1. SPINAL CORD INJURIES
ALIHUSSEIN KASSAM,
ERN DOCTOR
AZI MMOJA HOSPITAL, ZANZIBAR
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2. DEFINITION
Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic
function. This change is either temporary or
permanent.
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3. Mechanisms:
i) Direct trauma
ii) Compression by bone fragments /
haematoma / disc material
iii) Ischemia from damage / impingement on
the spinal arteries
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4. Statistics:
National Spinal Cord Injury Database
{ USA Stats }
• MVA 44.5%
• Falls 18.1%
• Violence 16.6%
• Sports 12.7%
• 55% cases occur in 16 – 30yrs of age
• 81.6% are male!
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5. South African Statistics (GSH Acute Spinal Cord Injury
Unit 2007)
• MVA 56%
• Falls 16%
• Gunshot Injuries 11%
• Blunt Assault 6%
• Diving Accidents 5%
• Stab Wounds 4%
• Sport Injuries 3%
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6. Other causes:
• Vascular disorders
• Tumours
• Infectious conditions
• Spondylosis
• Iatrogenic
• Vertebral fractures secondary to osteoporosis
• Development disorders
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7. ANATOMY :
Spinal cord:
• Extends from medulla oblongata – L1
• Lower part tapered to form conus medullaris
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9. On the surface :
• Deep anterior median fissure
• Shallower posterior median sulcus
Spinal cord segment :
• Section of the cord from which a pair of
spinal nerves are given off
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10. Hence: 31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
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12. • Dorsal root – sensory fibres
• Ventral root – motor fibres
• Dorsal and ventral roots join at intervertebral
foramen to form the spinal nerve
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14. PHYSIOLOGY AND FUNCTION
• Grey matter – sensory and motor nerve cells
• White matter – ascending and descending
tracts
• Divided into - dorsal
- lateral
- ventral
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16. Tracts :
1) Posterior column:
• Fine touch
• Light pressure
• Proprioception
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17. 2) Lateral corticospinal tract :
• Skilled voluntary movement
3) Lateral spinothalamic tract :
• Pain & temperature sensation
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18. • Posterior column and lateral corticospinal
tract crosses over at medulla oblongata
• Spinothalamic tract crosses in the spinal cord
and ascends on the opposite side
NB to understand this as it helps to understand
the clinical features of injury patterns and
the neurological deficit
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19. Dermatomes
• Area of skin innervated by sensory axons
within a particular segmental nerve root
• Knowledge is essential in determining level of
injury
• Useful in assessing improvement or
deterioration
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22. Myotomes :
• Segmental nerve root innervating a muscle
• Again important in determining level of injury
• Upper limbs:
C5 - Deltoid
C6 - Wrist extensors
C7 - Elbow extensors
C8 - Long finger flexors
T 1 - Small hand muscles
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26. Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is irreversible
ii) Loss of sensation
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27. Incomplete:
i) Some function is present below site of
injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although
they are rarely pure and variations occur
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28. Injury defined by ASIA Impairment Scale
ASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function
preserved in sacral segments S4– S5
B – Incomplete: sensory, but no motor function
in sacral segments
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29. C – Incomplete: motor function preserved below
level and power graded < 3
D – Incomplete: motor function preserved below
level and power graded 3 or more
E – Normal: sensory and motor function normal
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30. Muscle Strength Grading
• 5 – Normal strength
• 4 – Full range of motion, but less than
normal strength against resistance
• 3 – Full range of motion against gravity
• 2 – Movement with gravity eliminated
• 1 – Flicker of movement
• 0 – Total paralysis
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31. SPINAL SHOCK
• Spinal shock was first defined by Whytt in
1750 as a loss of sensation accompanied by
motor paralysis with initial loss but gradual
recovery of reflexes, following a spinal cord
injury (SCI) – most often a complete
transection
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33. Spinal Shock vs Neurogenic Shock
Spinal Shock :
• Transient reflex depression of cord function below level of
injury
• Initially hypertension due to release of catecholamines
• Followed by hypotension
• Flaccid paralysis
• Bowel and bladder involved
• Sometimes priaprism develops
• Symptoms last several hours to days
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34. Neurogenic shock:
• Triad of i) hypotension
ii) bradycardia
iii) hypothermia
• More commonly in injuries above T6
• Secondaryto disruption of sympathetic
outflow from T1– L2
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35. • Loss of vasomotor tone – pooling of blood
• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid infusion
alone
• Massive fluid administration may lead to overload
and pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
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38. TYPES OF INCOMPLETE INJURIES
i) Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome
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39. i) Central Cord Syndrome :
