Epidemiology Incidence 11,000 new cases/year in US 34% incomplete tetraplegia login to view 1 more bullet 25% complete paraplegia 22% complete tetraplegia 17% incomplete paraplegia Demographics bimodal distribution young individuals with significant trauma older individuals that have minor trauma compounded by degenerative spinal canal narrowing Anatomic location 50% in cervical spine Etiology Mechanism MVA causes 50% falls GSW iatrogenic it is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport Pathophysiology primary injury damage to neural tissue due to direct trauma irreversible secondary injury injury to adjacent tissue due to login to view 4 more bullets methylprednisolone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals Associated conditions acute phase conditions (see below) spinal shock neurogenic shock associated injuries closed head injuries noncontiguous spinal fractures vertebral artery injury login to view 8 more bullets Relevant Anatomy See spinal cord anatomy Classification Descriptive tetraplegia injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs paraplegia injury to the thoracic, lumbar, or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury arm function is preserved complete injury an injury with no spared motor or sensory function below the affected level patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an injury can be determined as complete classified as ASIA A incomplete injury an injury with some preserved motor or sensory function below the injury level incomplete spinal cord injuries include login to view 6 more bullets ASIA Classification ASIA Impairment Scale Motor Sensory A Complete No motor function Complete deficit B Incomplete No motor function Incomplete deficit C Incomplete Motor function partially preserved; more than half of key muscles below the neurological level have a muscle grade less than 3 Incomplete deficit D Incomplete Motor function is partially preserved; at least half of key muscles below the neurological level have a muscle grade of 3 or more Incomplete deficit E Normal Normal motor Normal sensory Acute Phase Conditions Neurogenic shock characterized by hypotension and relative bradycardia in a patient with an acute spinal cord injury potentially fatal mechanism circulatory collapse from loss of sympathetic tone login to view 5 more bullets treatment Swan-Ganz monitoring for careful fluid management pressors to treat hypotension Spinal shock defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury characterized by flaccid areflexic paralysis bradycardia and hypotension (due to loss of sympathetic tone) absent bulbocavernosus reflex login to view 1 more bullet timing variable but usually resolves within 48 hours at its conclusion, spasticity, hyperreflexia, and clonus slowly progress over days to weeks mechanism neurophysiologic in nature login to view 1 more bullet evaluation important because one cannot evaluate neurologic deficit until spinal shock phase has resolved login to view 2 more bullets ruled out when bulbocavernosus reflex present 48 hours has elapsed from time of injury stages of spinal shock Phase 1: hyporeflexic login to view 2 more bullets Phase 2: initial reflex return login to view 3 more bullets Phase 3: initial hyperreflexia login to view 1 more bullet Phase 4: spasticity login to view 2 more bullets Spinal vs. Neurogenic vs. Hypovolemic Shock Spinal Shock Neurogenic Shock Hypovolemic Shock BP Hypotension Hypotension Hypotension Pulse Bradycardia Bradycardia Tachycardia Reflexes / Bulbocavernosus Reflex Absent Variable/Independent Variable/Independent Motor Flaccid paralysis Variable/Independent Variable/Independent Time ~48-72 hours immediately after spinal cord injury ~48-72 hours immediately after spinal cord injury Following excessive blood loss Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli Disruption of autonomic pathway leads to loss of sympathetic tone and decreased systemic vascular resistance Decreased preload leads to decreased cardiac output Evaluation Field treatment treatment of potential spinal cord injuries begins at the accident scene with proper spinal immobilization immobilization should include a rigid cervical collar and transport on a firm spine board with lateral support devices patient should be rolled with standard log roll techniques with control of cervical spine spine boards should be used for transport only and patients should be removed when clinically safe login to view 1 more bullet athletes in the setting of sports-related injuries, helmets and shoulder pads should be left on until arrival at the hospital OR until experienced personnel can perform simultaneous removal of helmet and shoulder pads in a controlled situation Initial evaluation primary survey airway breathing login to view 1 more bullet circulation initial survey to inspect for obvious injuries of head and spine login to view 2 more bullets secondary survey cervical spine exam login to view 8 more bullets cervical spine clearance Initial Medical Treatment Medical / Prevention DVT prophylaxis indications login to view 4 more bullets modalities login to view 3 more bullets cardiopulmonary management careful hemodynamic monitoring and stabilization is critical in early treatment login to view 1 more bullet implement immediate aggressive pulmonary protocols decubitus ulcer prevention Steroids high dose methylprednisolone indications login to view 6 more bullets historical contraindications include login to view 5 more bullets technique login to view 4 more bullets outcomes login to view 2 more bullets monosialotetrahexosylganglioside (GM-1) indications login to view 3 more bullets Reduction acute closed reduction with axial traction indications login to view 2 more bullets technique login to view 4 more bullets Hypothermia systemic and local evidence is weak and limited currently not recommended due to increased complications login to view 5 more bullets Definitive Treatment Nonoperative bracing and observation indications login to view 2 more bullets Operative surgical decompression and stabilization indications login to view 13 more bullets Rehabilitation Goals assess and identify mechanisms for reintegration into community based on functional level and daily needs patients learn transfer techniques, self care retraining, mobility skills Restoring hand function hand function is often limiting factor for many patients tendon transfers can be used to restore function to paralyzed arms and hands by giving working muscles different jobs Modalities functional electrical stimulation is a technique that uses electrical currents to stimulate and activate muscles affected by paralysis Spinal Cord Injury Level and Function Level Patient Function C1-3 Ventilator-dependent with limited talking Electric wheelchair with head or chin control C3-4 Initially ventilator-dependent, but can become independent Electric wheelchair with head or chin control C5 Ventilator independent Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function C6 C6 has much better function than C5 due to ability to bring the hand to mouth and feed oneself (wrist extension and supination intact) Independent living; manual wheelchair with sliding board transfers, can drive a car with manual controls C7 Improved triceps strength Daily use of a manual wheelchair with independent transfers C8-T1 Improved hand and finger strength and dexterity Fully independent transfers T2-6 Normal UE function Improved trunk control Wheelchair-dependent T7-12 Increased abdominal muscle control Able to perform unsupported seated activities; with extensive bracing walking may be possible L1-5 Variable LE and B/B function Assist devices and bracing may be needed S1-5 Various return of bowel/bladder and sexual function Walking with minimal or no assistance Prognosis Complete Injuries improvement of one nerve root level can be expected in 80% of patients improvement of two nerve root levels can be expected in 20% of patients only 1% have complete recovery at time of hospital diagnosis ASIA A injuries have the least chance for marked recovery and the highest lifetime healthcare costs Incomplete Injuries trends of improvement include the greater the sparring, the greater the recovery patients that show more rapid recovery have a better prognosis when recovery plateaus, it rarely resumes improvement Conus medullaris syndrome has a better prognosis for recovery than more proximal lesions Complications Skin problems treatment is prevention start in ER do not leave on back board start log rolling early proper bedding Venous thromboembolism prevent with immediate DVT prophylaxis Urosepsis common cause of death strict aseptic technique when placing catheter do not let bladder become overly distended Sinus bradycardia most common cardiac arrhythmia in acute stage following SCI Orthostatic hypotension occurs as a result of lack of sympathetic tone Autonomic dysreflexia potentially fatal presents with headache, agitation, hypertension caused by unchecked visceral stimulation check foley disimpact patient radiographs of lower extremity if there is concern for undiagnosed fracture Major depressive disorder ~11% of patients with spinal cord injuries suffer from MDD MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase Prognosis Only 1% have complete recovery at time of hospital diagnosis conus medullaris syndrome has a better prognosis for recovery than more proximal lesions