Make an appointment:

MediClinic Cape Town


Netcare Blaauwberg Hospital


British Medical Books Health Issues Computerized Tomography

Successful long-term treatment

  • early recognition of injury
  • prompt resuscitation
  • stabilization of injury
  • prevention of additional neurological injury
  • avoidance of complications - improvement of emergency care
  • ATLS -> better survival
  • huge cost on society

Incidence

  • 3.2 - 5.3 new spinal-cord injuries per 100,000 persons in USA
  • late spring / summer
  • highest prevalence between 15 – 24 yrs old
  • second, smaller peak > 55 yrs old
  • more frequent in boys & men

Aetiology

  • MVA - 40 - 55%
  • falls from a height 20 - 30%
  • gunshots 10 - 20%
  • sports-related activities 6% (primarily diving)
  • varies with age

Anatomical location

  • 60% cervical spine
    • diving -> 97% involved C-spine (C5-6-7)
    • MVA -> 65% (C1 & C5-6-7)
    • fall from height -> 55% (C5-6-7)
    • GSW -> 35% random distribution

Pathophysiology

Injury Mechanism

  • Allen classified fracture-dislocations into six groups
    • compressive flexion
    • distractive flexion
    • vertical compression
    • compressive extension
    • distractive extension
    • lateral flexion

Cervical instability - White & Panjabi

  • > 11° of angular rotation compared with adjacent levels
  • 3,5 mm sagittal translation
  • clinical signs of injury of medulla or nerve root

Spinal Cord Injury

  • energy of impact -> micro-haemorrhage in cord -> biochemical cascade (inflammatory response) -> neurolysis
  • spinal cord lesion progresses
    • vascular theory (endothelial damage & thrombus formation -> ischemia)
    • neuronal theory (injury of neurological membrane of axon -> cascade -> neurolysis)

Neurological Classification Complete

  • no sensory or motor function caudad to level of injury
  • spinal shock must be over (bulbocavernosus reflex returns)

Incomplete

  • voluntary muscle power or sensation distal to level of injury
  • check for sacral sparing!!!
  • recovery possible

Anterior Cord Syndrome

  • loss of neurological function in anterior 2/3 of spinal cord
  • lost pain & temperature (spinothalamic) & motor function (corticospinal)
  • retain proprioception, sense vibration & deep pressure
  • usually flexion injury, fracture-dislocation or burst fracture
  • prognosis poor

Central Cord Syndrome

  • most common incomplete sy.
  • hyperextension injury -> pinching of cord between ligamentum flavum & intervertebral disc or posterior vertebral body bone spurs
  • mixed upper & lower-motor-neuron lesion
    • flaccid paralysis of upper extremities (LMN lesion)
    • spastic paralysis of lower extremities (UMN)
  • sacral sparing
  • recovery fair -> lower extremities better function than hand

Brown-Sequard syndrome

  • unilateral damage to spinothalamic & corticospinal tracts
    • ipsilateral motor paralysis
    • loss of contralateral pain & temperature sensation
  • penetrating trauma or unilateral facet fracture or dislocation
  • good prognosis for walking & bladder/bowel control

Posterior Cord Syndrome

  • rare syndrome
  • loss of dorsal column function (deep pressure and proprioception)
  • prognosis good - motor function preserved, but slapping gait

Cervical root syndrome

  • isolated deficit in a specific nerve root
  • with acute disc protrusion or facet dislocation
  • expected to recover
  • except if root avulsion (brachial plexus injury)

Immediate Patient Care Accident Scene Management

  • recognition or suspicion of cervical injury -> immobilise
    • delayed or missed diagnosis common
    • concurrent head injury, unconsciousness
  • ABC’s of resuscitation
    • loss of sympathetic tone (bradycardia, hypotension) -> avoid overload
    • patient in Trendelenburg position
    • increases central venous return & reduces aspiration
    • IV atropine (0.4 mg) to block vagal effects

Hospital Management

Resuscitation

  • re-evaluate respiratory & circulatory status
  • placement of IV lines, nasogastric tube & Foley catheter
  • blood gases, electrolytes & Hb

Physical Examination

  • accident history
  • neurological examination
    • cranial nerve function
    • sensory & motor function
    • rectal tone, reflexes (also bulbocavernosus reflex)

Spinal shock

  • condition of altered spinal-cord conduction with transient loss of all motor, sensory & reflex function caudad to the injury
  • persist for forty-eight hours and occasionally longer
  • definitive neurological status cannot be assessed
  • return of bulbocavernosus or anal wink reflex signals end