• Typically in older patients
• Hyperextension injury
• Compression of the cord anteriorly by
osteophytes and posteriorly by ligamentum
flavum
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40. • Also associated with fracture dislocation and
compression fractures
• More centrally situated cervical tracts tend to
be more involved hence
flaccid weakness of arms > legs
• Perianal sensation & some lower extremity
movement and sensation may be preserved
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43. ii) Anterior cord Syndrome:
• Due to flexion / rotation
• Anterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal
• Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia
of blood supply (anterior spinal arteries)
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44. Clinically:
• Loss of power
• Decrease in pain and sensation below lesion
• Dorsal columns remain intact
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46. ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures of
the posterior elements of the vertebrae
Clinically:
• Proprioception affected – ataxia and
faltering gait
• Usually good power and sensation
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48. iv) Brown – Sequard Syndrome:
• Hemi-section of the cord
• Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
• Fractures of lateral mass of vertebrae
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49. Clinically:
• Paralysis on affected side (corticospinal)
• Loss of proprioception and fine discrimination
(dorsal columns)
• Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
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51. v) Cauda Equina Syndrome:
• Due to bony compression or disc protrusions
in lumbar or sacral region
Clinically
• Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia
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57. TRAVELING IN RURAL AFRICA
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58. CLASSIFICATION OF C/SPINE INJURIES
1. Flexion injuries
2. Flexion and rotation
injuries
3. Extension injuries
4. Compression injuries
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59. Causes of flexion / flexion-rotation injuries
• Motor cycle spills
• Diving in shallow water
• Pole vaulting
• Rugby football
• Blows at the back of the head
• Rapid deceleration as in head-on car collisions
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60. • Blow at the back of the head
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61. Hyperextension injuries
• Often due to a blow on the forehead..look for
a bruise on the brow
• Rear impact car accidents, the head
overextends
• Susceptible people are:
Pathological spines..spondylotic spines,
middle and elderly aged people, congenital
anomalies
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62. The pathology of hyper-extension injury
• Neck hyperextends (1)
• Stretching and tearing of the
anterior longitudinal ligament (2)
• Stretching of the cord (3)
• Nipping of the cord by
osteophytes (4)
• Stretching and kinking of spinal
vessels leading to spreading
thrombosis (5)
• Contusion and hemorrhage
inside the cord (6)
• Spontaneous reduction is the
rule, Xrays may be normal
• A tear drop fracture when
present may be the only tale-tell
sign, or a increased
retropharyngeal shadow
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63. Clinical features of hyperextension injuries
• Diffuse cord damage that does not correspond with the level
of injury
• Anterior cord syndrome..motor paralysis
• Rarely central cord syndrome..and if so..mostly motor
signs… and lower limbs more severely affected than the
upper limbs
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64. SOFT TISSUE INJURIES OF THE NECK
Whiplash injuries
Terminology loosely used
to denote soft tissue
injuries without
fracture sustained in
road traffic accidents
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65. SOFT TISSUE INJURIES OF THE NECK, WHIPLASH
INJURIES
• Consist of hyperflexion and hyperextension
mechanisms
• Often no radiologic lesions are demonstrable
• Mostly soft tissue strains
• No neurological lesions
• Resolve slowly up to 3 years
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66. Compression fractures
of the cervical spine
Mechanisms
• A blow to the vertex of the head e.g in a
car accident the vertex strikes the roof of
the car.
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67. Compression fractures, clinical features
• There is a bruise or hematoma at the vertex
• There is a quadriplegia often mostly motor and upper limbs more
severely affected than the lower limbs
• There may be loss of temperature and pain modalities
• Proprioception and touch could be spared
• On X-ray: There is a fracture of the vertebral body which can be a
fissure, a burst type or compression
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68. Fractures of the upper 2 cervical vertebrae
(the atlas, axis)
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69. FRACTURE OF THE PEDICLE OF C2 =
HANGMAN’S FRACTURE
This can occur in 2 ways:
1.Traction and a hyperextension jerk or
2. Vertical compression and a hyperextension jerk
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70. ODONTOID FRACTURES
• Best imaged by through open mouth X-ray views
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71. The odontoid process and the transverse ligament of the axis
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72. When there is a rupture of the transverse ligament the cord is in a more perilous
situation
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73. Fracture-dislocations of the atlas and axis
• Treatment: first by skull traction and later by surgical fusion
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74. Fractures of the odontoid process, 3 types
1=apical fractures
