AADO Nurse Subcommittee Trauma Series I

Spinal Injury Workshop 22-23 February 2014

Dr. Law Sheung Wai

Consultant Spine and Orthopedic Rehabilitation Team

Department Of Orthopedics and Traumatology

羅尚尉醫生 香港中文大學醫學院 矯形外科及創傷學系榮譽臨床助理教授

矯形外科及創傷學科顧問醫生

香港中文大學內外全科醫學士

香港外科醫學院院士 英國愛丁堡皇家外科醫學院院士

香港骨科醫學院院士 英國愛丁堡皇家外科醫學院骨科院士

香港醫學專科學院院士(骨科) 香港中文大學流行病學與生物統計學理學碩士

香港中文大學職業醫學碩士 臨床老人學學士後文憑

Spinal Trauma can be disable

and is a life long event

F /18

C4/5 dislocation

With high Tetraplegia!

INITIAL MANAGEMENT OF SPINAL INJURY PATIENTS

• ABC, Spinal board, hard collar History • Strongly suspect spinal injury if any major accident,

unconscious patient, fall from a height, sudden jerk of neck after rear end car collision, facial injuries or head injury .

• Ask about neck or back pain, numbness, tingling, weakness, ability to pass urine

This MRI is the side view

of a patient with an

incomplete spinal cord injury

Had the patient not been

immobilized properly the

injury could have become

complete

Multiple Trauma High Velocity Injury – Spinal Trauma until Proven Otherwise

Neurological Examination

• LOC • Deteriorating course • Neck, back pain and/or bladder, bowel incontinence

should increase suspicion of sc injury • Define level of lesion • Motor function • Sensory level • Proprioception testing • DTRs • Anogenital reflexes

Examination

• Logroll- look for bruising, palpate for a step, tenderness

• Repeated neurological examination to determine neurological damage and its progression/resolution

• Thorough overall examination for fractures etc as patient may not feel pain

NEUROLOGICAL ASSESSMENT IN SPINAL INJURIES

• To determine the level of the lesion- counted as the

lowest level at which neurological function is intact bilaterally

• To determine whether damage is complete/ incomplete

• To determine prognosis • May be difficult until period of spinal shock (flaccidity,

areflexia) is over (24-48 hrs after injury)

Diaphragm C3-4-5

Shrugging shoulders C4

Flex elbows C5,6

Extend elbows C7

Abduct fingers C8

Active chest expansion T1-T12

Hip flexion L2

Knee extension L3-4

Ankle dorsiflexion L5-S1

Ankle plantar flexion S1-S2

Eversion of foot L5

Inversion of foot L4

Reflexes

Biceps C5-6

Triceps C6-7

Supinator C5-6

Knee jerk L3-4

Ankle jerk L5-S1

Plantar response If upgoing = UMN lesion

Abdo cutaneous reflexes

If lost = UMN lesion

Bulbo cavernosis reflex

Pull penis, causes anal sphincter tightening If returned, period of spinal shock is over

Dorsal column

Anterior spino-

thalamic tract

Cortical

spinal tract

Commonest Incomplete SCI

Central Cord Syndrome

Older patients

Preexisting central

spondylosis

Hyperextension injury

Injury affects central cord>

peripheral cord

Damage to corticospinal

and spinothalamic tracts

Upper extremities>thoracic

>lower extremities>sacral

CCS

Present with: Decreased strength

Decreased pain and temperature sensation

Upper>lower extremities

Spastic paraparesis/quadriparesis

Maintain bladder and bowel control

Prognosis: GOOD Although fine motor recovery of the upper

extremities is rare

Complete vs Incomplete Incomplete:

Sensory, motor or both functions are partially present below the neurologic level of injury

Some degree of recovery

Complete: Absence of sensory and motor function below the level of

injury

Loss of function to lowest sacral segment

Minimal chance of functional motor recovery

If neurological damage

• Catheterise • Note reduced BP and bradycardia due to neurogenic

shock (temporary generalised sympathectomy). Rule out hypotension due to haemorrhage elsewhere. May need treatment with vasopressors, not fluid resuscitation.

• Invasive monitoring required • Give methylprednisolone IV 30mg/kg over 15

mins then 5.4mg/kg/hr for next 23 hours. Needs to be given within 8 hrs. Discuss with the spinal team.

