Spinal cord injury

 

 

Assessment of cervical spine after Trauma

1. 역학
1) SCI (young, predominantly male), 10~20% of cervical fx result in SCI
2) MVA : 35~45% of all SCI ( m/c in C spine ), Fall : m/c cause of C spine & SCI in Elderly
3) Ped spine trauma – different levels according to age – 18세 이상(3/4 below C4), 8세 미만 (70% C3이상)
4) Primary reason for the difference in injury pattern – young children (relatively larger HEAD in relation to c
spine/ Higher center of gravity of craniocervical region)
@ 소아척추손상
(1) atlanto-occipital 손상의 70%에서 사망
(2) SCIWORA – 75%에서 신경학적 예후불량
(3) 에어백 손상에 의해 occipto-cervical 손상 증가 경향
2. Acute care of C spine injuries
1) Prehospital – Immobilization (All accident victims must be assumed to have an UNSTABLE C spine until proven otherwise)
2) acute evaluation & Mx in ER: Stable V/S after trauma ≠ Absence of serious injury

 

3. Type of injury mechanism
1) Penetrating -> SC hemisection (Brown-Sequard syndrome)
a) best Prognosis (90% pts regaining the ability to ambulate independently & control sphincter function
b) ipsilateral paralysis, proprioception loss / contralateral pain&temp loss(slightly below lesion)

2) Acute hyperextension injury -> Central cord syndrome
a) frequently in pre-existing congenital stenosis/ 50% eventually recover to ambulate independently / recovery of U/Ex function – POOR, absent fine motor control / bowel & bladder control is frequently recover
b) weakness : UE>LE / variable sensory loss below lesion
@ 보통 C5-7에 호발하는데 척수 중심부에 출혈이나 부종 등이 발생된 경우 나타남

3) Vertical compression or Hyperflexion injury -> Anterior cord syndrome poor Prognosis 
a) cord infarction in the vascular territory supplied by ASA/ POOREST Px of incomplete cord syndrome / only 10~20% recover functional motor control
b) bilat motor paralysis and pain & temp loss / proprioception & vibration –preserved 
@ 단순 방사선 영상에서 확인 어려운 척추골절이나 전위가 흔히 동반.

4) Posterior Cord Syndrome

• damage to the posterior part of the spinal cord. 

• Most cases of posterior cord syndrome present with poor coordination

• Muscle power and pain and temperature are preserved.

• Seen in neurosyphilis.

 

5) Conus Medullaris

• S4-5 exit at L1; may have L1 fracture

• Areflexic bowel and bladder, flaccid anal sphincter

• Variable lower extremity loss

 

6) Cauda Equina

• Lumbar sacral nerve roots, with or without fracture

• Variable loss; areflexia; radicular pain

• Potential for improvement if root not completely transected

 

4. High dose Methylprednisolone
@ Indication – motor deficit을 보이는 complete injury가 아니며, 수상 8시간 이내
1) 수상 3시간이내 -> 24hr period MPS / 수상 3~8시간 이내 -> 48hr period
2) 수상8시간 이후에는 no benefit
3) initial bolus (30mg/kg, 15 min) -> 45분 후 5.4mg/kg로 시간당 투여

5. C spine series x-ray : Ix
1) Localized pain, deformity, crepitus, or edema,

2) Altered M/S, neurological dysfunction, or head injury
3) Patient with multiple or severe trauma, 4) Intoxicated pts

6. Flexion-extension film : CIx
1) neurologic deficits

2) Obvious fx, instability

3) Hx of transient, resolved deficit after trauma
4) acute intoxication, disorientation, and heavy analgesic administration

7. Asymptomatic pts
1) neurologically intact pts  incidence of spinal injury or acute fx: 1% 이하
2) Nexus low-risk criteria (다발성 손상환자에서 C spine clearing 원칙)
(이 조건 충족하면 low probability of C spine injury, 아니면 C spine imaging 고려)
a) No midline Td, No evidence of intoxication, A normal level of alertness,
b) No focal neurologic deficit, No painful distracting injury
3) Canadian study – for alert & stable pts where C spine injury is concern

 

8. Subaxial injury classification & severity score system (SLIC system)
1) Morphology : no abnl (0), compression (1), burst (2), distraction (3), rotation/translation (4)
2) Neurologic status: intact (0), root injury (1), complete cord injury (2), incomplete cord injury (3), continuous cord compression in the setting of neuro deficit (4)
3) Disco-ligamentous complex : intact (0), indeterminate (1), disrupted (2)
-> 4미만 (non op), 4점 (op 또는 non op), 5점 이상 (op!)

9. Clinical stability of C spine – 3 assumption
1) No excessive displacement or deformity under physiologic loading
2) No deformity or abnormal displacement during the healing process
3) No compression or injury to neurologic element overtime under physiologic loading

 

10. Closed reduction
1) early closed reduction rationale: rapid cord decompression & immobilization
2) reduction of C spine in awake pt by traction – transient deficit (2~4%), permanent deficit (1%)

 

11. Restoration of spinal stability
1) goal – Minimize risk for secondary injury, Allow early mobilization of pts, Minimize the risks associated with prolonged bed rest
2) External orthoses – Halo vest (most reliable device/ upper C spine의 motion줄임 / cannot eliminate all the motion of C spine)
3) Surgical stabilization 
a) timing – controversial/progressive deficit after injury -> acute decompression 
b) early surgical decomp의 장점 – Minimization of secondary injuries with improved perfusion,
Decreased anatomic distortion, Restoration of CSF circulation, Reduction of risk for further mechanical injury, More rapid mobilization
c) Advocates of delayed surgery – Injured cord (vulnerable to manipulation & hemodynamic changes), Concurrent injuries (↑surgical risk& potential morbidity), Closed reduction (rapid decompression)