2 =waist fractures (bad prognosis
due to high frequency of
non-union)
3=base fractures
Other diagram shows
immobilisation by
skull halo -body orthosis
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75. diagnosis
Suspect c/spine injury when patient:
1. Complains of neck pain, occipital,
shoulder after trauma
2. Has torticollis (wry neck)
3. Complains of restricted neck
movements
4. Supports head with the hands
5. Unconscious after head injury
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76. • Palpate the neck for tenderness
and muscle spasm
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78. Diagnosis - radiology
X-rays:
AP and Lateral views, C7-T1 junction must be seen. If necessary be in the Xray
room to pull down the shoulders
Special views:
• Flexion / extension views to assess stability
• Oblique views will show the intervertebral foramina; good to assess
facetal locking, radicular symptoms and nerve roots compressions
• Open mouth views are good for assessing C1, C2 lesions
• CT-scan
• MRI scan
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79. Diagnosis, radiology
In the X-ray department support the head
when Xrays are being taken to obtain
good views
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80. Initial Management of spinal cord injury
• Immobilization
– Rigid collar
– Sandbags and straps
– Spine board
– Log-roll to turn
• Prevent hypotension
– Pressors: Dopamine, not Neosynephrine
– Fluids to replace losses; do not overhydrate
• Maintain oxygenation
– O2 per nasal canula
– If intubation is needed, do NOT move the neck
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81. Management in the hospital
• NGT to suction
– Prevents aspiration
– Decompresses the abdomen (paralytic ileus is common in the first
days)
• Foley
– Urinary retention is common
• Methylprednisolone (Solu-Medrol)
– Only if started within 8 hours of injury
– Exclusion criteria
• Pregnancy
• Age <13 years
• Patient on maintenance steroids
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82. CT scan
• Good in acute situations
• Shows bone very well
• Soft tissues (discs, spinal cord) are poorly
visualized
• Do NOT give contrast in trauma patients
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83. MRI
• Almost never an emergency
• Shows tumors and soft tissues (e.g., herniated
discs) much better than CT scan
• May be used to clear c-spine in comatose
patients
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84. Treatment of Spinal Injuries
• No Current Effective Treatment
• Prevention is Key
– all current medical and surgical treatments aimed
to prevent further injury to the spinal cord.
ATLS principles
• A irway; protect Cspine
• B reathing
• C irculation
• D isability, Dx and Rx shock
• E xpose patient
• Treat (IV, XR chest/Cspine)
• Secondary surveySaturday, December 12, 2015 84
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85. Complex spinal trauma
Cervical spineRadiological evaluation
X-ray Guidelines (cervical)
• AAdequacy, AAlignment
• BBone abnormality, BBase of
skull
• CCartilage, CContours
• DDisc space
• SSoft tissue
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86. Immediate Management-
Goals:
• Resuscitation according to ATLS guidelines
• Determination of neurological injury
• Prevention of neurological deterioration
• Ongoing ID & Tx of assoc injuries
• Prevention of complications
• Initiation of definitive management for
vertebral column injury or SCI
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87. Decision to Intubate:
• Need for Artificial Airway is Usually Related to Resp Compromise e.g.
– Loss of innervation of the diaphragm
(C 3-4-5 keep the diaphragm alive)
– Fatigue of innervated resp muscles
– Hypoventilation
– V/Q mismatch
– Secretion retention
– Associated injuries
• Occiput - C3 Injuries
(ASIA A & B)
– Require immediate intubation
and ventilation due to loss of innervation of diaphragm
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88. Decision to Intubate
Related to Neurological Level
cont’d
• C4-C6 Injuries (ASIA A & B)
–Serious consideration for prophylactic
intubation and ventilation if:
• Ascending injury (requires serial M/S assessment
by a trained clinician)
• Fatigue of unassisted diaphragm
• Inability to clear secretions
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89. Co-Morbidities to Consider…
• Advanced age
• Premorbid conditions
• Chest trauma
• Hx of aspiration
• Head injury or substance
abuse
• Acute ileus
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91. Breathing cont’d
• Intervention
– O2 therapy
– Assisted ventilation PRN
– Medications
(bronchodilators)
– Positioning and
mobilizing
– Chest physio
– Assisted Cough
Baseline Resp Assessment
• Clinical Observations
– RR
– Type of ventilation and
FiO2
– Resp muscle activity
– Skeletal Integrity
– Breathing pattern
– Chest mobility
– Cough Function
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92. Circulatory
Spinal Shock
• Temporary suppression of all
reflex activity below the level
of injury
• Occurs immediately after
injury
• Intensity & duration vary
with the level & degree of
injury
• Once BCR returns, spinal
shock is over
Neurogenic Shock
• The body’s response to the
sudden loss of sympathetic
control
• Distributive shock
• Occurs in people who have
SCI above T6 (> 50% loss of
sympathetic innervation)
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93. Hemodynamic State
Unopposed parasympathetic outflow can lead to cardiac
dysrhythmias and hypotension (most common within first
14 days)
• Hypotension is due to loss of
vasomotor tone-peripheral pooling
of blood and decreased preload
• Most common dysrhythmia is
bradycardia
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94. Circulatory Assess
• Level of SCI?
• Complete or
incomplete?
• Heart rate and rhythm?
• B/P? Premorbid
hypertension?
• LOC?
• U/O?
• Volume status?