• Attend to skin by turning

DI

C-spine films as per c-spine rules/nexus

CT

MRI: better for visualizing neurological, muscular and soft tissue

If CT negative and patient has positive neurological findings, this is next step

Important to image entire spine as 10% have 2nd injury

Management:

• Trauma series X-rays

Clear c spine if all the following fulfilled

• Alert , not intoxicated

• No neurological symptom or sign

• No midline neck pain or tenderness

• Painless , full range of movement

• Absence of a distracting painful injury

Adequate Cervical spine X ray

• Lateral- must be good quality and

adequately visualize the base of occiput to upper T1.

• AP- seen spinous process of C2 to C7

• Open mouth- must see the entire dens and lateral masses of C1.

C1

C2

C3

C4

C5

C6

C7

Open mouth view

If possible

C2

Can’t see C7 ?

• Pulled shoulder

• Swimmer view

• CT or MRI

Swimmer’s View

Soft tissue swelling

Pull

Shoulder

C1 Fracture

Fracture

C1 Fracture

C1 Fracture

C 2 fracture

Fracture line

C 2 fracture

C 2 fracture

C 7 Fracture

C 7 Fracture

Acute Phase

• Spinal Shock vs Neurogenic shock

• Role of Steroid in management of spinal cord injuries

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

Spinal Shock Symptoms:

Flaccid paralysis Loss of sensation Loss of DTRs Bladder incontinence Bradycardia Hypotension Hypothermia Intestinal ileus

Neurogenic shock:

• Triad of i) hypotension

ii) bradycardia

iii) hypothermia

• More commonly in injuries above T6

• Secondary to disruption of sympathetic

outflow from T1 – L2

• 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

Hypotension Must determine cause:

Spinal cord injury

Blood loss

Cardiac injury

Combination of above

Blood loss is the cause of hypotension until proven otherwise!

Vitals are often non specific

R/O other causes with: CXR, FAST, CT

Corticosteroids

Controversial

Based on NASCIS trials

Methylprednisolone improved both motor and sensory

functional outcomes in complete and incomplete injuries

Benefit dependent on dose and timing of dose

Corticosteroids NASCIS recommends:

1. Treatment must begin within 8h of injury

2. Methylprednisolone 30mg/kg bolus iv over 15 minutes

3. 45 minute pause post bolus

4. Maintenance infusion 5.4mg/kg/h methylprednisolone is continued x 23h

• Evaluated in blunt injury only

• Large doses of steroids in penetrating injury may be detrimental to recovery of neurological function

Steroid Therapy as per NACSIS

Attributed to antioxidant effects

Treat for 24h in patients treated within 3h of injury

Treat for 48h in patients treated within 3-8h of injury

Worse outcome if started 8h post injury

Conflicting evidence re benefit therefore more trials required

Pros Cons Believed to inhibit

formation of free radical-induced peroxidation

May increase spinal cord blood flow

Increase extracellular calcium

Prevent potassium loss from cord

Pneumonia

Sepsis

Wound infection

GIB

Delayed healing

NASCIS I Bracken et al. 1984. Efficacy of methyprednisolone in

acute spinal cord injury, JAMA, 251:45-52

Prospective, randomized double blind trial with 330 patients

2 treatment arms: 100 mg bolus MP, then 25 mg q6h x 10 d 1000 mg bolus, then 250 mg q6h x 10 d

No sig difference in primary outcomes

4x increase in wound infections in high dose group

“Trend” towards increased sepsis, PE, death in higher dose group

NASCIS II Bracken NEJM 1990; 322: 1405-11

DBRCT of methylprednisone vs naloxone vs placebo (total N=487)

Methylprednisone 30 mg/kg bolus then 5.4 mg/kg/hr X 23 hours

Outcome = neurological function at 6 weeks and 6 months assess by a neuro function score

NO benefit of naloxone

NO benefit of steroids overall

NO difference in mortality

Trend to more infections and GI bleeds with steroids

NASCIS II

Post – hoc SUBGROUP ANALYSIS showed a benefit at 6 months in the subgroup treated within 8 hrs Improved motor score: 4 points (p < 0.03)

Improved Touch score: 5 points (p < 0.03)

Improved pin-prick score: 5 points (p < 0.02)

Concluded that steroids were indicated if started within 8hrs

One year data showed similar improvement in motor score but no difference in sensory scores (Bracken. J Neurosurg

1992; 76; 23-31)

NASCIS III Bracken JAMA 1997: 277(20); 1597-1604

DBRCT of methylprednisone 24hrs vs 48 hrs vs Tirilazad (total N=499)

NO placebo arm

Overall, NO difference between the three groups

Post-hoc subgroup analysis: 48 hour steroid group showed improved motor scores at 6 weeks and 6 months if started between 3-8hrs 6 weeks: 5 points motor score (p <0.04)

6 months: 4.4 points (p <0.01)

