Acute Care of Spinal Cord Injury. Meghan Smith, RN, PA-C

Transcription

1 Acute Care of Spinal Cord Injury Meghan Smith, RN, PA-C Physician Assistant, Neuro Surgical, Trauma Services, Intermountain Medical Center, Intermountain Healthcare; Salt Lake City, Utah Objectives: Discuss immediate hospital care/assessment - Immobilization - Assessment neuro function, level of injury (motor/sensory) - Imaging Review types of SCI - complete vs. incomplete Identify SCI syndromes Review need for prevention of secondary injury - eval and treat neurogenic shock - maintenance of spinal cord perfusion MAP goals - use of steroids Discuss need for reduction via traction surgical stabilization

2 Management of Acute Spinal Cord Injury September 2015 Meghan Smith MPAS, PA-C

3 Objectives Outpatient care/assessment of suspected spinal cord injury Hospital care Imaging Types of SCI Complete Vrs Incomplete Prevention of secondary injury Reduction - traction/surgery Role of steroids

4 Statistics 40 million cases in the US a year Causes of TSCI Motor vehicle accidents 48% Falls 16% Violence (GSW esp) 12% Sports 10% Risk Factors Male age median 22 Alcohol 25% Cervical spondylosis/osteoporosis

5 Pathophysiology Initial injury to the spinal column Fracture of the bony elements Dislocation of a joint Fracture and dislocation commonly seen Tearing of the ligaments Disruption and/or herniation of the intervertebtal disc 50% TSCI present quadriparesis or plegia

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7 Case Patient X is a 62 yr old healthy male on a who dived into a lake. He surfaced face down, and was unable to move or breathe well Family pulled him out of the water and gave CPR, EMS was called and responded intubating the patient in the field Initially went to an OSH and was hypotensive, started on levophed MAP > 80 goal

8 Immobilization - Field Care Level II recommendation for spinal immobilization - if cervical spine injury, spinal cord injury or a mechanism of injury c/w the above is present Not indicated if awake, alert, not intoxicated, w/o neck tenderness, or abnormal exam, and no distracting injury Level III recommend for rigid collar, support blocks, backboard

9 Transport Level III recommendation - transport to the nearest capable medical facility. Whenever possible transport to specialized acute injury treatment centers recommended.

10 Hospital Care Clinical Evaluation ABCDs (efficacy of respiratory status) (prevention of hypotension) Pain in the spinal region Asia scoring - paresis or plegia Distracting injuries Evaluate and stabilize other injuries

11 Case - Arrival at Level 1 Center Physical exam - weak grip LUE, all other 0/5, bilat shoulder shrug, LLE 4+/5, full sensation all extremities, rectal tone intact BP stable, awake, intubated CT scan spinal fracture dislocation C2/C3 with R locked facet, anterolisthesis C2 on C3

12 EXAMINATION

13 American Spinal Injury Association Impairment Scale A B C D E Complete cord injury. No motor or sensory function is preserved in the sacral segments S4-S5. Sensory incomplete. Sensory but no motor function below the injured level, including the sacral segments (light touch, pin prick, or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body Motor incomplete. Motor function is preserved below the level of injury more than half of the muscles with a function grade of < 3 Motor incomplete. Motor function is preserved below the injured level with half or more of the muscle function grade > = 3 Normal. Sensation and motor function are graded as normal in all segments.

14 Imaging - Awake patient Level I recommendation - awake asymptomatic - no imaging necessary Level I recommendation - awake symptomatic patient than obtain CT If CT is not available then 3 view x-ray AP/lateral/odontoid Level III recommendation - normal CT and pain - immobilize then obtain flex/extension x- rays when able if normal discontinue immobilization or obtain MRI studies

15 Imaging - Obtunded/unevaluable Level I recommendation - CT as the initial imaging if not available 3 view xray Level III recommendation - If cervical spine normal on CT - continue immobilization until able to evaluate or DC if normal MRI done Flex/ex not recommended

16 Spinal Anatomy

17 QuickTime and a decompressor are needed to see this picture. - QuickTime and a decompressor are needed to see this picture. CT Imaging - Non-contrast - Sagittal/axial views - Previous ACDF

18 Traction - Closed reduction Level III recommendation in awake patients for early closed reduction - restore normal alignment *80% of patients are successfully reduced by traction *Neurosurgery March 2013, vol 72 spp2 - Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries

19 QuickTime and a QuickTime and a decompressor are needed to see this picture. MRI Imaging decompressor are needed to see this picture. Sagittal T2 showing cord compression at C2/C3 Sagittal Stir imaging showing contused cord

20 Case Posterior fusion completed C2-C3 hospital day #2 Stabilize the spine Early surgery to begin mobilization, shorter ICU stay Tracheostomy done at this time as well

21 Incomplete Injury Varying degrees of motor function in muscle groups located below the level of injury Sensation is also preserved, often more so than motor function (sensory tracts are located more peripherally - anal reflex present Central Cord Syndrome - more common Anterior Cord Syndrome Posterior Cord Syndrome - rare Brown-Sequard Syndrome

