Spinal cord injury (SCI) is an insult to the
spinal cord resulting in a change, either temporary or
permanent, in the cords normal motor, sensory, or
autonomic function.
Patients with spinal cord injury usually have permanent
and often devastating neurologic deficits and disability
According to the National Institutes of Health (NIH),
"among neurological disorders, the cost to society of
automotive SCI is exceeded only by the cost of mental
retardation."
Department of Surgery
Faculty of Medicine
Mulawarman University

Epidemiology

The percentage of spinal cord injuries as classified by the


American Spinal Injury Association (ASIA) is as follows:
Incomplete tetraplegia: 29.5%
Complete paraplegia: 27.9%
Incomplete paraplegia: 21.3%
Complete tetraplegia: 18.5%
The most common neurologic level of injury is C5
In paraplegia, T12 and L1 are the most common level.

Department of Surgery
Faculty of Medicine
Mulawarman University

Etiology

By Vitale et al
Motor vehicle accidents - 56%
Accidental falls - 14%
Firearm injuries - 9%
Sports injuries - 7%

Department of Surgery
Faculty of Medicine
Mulawarman University

Spinal Cord Injury


The spinal cord is divided
into 31 segments, each with
a pair of anterior (motor) and
dorsal (sensory) spinal nerve
roots
The spinal cord extends from
the base of the skull and
terminates near the lower
margin of the L1 vertebral
body
Thereafter, the spinal canal
contains the lumbar, sacral,
and coccygeal spinal nerves
that comprise the cauda
equina.
Department of Surgery
Faculty of Medicine
Mulawarman University

Spinal Cord Injury

Department of Surgery
Faculty of Medicine
Mulawarman University

Spinal Cord Injury

Department of Surgery
Faculty of Medicine
Mulawarman University

Spinal Cord Injury

Department of Surgery
Faculty of Medicine
Mulawarman University

Spinal Cord Injury

The spinal cord itself is organized into a series of tracts


or neuropathways that carry motor (descending) and
sensory (ascending) information

Department of Surgery
Faculty of Medicine
Mulawarman University

Motoric Pathways

The corticospinal tracts are


descending motor pathways
located anteriorly within the
spinal cord
They decussate in the medulla
before entering the spinal cord
Injury to the corticospinal tract
results in ipsilateral paralysis

Department of Surgery
Faculty of Medicine
Mulawarman University

Sensoric Pathways
The dorsal columns are ascending
sensory tracts that transmit light
touch, proprioception, and
vibration information to the
sensory cortex.
The lateral spinothalamic tracts
transmit pain and temperature
sensation.
The anterior spinothalamic tract
transmits light touch.
Department of Surgery
Faculty of Medicine
Mulawarman University

Autonomic
Pathways
Autonomic function traverses
within the anterior interomedial
tract
Sympathetic nervous system
fibers exit the spinal cord
between C7 and L1
Parasympathetic system
pathways exit between S2 and
S4
Department of Surgery
Faculty of Medicine
Mulawarman University

Pathophysiology
Spinal cord injury can be sustained through different
mechanisms, with the following 3 common abnormalities
leading to tissue damage:
Destruction from direct trauma
Compression by bone fragments, hematoma, or disk
material
Ischemia from damage or impingement on the spinal
arteries
Might result in shock state (Neurogenic/spinal)
emergency!
Department of Surgery
Faculty of Medicine
Mulawarman University

Pathophysiology
Complete Spinal Cord Syndrome : complete loss of motor
and sensory function below the level of the traumatic
lesion
Incomplete cord syndromes have variable neurologic
findings with partial loss of sensory and/or motor function
below the level of injury; these include the anterior cord
syndrome, theBrown-Squard syndrome, and the central
cord syndrome
Other cord syndrome : conus medullaris syndrome, cauda
equina syndrome, and spinal cord concussion
Department of Surgery
Faculty of Medicine
Mulawarman University

History & PE

As with all trauma patients, initial clinical evaluation


begins with a primary survey focuses on lifethreatening conditions ABC
History taking:
Symptoms related to the vertebral column (most
commonly pain) and any motor or sensory deficits
Ascertaining the mechanism of injury is also important in
identifying the potential for spinal injury

Department of Surgery
Faculty of Medicine
Mulawarman University

PE

Studies show a high incidence of autonomic dysfunction,


including orthostatic hypotension and impaired
cardiovascular control, following spinal cord injury
recommended to assess:
Autonomic function
American Spinal Injury Association (ASIA) assessment

Department of Surgery
Faculty of Medicine
Mulawarman University

PE

Studies show a high incidence of autonomic dysfunction,


including orthostatic hypotension and impaired
cardiovascular control, following spinal cord injury
recommended to assess:
Autonomic function
American Spinal Injury Association (ASIA) assessment

Department of Surgery
Faculty of Medicine
Mulawarman University

PE

In all patients with spinal cord injury and hypotension, a


diligent search for sources of hemorrhage must be made
before hypotension is attributed to neurogenic shock
In acute spinal cord injury, shock may be neurogenic,
hemorrhagic, or both

Department of Surgery
Faculty of Medicine
Mulawarman University

PE
Clinical "pearls" useful in distinguishing hemorrhagic
shock from neurogenic shock:
1. Neurogenic shock ONLY in acute spinal cord injury
above T6; hypotension and/or shock with acute spinal
cord injury at or below T6 is caused by hemorrhage
2. Hypotension with a spinal fracture alone, without any
neurologic deficit or apparent spinal cord injury, is
invariably due to hemorrhage