NASCIS III

Adverse outcomes Severe pneumonia higher in 48hr group 2.6% vs 5.8% (p<0.02)

Severe sepsis higher in 48hr group 0.6% vs 2.6% (p< 0.07)

They concluded Steroids indicated for SCI

If started within 3hrs, treat for 24hrs

If started within 3-8hrs, treat for 48hrs

Cochrane Review “the randomized trials of MPSS in the treatment of acute

SCI provide evidence for a significant improvement in motor function recovery after treatment with the high dose regimen within 8 hours of injury”

Bracken November 2000

Update in Spine 2001 by Bracken

4 trials and 797 patients randomized to get high dose methylpred vs placebo for 24 hours

Cochrane Review Results

Primary outcome = neurological

improvement at 6 weeks, 6 months, 1

year

Complicated motor and sensory exam

High dose methylpred associated with

4/70 point increase in motor function at

6 weeks, 6 months but not one year

SCI and Steroids

Clinical relevance? 4 points spread over 14 muscle segments unilaterally

Not validated score

No inter-rater reliability

Conclusions based on post-hoc analysis of small subgroup from 1 trial 65 patients per arm

Data drudging

High risk of alpha error

Serious complications (not statistically significant) GI bleed and wound infection (RR 4.00, 95% CI 0.45-35.58)

Severe pneumonia (RR 2.25, 95% CI 0.71-7.15)

Range of values in CI huge do the risks outweigh the benefits??

SCI and Steroids Author consultant for Pharmacia (they make

methylprednisolone)

Weak support for use of high dose methylpred in acute SCI + may be increased risk of severe adverse outcomes.

Bottom Line

CAEP position statement : steroids are NOT

STANDARD OF CARE

There is insufficient evidence to support the use

of high dose methyprednisolone within 8 h of

acute SCI

Significant harm to using steroids

NASCIS subgroup data needs to be validated in

prospective, randomized, blinded trials

No new literature to argue for or against this

Treatment

Prevent secondary injury

Alleviate cord compression

Establish spinal stability

Assess the neurological deficit and

spinal stability

Definitive management

• Preserve neurological function, by immobilizing and giving steroids

• Relieve reversible nerve or cord compression by reduction of fracture/dislocation

• Stabilize the spine • Rehabilitate patient

SCI Goals of Care

There's no way to reverse damage

Treatment focuses on: 1. Preventing further injury

2. Enabling people to return to an active and

productive life within the limits of their disability

68

Reduction

• Can improve comfort, can relieve nerve tension, can decompress neural structures

• Traction

– 1.Gardner Wells Tongs. 2kg increments with Xray assessment and neurological examination after each increment

– 2. Halo Rings- can later be converted into halo vest config to hold neck as definitive treatment

– 3. Halter traction for C1/2 subluxations

– Ideally MRI compatible

– Open at surgery

1 cm

Gardner Wells Tong

Fixation till healing

• External fixation – Hard SOMI collar, (Sterum Occipital Mandibular Immobilisation), if stable fractures

• Halovest, if unstable. Safe, effective. Can be used from acute situation to end of treatment. Not preferred treatment if neurological deficit

• Continued traction in supine position, rarely used these days, but can be used if delay in going to theatre, or patient refuses surgery

• Internal fixation- anterior or posterior fusion (see below)

• Selection of Holes:

• optimum positioning of the halo is critical to ensure stability, durability and patient comfort

• 4 holes are placed in the scalp, 2 anteriorly and 2 posteriorly

• anterior pin sites: – centered in groove at upper margin

of eyebrows, between supraciliary ridge and the frontal prominences

– sagitally, the pins should be placed just superiorly to outer half of eyebrows, to avoid the supraorbital nerve and vessels

– placed too inferiorly, the pins might encroach on the orbit

– they should be placed as close to midline of eyebrow as possible, as thickest mass of bone is central

– placed too medially, however, the pins might encroach on the frontal sinus

• posterior holes: – this placement of halo

ensures that it will be below maximum diameter of skull and the will not migrate

superiorly

Role of surgical intervention

• Stabilization

• Achieve fusion of Involved segment

• Prevention of pain

• Prevention of deformity

• Allow early mobilization

• Facilitate nursing care

Urgent Surgery recommended when

• Progressive neurological deficit with persistent dislocation or neurocompression not corrected by closed traction

• Persistence of incomplete spinal cord injury with continued impingement on neural elements

Less urgent surgery recommended when

• Unstable dislocations which have been reduced. (ligamentous injuries less likely to heal. Fusion indicated)