22 Complete Spinal Cord Injury Rostral zone of spared sensation Reduced sensation in the next caudal level w no sensation in the levels below (including sacral segments S4-S5) Reduced strength in the level below the injury and none more caudally - priapism in males Early injury - absent reflexes, flaccid tone, urinary retention

23 Complete Spinal Cord Injury 3% with complete injury will have some recovery in the first 24 hrs No benefit for early surgery Surgery is done for spinal stabilization If no improvement in the first 24 hrs no expected recovery

24 Neurogenic Shock Unopposed parasympathetic activity occurs due to interruption in the descending sympathetic tracts Causing vasodilation, with no sympathetic vasoconstriction - loss of muscle tone as well (venous pooling) Bradycardia mediated by the Vagus nerve Commonly occurs in injuries involving the cardiac sympathetics T2-T5 Hypothermia

25 ICU MAP Goal and neurogenic shock - IV fluids, vasopressors dopamine, levophed (acutely) consider midodrine for long term use Intubation - RSI Early tracheostomy Frequent respiratory parameters SBP > 90 and Maintain MAP > 85 for 3-7 days, prevent secondary injury that can occur with hypo-perfusion of the spinal cord *Level III recommendation Hypoventilation and atelectasis from weak diaphragmatic and intercostal muscles

26 ICU Bradycardia DVT risk Delayed gastric emptying/ileus Hemodynamic monitoring Skin breakdown Atropine 9% of SCI get a DVT SCDs+ anticoagulant NG tube, bowel meds Adequate volume resuscitation Rotational bed, log rolling

27 Central Cord Syndrome Incomplete lesion affects the central portion of the cord, hyperextension injury damages the spinothalamic tract - vascular watershed Upper ext weaker than lower - burning hands syndrome, varying areas of intact sensation, urinary retention Higher incidence among patients with cervical stenosis, spondylosis Recovery - approx 50% will recover LE strength to ambulate independently (Age < 50) UE does not recover as well, fine motor recovery is poor

28 Anterior Cord Syndrome Lesions anterior ventral portion of the cord - sparing dorsal columns - reflect injury to the anterior spinal artery by bone fragments disc Paraplegia, higher than C7 - quadriplegia Sensory - loss of pain/temp, preserved 2 pt discrimination, deep pressure Recovery - the worst prognosis 10-20% have return of functional motor control

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30 Brown-Sequard Syndrome Spinal cord hemi-section usually from penetrating trauma, or spinal epidural hematoma cord compression 2-4% of spinal injuries Contralateral loss of pain/temp below lesion Ipsilateral loss proprioception/vibration and motor loss below the lesion Best prognosis 90% will ambulate independently

31 Posterior Cord Syndrome Rare, usually contusive Pain, paresthesias upper arms, neck, torso Paresis of upper extremities

32 Surgical Considerations - Goals No evidence based guidelines regarding the indications for, or timing of surgery TSCI *Bagnall AM, Cochrane Database 2008 Stabilize the spine Reduction of dislocations Cervical spine - cord compression with neurologic deficits, esp progressive, unstable Central cord syndrome caused by a disc

33 Surgical Considerations - Timing Controversial - a recent meta-analysis suggest surgery within 8 hrs of injury with relief of spinal compression leads to a better outcome Noonan, Journal of Neurotrauma 2011 Newer studies suggest early surgery decreases medical complications allowing earlier mobilization, shorter ICU stay STASCIS Study - pros/non randomized study 313 pts with surgery < 24 hrs after injury 2.83 x higher chance of improvement of 2 grades of AIS with no difference in complications

34 Steroids NASCIS II RCT improvement in a subset of patients, but no difference between treatment groups at a year NASCIS III RCT motor not fuctional improvement, more sepsis, pneumonia with longer duration steroids

35 Steroids Level I - Methylprednisone is not recommended for use based on the available evidence American Association of Neurological Surgeons and Congress of Neurological Surgeons Steroids are a treatment option but not a recommendation

36 American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery, Official Journal of the Congress of Neurological Surgeons (2013):pp Bagnall AM, Jones L, Duffy S, Riemsma RP. Spinal fixation surgery for acute traumatic spinal cord injury. Cochrane Database Syst Rev 2008; :CD Decker, Jason E. Overview of spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete. Up To Date, Web. Sept of spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete?source Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012; 7:e Furlan, Julio C. Timing of Decompressive Surgery of Spinal Cord after Trqumatic Spinal Cord Injury: An Evidence -Based Examination of Pre-Clinical and Clinical Studies. Journal of Neurotrauma Aug; 28 (8): Greenberg, Mark S. "Spine Trauma." Handbook of Neurosurgery. 6th ed. Lakeland, FL: Greenberg Graphics, Print. Hansebout, Robert R. "Acute Traumatic Spinal Cord Injury." Up To Date, Web. Oct < McKinley, MD, William. "Cardiovascular Concerns in Spinal Cord Injury. Medscape, 28 Oct Web. 21 May < Ploumis, A. et al. A systematic review of the evidence supporting a role for vasopressor support in acute SCI. Spinal Cord (2010) 48, Official Journal of the Congress of Neurological Surgeons (2002): S Print. Bracken MB, Shepard MJ, Collins WF Jr, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg 1992; 76:23.. Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997; 277:1597. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev 2012; 1:CD