Department of Surgery
Faculty of Medicine
Mulawarman University

PE

3. Patients with a spinal cord injury above T6 may not


have the classic physical findings associated with
hemorrhage (eg, tachycardia, peripheral
vasoconstriction); this vital sign confusion attributed to
autonomic dysfunction is common in spinal cord injury
4. The presence of vital sign confusion in acute spinal
cord injury and a high incidence of associated injuries
requires a diligent search for occult sources of
hemorrhage
Department of Surgery
Faculty of Medicine
Mulawarman University

History & PE

Examination of the Vertebrae


The axial skeleton to identify and provide initial
treatment of potentially unstable spinal fractures from
both a mechanical and a neurologic basis
The posterior cervical spine and paraspinal tissues
should be evaluated for pain, swelling, bruising, or
possible malalignment

Department of Surgery
Faculty of Medicine
Mulawarman University

ASIA Impairment
Scale

Department of Surgery
Faculty of Medicine
Mulawarman University

ASIA Impairment
Scale

Department of Surgery
Faculty of Medicine
Mulawarman University

Workup

With regard to laboratory studies, the following may be


helpful:
Arterial blood gas (ABG)measurements may be useful to
evaluate adequacy of oxygenation and ventilation
Hemoglobin and/or hematocrit levels may be measured
initially and monitored serially to detect or monitor
sources of blood loss
Urinalysis can be performed to detect any associated
genitourinary injury

Department of Surgery
Faculty of Medicine
Mulawarman University

Workup

Diagnostic imaging
Standard radiographs of the affected region of the spine
radiography is insensitive to small fractures of the
vertebra
standard 3 views of the cervical spine are recommended
in patients with suspected spinal cord injury (SCI):
anteroposterior (AP), lateral, and odontoid
must include the C7-T1 junction to be considered
adequate

Department of Surgery
Faculty of Medicine
Mulawarman University

Workup
CT scanning with sagital and coronal reformatting is more
sensitive than plain radiography for the detection of
spinal fractures
Perform CT scanning in the following situations:
When plain radiography is inadequate or fails to
visualize
Convenience and speed: CT scan of the head CT of
the cervical spine at the same time
To provide further evaluation when radiography depicts
suspicious and/or indeterminate abnormalities
When radiography depicts fracture or displacement
provides better visualization of the extent and
displacement of the fracture
Department of Surgery
Faculty of Medicine
Mulawarman University

Workup

Magnetic resonance imaging (MRI) is best for suspected


spinal cord lesions, ligamentous injuries, or other softtissue injuries or pathology.

Department of Surgery
Faculty of Medicine
Mulawarman University

Management

Transfer stabilize first


Consultation to neurosurgeon and/or arthopaedist
at ER:
Airway management The cervical spine must be
maintained in
neutral alignment at all times
jaw thrust
Clearing of oral secretions and/or debris
Breathing
adequate oxygenation

Department of Surgery
Faculty of Medicine
Mulawarman University

Management
Circulation
Once occult sources of hemorrhage have been excluded,
initial treatment of neurogenic shock focuses on fluid
resuscitation.
Judicious fluid replacement with isotonic crystalloid
solution to a maximum of 2 L is the initial treatment of
choice.
Overzealous crystalloid administration may cause
pulmonary edema, because these patients are at risk for
the acute respiratory distress syndrome (ARDS) check
routinely for ronchi
Department of Surgery
Faculty of Medicine
Mulawarman University

Management

The therapeutic goal for neurogenic shock is adequate


perfusion with the following parameters:
A systolic BP of 90-100 mm Hg should be achieved;
systolic BPs in this range are typical for patients with
complete cord lesions maintain BP above 90 mmHg
Maintain adequate oxygenation and perfusion of the
injured spinal cord supplemental oxygenation and/or
mechanical ventilation may be required

Department of Surgery
Faculty of Medicine
Mulawarman University

Management
Heart rate should be 60-100 bpm (in normal sinus
rhythm)
Hemodynamically significant bradycardia may be
treated with atropine
Urine output should be more than 30 mL/h Foley
catheter to monitor urine output and to decompress the
neurogenic bladder
Rarely, inotropic support with dopamine or
norepinephrine is required; this should be reserved for
patients who have decreased urinary output despite
adequate fluid resuscitation; usually, low doses of
dopamine in the 2- to 5-mcg/kg/min range are sufficient
Department of Surgery
Faculty of Medicine
Mulawarman University

Prevent hypothermia

Management

Surgical interventions decompression and


stabilization

Department of Surgery
Faculty of Medicine
Mulawarman University

Medication

The goal of pharmacotherapy is to improve motor function


and sensation in patients with spinal cord injuries (SCIs)

Department of Surgery
Faculty of Medicine
Mulawarman University

Medication

Methylprednisolone is used to reduce the secondary


effects of acute spinal cord injury (SCI)
The National Acute Spinal Cord Injury Studies (NASCIS) II
and III have verified significant improvement in motor
function and sensation in patients with complete or
incomplete spinal cord injuries (SCIs) who were treated
with high doses of methylprednisolone within 8 hours of
injury

Department of Surgery
Faculty of Medicine
Mulawarman University

Medication

Analgetics
GABA analogs have been shown to be effective in treating
neuropathic pain in spinal cord injuries More patients
taking pregabalin (150-600 mg/d) showed 30% and 50%
reductions in pain than those taking placebo

Department of Surgery
Faculty of Medicine
Mulawarman University

Complications
Neurologic deterioration
often increases during the hours to days following
acute injury, despite optimal treatment
Pressure sores
Careful and frequent turning of the patient is required
to prevent pressure sores
Denervated skin is particularly prone to this
complication
Remove belts and objects from back pockets, s.a. keys
and wallets
Aspiration and pulmonary complications
Nasogastric decompression of the stomach is
mandatory
Department of Surgery
Faculty of Medicine
Mulawarman University

Thank You Very Much

Department of Surgery
Faculty of Medicine
Mulawarman University