Spinal Cord Injuries
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- Neurogenic shock – Hypotension and relative bradycardia due to loss of sympathetic tone
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- Will need vasopressors - Adrenaline or nor-adreanline
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- Primarily affects inspiration
- C3,4,5 - diaphragm
- C2 - 7 - accessory muscles - SCM, scalene, upper trapezius
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- Spinal Shock – Temporary loss of spinal cord function = Flaccid. Also has hypotension and brady. Check Bulbocavernosus reflex OR anal reflex
- Clinically, when spinal cord injury, there should be spastic paralysis, hyperreflexia below the lesion, sensory loss, along with neurogenic bowel and bladder and sexual dysfunction
- but in spinal shock, there is flaccid paralysis and hyporeflexia
- https://www.nature.com/articles/s41394-019-0251-3
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- required to squeeze the glans penis in men and most commonly touching the clitoris (or labium minus) in women to stimulate the reflex while checking for a reflex contraction of the external anal sphincter
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- For the anal reflex, the testing of the S4-5 dermatome by a safety pin is already performed as part of the ASIA score and as such, the examiner only needs to monitor for the visible contraction of the anal sphincter muscles during this test.
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- No need because spinal shock can last for days to weeks
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- A - total loss of sensation and motor
- B - sensation only, motor 0 (”anal sparing”
- C - sensation + motor < 3/5
- D - sensation + motor > 3/5
- E - normal
- Spinal level is defined as the most caudal (inferior) functioning root level with intact sensation and Grade 3 or greater motor function; however, the lowest normal sensory level may be substituted in regions without readily testable myotomes (such as in the thoracic spine).”
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- No motor or sensory function preserved in sacral segments!
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- Aim is to prevent secondary cord injury and to maintain perfusion to the spinal cord
- IV fluids to maintain BP
- Urinary catheterization to monitor output
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- Clinical - BP, urine output, skin turgor
- Bedside - US for IVC filling, kissing ventricles
- Blood investigation - ABG, lactate
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- Based on UK NICE Guidelines, I will not give
- Also 2016 Cochrane reviews that pooled evidence from 3 RCT did not demonstrate benefit for methylprednisolone
- However, aware that this is controversial and is dependant on my specialist spine consultant and i will consult him
- Aware that the AO spine 2017 CPG by Fehlings et al. recommend steroid if < 8 hour from injury; to give 24 hours of high does MPSS (30 mg/kg bolus followed by 5.4 mg/kg/h for 23 h)
- Also Aware that NASCIS 3 trial post-hoc analysis shows that if methylpred given within 3-8 hours and continued for 48hr, more likely to improve one motor grade at 6 months
- Singapore - most do not give Methylprednisolone. However, most give dexamethasone.
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- National Acute Spinal Cord Injury Studies by Bracken et al.
- There were 3 RCTs in this trial series
- 1984 trial - no difference BUT early case fatality and wound infection higher with steroids
- 1990 trial - no difference.
- 1998 trial - no difference
- BUT in NASCIS 2 and 3, post hoc subgroup analysis showed that if given within 8 hours, more likely to improve one motor grade at 6 months
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- STASCIS trial - Surgical Timing in Acute SCI Study by Fehling et al. 2012
- Decompression in < 24 hrs more likely for ASIA score to improve by 2 grades or more at 6 months
- 20% vs 8.8% chance. Odds 2.8x
- Early intervention (24hours) should be considered.
- Recent Pooled analysis of 1500 patients in Lancet.
- Surgical decompression within 24 h of acute SCI is associated with improved sensorimotor recovery. The first 24–36 h after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive surgery following acute SCI.
- https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(20)30406-3/fulltext#:~:text=Surgical%20decompression%20within%2024%20h,decompressive%20surgery%20following%20acute%20SCI.
STACIS.pdf218.7KB
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- Autonomic dysreflexia is a condition that emerges after a spinal cord injury, usually when the injury has occurred above the T6 level
- Dysregulation of the autonomic nervous system leads to an uncoordinated autonomic response that may result in a potentially life-threatening hypertensive episode when there is a noxious stimulus below the level of the spinal cord injury. In about 85% of cases, this stimulus is from a urological source such as a UTI, a distended bladder, or a clogged Foley catheter. There is a significantly increased risk of stroke by 300% to 400%
- Patients usually develop autonomic dysreflexia one month to one year after their injury.
- Objectively, an episode is defined as an increase in systolic blood pressure of 25 mm Hg.
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- The most common stimuli are distention of a hollow viscus, such as the bladder or rectum. Pressure ulcers or other injuries such as fractures and urinary tract infections are also common causes.
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- Monitoring of BP
- Correct noxious stimuli
- Bladder - check fo retention, foley blockage, kinking
- Rectum - check for impaction (gentle)
- Reduce BP
- Sit patient upright
- If BP still high ➔ pharmacologics = nitrates (either nitropaste or sublingual), nifedipine (oral or sublingual), sublingual captopril, intravenous hydralazine, intravenous labetalol
CENTRAL CORD SYNDROME
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- Answer by drawing the spinal cord anatomy (CTLS sequence)
- Most common type of incomplete spinal cord injury
- Acute on chronic condition where by there is baseline cervical central stenosis and after hyperextension injury, develops central cord edema, resulting in impairment of the region in the central cord
- Blood supply is centripetal ➔ so there is also compromise of blood supply
- Because of CTLS sequence, cervical nerves are affected preferentially; in the UL, distal weaker than proximal.
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- Traumatic vs Atraumatic causes
- Traumatic - pre-existing cervical stenosis
- Atraumatic - Syringomyelia, intramedullary cord tumors
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- Good prognosis, most are ambulatory at follow up
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- LL ➔ then bowel bladder ➔ proximal UL ➔ hand function last
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- Management is controversial and surgery can be considered if there is presence of mechanical instability or ongoing compression
- Quote STACIS trial regards to timing
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- Anterior or posterior approach depending on direction of compression
- Usually, if the compression is restricted to one or two levels, the anterior approach is preferred; if more than two levels are involved, the posterior approach may be more advantageous.
BROWN SEQUARD SYNDROME
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- Hemisection of cord resulting in ipsilateral loss of motor and contralateral loss of sensation
ANTERIOR CORD SYNDROME
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- Direct compression/ Anterior Spinal Artery injury (supplies 2/3 of spinal cord)
- LL > UL
- Worst prognosis
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- Supplied by the Anterior and Posterior Spinal arteries
- Anterior Spinal arteries come from the intercostal arteries that then give rise to the artery of Adamkiewicz that runs on the anterior aspect of the spinal cord, supplying anterior 2/3 of the cord
- Posterior spinal arteries comes from the vertebral artery to supply the posterior 1/3 of the cord