• First Line:
Volume |Resuscitation (1-2 L)
• Second line:
Vasopressors-
(dopamine/norepinephrine)
to counter loss of sympathetic
tone and provide
chronotropic support to the
heart
Hemodynamic Instability:
Intervention
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95. Bradycardia: Intervention
• Prevention:
– Avoid vagal stimulation
– Hyperventilate and hyperoxygenate prior to
suctioning
– Pre-medicate patients with known hypersensitivity
to vagal stimuli
• Treatment of Symptomatic Bradycardia:
– Atropine 0.5 - 1.0 mg IV
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96. GI System
• Risk of aspiration is high d/t:
– cervical immobilization
– local cervical soft tissue
swelling
– delayed gastric emptying
• Parasympathetic reflex activity is altered,
resulting in:
– decreased gut motility and
– often prolonged paralytic
ileus.
• Minimizing Risk for
Aspiration:
–Nasogastric tube
• Minimizing Risk of Gastric
Ulceration:
–IV Ranitidine
50mg IV q8h
GI Intervention
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97. GU System
• All ASCI patients initially managed with
indwelling urinary catheter
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98. Skin Care: Common Sites of
Pressure Sores
OcciputOcciput
SacrumSacrum
TrochanterTrochanter
IschiumIschium
AnkleAnkle
HeelHeel
• Remove spine board
• Turn or reposition
individuals with SCI initially
every 2 hours in the acute
phase if the medical
condition allows.
Skin Intervention
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99. Pain Management
Proposed 2 Broad Types:
NociceptiveNociceptive: Musculoskeletal and Visceral
–Responds well to opioids and NSAIDS
• NeuropathicNeuropathic: Above Injury/At Injury Level/Below Injury
Level
– Somewhat sensitive to Morphine
– More sensitive to anticonvulsants
(gabapentin) and tricyclics (nortryptiline)
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100. Pharmacologic Therapy
• Option: Methylprednisolone
• NASCIS II (1992)NASCIS II (1992) (National Acute Spinal Cord Injury Study)
– 30mg/kg IV loading dose + 5.4 mg/kg/hr (over
23hrs) effective if administered within 8 hours of
injury
• NASCIS III (1997)NASCIS III (1997)
– If initiated < 3hrs continue for 24 hrs, if 3-8 hrs
after injury, continue for 48hrs (morbidity higher -
increased sepsis and pneumonia)
Both studies criticized for methodologyBoth studies criticized for methodology
MPSS Evidence
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101. • Meta-analysis showed insufficient evidence to support
use of high dose MPSS in ASCI as a treatment standard
or guideline for treatment.
• Weak clinical evidence to support MPSS as per NASCISNASCIS
II but not NASCIS IIIII but not NASCIS III protocol as an option for
treatment.
MPS Clinically Effective?
Canadian Association of Emergency Physicians Jan 2003
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102. Transfer Checklist
Spinal immobilisation
Airway risk is identified
ETT if PaCO2 =
50mmHg or
greater
Supplemental O2
Assisted ventilation PRN
MPSS in progress if
appropriate
NG insitu
Foley catheter
Skin is protected
Level of SCI documented
X-rays, CT, MRI
accompany patient
Family contacts
documented
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103. Cervical Traction
• Gardner-Wells tongs
• Provides temporary stability of the cervical spine
– Contraindicated in unstable hyperextension injuries
• Weight depends on the level (usually 5lb/level, start with
3lb/level, do not exceed 10lb/level)
• Cervical collar can be removed while patient is in traction
• Pin care: clean q shift with appropriate solution, then apply
povidone-iodine ointment
• Take XRays at regular intervals and after every move from
bed
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105. Surgical Decompression and/or Fusion
• Indications
– Decompression of the neural elements (spinal
cord/nerves)
– Stabilization of the bony elements (spine)
• Timing
– Emergent
• Incomplete lesions with progressive neurologic deficit
– Elective
• Complete lesions (3-7 days post injury)
• Central cord syndrome (2-3 weeks post injury)
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106. Soft and hard collars
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107. Minerva vest and halo-vest
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108. Long term care
• Rehab for maximizing motor function
• Bladder/bowel training
• Psychological and social support
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Editor's Notes
Resuscitation according to ATLS guidelines – you know this
We will talk about
Determination of neurological injury
Prevention of neurological deterioration
Ongoing ID & Tx of assoc injuries
Prevention of complications
Initiation of definitive management for vertebral column injury or SCI
Gabapentin not shown effective in Acute SCI
Many of you are likely familiar with the use of Solumedrol post spinal cord injury to reduce the secondary injury associated with SCI
Reference?
In fact the Canadian Association of Emerg Physicians did a meta – analysis of NASCIS trials and found that there was weak clinical evidence to support the use of MPSS as a standard/guideline of treatment and recommend it as an option of care.