Radiographic Examination

  • for all alert patients who have neck pain or tenderness
  • if neurological deficit, polytrauma, or craniofacial injuries
  • all intoxicated or unconscious patients

Standard Radiographic Study

  • lateral radiograph (first), AP, odontoid
  • swimmer’s view for cervicothoracic junction
    • non-contiguous vertebral injuries
    • associated thoracic, pelvic, or long-bone

Computerized Tomography

  • inadequate cervical radiographic findings
  • standard cuts 5 mm
  • suspect areas 3mm cuts -> allows for sagittal reconstruction

Magnetic Resonance Imaging

  • excellent visualization of soft-tissue
  • clear definition of canal compromise
  • spinal cord signal

Indicated

  • patients with complete or incomplete neurological deficit
  • neurological status deteriorated
  • suspicion of disc retropulsion

Contraindicated

  • pacemaker, aneurysm clips, metallic fragments in the eye or spinal cord
  • severe claustrophobia

Tomograms

  • fracture of the odontoid process
  • extent of a facet or a lateral mass injury

Dynamic Radiographs

  • strong suspicion of ligamentous instability -> “stretch test”
  • moderate suspicion -> flexion test (Nash)
  • low suspicion -> flexion-extension views

Immobilization and Realignment

  • if instability -> skeletal traction (Gardner-Wells tongs, Cone’s callipers or halo ring)
  • ten pounds (4.5 kilograms) of weight applied to the tongs
  • monitored for any change in neurological condition
  • post-traction alignment must be confirmed by a lateral radiograph

Closed reduction – if malalignment

  • under the supervision of a physician
  • patient awake & alert
  • skeletal traction
    • 10 pounds (4.5 kgs) for occiput
    • additional 5 pounds (2.3 kilograms) for each vertebra

Attempts Discontinued

  • when reduction achieved
  • > 1 cm distraction occurs at site of injury or at any level
  • neurological status deteriorates
  • evident that reduction cannot be achieved
  • once reduction achieved -> traction weight reduced

Pharmacological Treatment

High-dose methylprednisolone

  • reduction of edema, anti-inflammatory effect & protection of neuronal membranes
  • within 8 hrs
  • 30 mg/kg IV bolus over 15 minutes
  • followed by 5,4 mg/kg/hour infusion for 23 hrs
  • complications included wound infection, GIT haemorrhage

GM-1 Ganglioside

  • major component of cell membrane
  • enhance neurological motor function at a one-year follow-up
  • 100 mg IV daily for eighteen to thirty-two days
  • must start within seventy-two hours after injury
  • all patients also received a bolus of 250 mg of methylprednisolone followed by 125 mg IV every 6 hrs for 72 hours
  • facilitation of neurite growth, modulation endotoxicity

21-Aminosteroids (Tirilizad Mesylate-U74006F)

  • lack the drawbacks of the glucocorticoid-modulated systemic effects
  • neuroprotective effect

Naloxone & Thyrotropin-Releasing Hormone

  • opiate-receptor antagonists
  • blockade of release of endogenous spinal-cord opioids
    • reversal of systemic hypotension
    • decreased spinal cord blood flow
  • controversial

Vitamin E

  • anti-oxidation effect & phospholipid membrane stabilization
  • need for pre-injury treatment

Calcium-channel blockers

  • stabilization of postinjury calcium influx -> minimizing injury cascade
  • decreased post-traumatic spinal-cord ischemia in some models

Osmotic diuretics

  • mannitol, glycerol & low-molecular weight dextran
  • no evidence of clinical effectiveness

Physical Approaches

Hypothermia

  • cooling of traumatized spinal-cord segments
  • local decrease of spinal cord metabolism and oxygen consumption
    • reduction of edema
    • blockade of injury biochemical cascade
  • controversy with regard to degree & duration of cooling
  • experimental

Acute Operative Treatment (Decompression)

Benefits

  • removal of mechanical compression
  • correction of malalignment
  • improved neurological circulation

Opponents

  • maximum damage to spinal cord occurs at time of injury
  • neurological deterioration if within five days after spinal cord injury

Absolute indication

  • progressive neurological deterioration
  • presence of irreducible canal compromise
  • grossly unstable osseous or ligamentous injury patterns

Contraindication

  • deteriorating neurological status w/out evidence of canal compromise
    • suggests irreversible ascending necrosis of cord

`