• Complete spinal injury with unstable fractures, to enable early rehabilitation

M/25 RTA fracture C7 with tetraplegia

Spinal Cord Injury Rehabilitation Management

Regional Centre Programmatic Approach

• Rescue

• Emergency care

• Acute care

• Rehabilitation

• Long Term Care

• Community reintegration

Rehabilitation-Team Approach

• Ortho Surgeon/Urologist/Plastic Surgeon

• Rehabilitation Physician

• Nurses

• Physiotherapist/Occupational Therapist

• Prosthetist and Orthotist

• Social Worker

• Clinical Psychologist

Rehabilitation Team 康复团队

康复医师

物理治疗师

作业治疗师

假肢及矫形师

康复护士

心理治疗师

以伤员或病人为中心

Goal of Rehabilitation

• To reintegration patient back to the society

by 1)To minimize the potential

complication

2)To maximize the remaining potential

Complication in SCI Respiratory System

• Most common respiratory complication

pneumonia and atelectasis

• Risk factors-neurological level above T10

-smoking history

-obesity

-recent history of GA

• Cough suppression and increase secretion

• Chest physiotherapy

Complication in SCI DVT and pulmonary Embolism

• DVT in 15% paraplegic and 4% tetraplegic

• High risk for best rest patient

• Regular thigh and calf assessment

• Doppler ultrasonography/venography

• Antiembolic stocking/mechanical pump

• Prophylactic anticoagulation controversial

Complication in SCI Urinary System

• Most common complication

Urinary Tract infection(66% in paraplegics

and 70% in tetraplegics)

• Spinal shock : flaccid bladder

• Urethral catheterization

• Urodynamic assessment

• Bladder Training

• Intermittent catheterization

• Treatment of asymptomatic bacteriuria

Complication in SCI Digestive System

• Paralytic ileus ( 3 to 5 days )

• Return of bowel sound : Bowel programme

• Use of H2 blocker/gastric mucosal protection agent to prevent stress ulcer

Complication in SCI Skin

• Decubitus ulcer(pressure necrosis) • Pressure Vs time relationship • Most costly(5 fold increase of cost) • Dependent area over bony prominences • Prevention by meticulous and alert carers • Turning patient every 2 hours • Regular careful inspection of high risk areas • Redness failed to fade after 15 mins:alter turn prog • Perineum checked for soilage • Intravenous lines inspected • Catheter checked for proper drainage

Complication in SCI Musculoskeletal System

• Flaccid in acute stage

• Development of joint contracture

• Muscle atropy

• Osteoporosis

Complication in SCI Autonomic Hyperreflexia

• In lesion above T6

• Precipitated by blockage of urinary catheter with bladder distention,visceral distention from full bowel,irritative pressure sore,IGTN

• Clinical sign: bradycardia,sweating,rhinorrhoea,pounding headache and severe paroxysmal hypertension

• Serious consequences:epileptic fits,CVA,death

• Treatment : Remove the causes,antiHT drug

Complication in SCI Spasticity

• Gradual increase in tone of paralysed muscle due to excessive reflex activities below level of lesion

• Average time for appearance

Cervical injury-6 weeks

Thoracic injury-10 weeks

• Maximum at 2 years after SCI and gradually diminishes

Complication in SCI Spasticity

• Almost all cervical injuries have spasms

75% of thoracic lesions

Less than 58% of lumbar lesions

Less than 25% of conus-cauda equina

Partial lesion more severe spasm than complete lesion

• A nuisance to spinal patient affecting positioning and personal hygiene

Complication in SCI Spasticity

• Treatment

Prevention-full ROM exercise of paralysed

muscle and passive stetching of

spastic muscles

-uprighted posture encouraged

-correct any irritating foci below

level of lesions

Complication of SCI Spasticity

Conservative treatment Physiotherapy Drugs-valium,baclofen,clonidine,gabapentin Nerve blocks (phenol or alcohol) Motor point blocks Surgical Management Neurectomy Rhizotomy Myelotomy Orthopaedic procedures

Complication of SCI Psychological system

• Classic phases of reaction: shockdenialangerdepression

gradual elevation of spirits

• Family support

• Doctor-patient relationship

• Keep informed of the medical status of patient

• Hope for the best but prepare for the worst

Bladder Training • Urodynamic Study

• Early Bladder management

To achieve a catheter-free state,the bladder consistently empties completely,the urine is sterile and the patient remains continent

Bladder Training Intermittent Catheterization

6 times per 24 hours

Fluid intake restricted to 150-200ml per hr

Gradually fewer catheterization required

1 to 3 months for return of detrusor activity

Bladder stimulated to initiate the reflex detrusor contraction and to empty the bladder completely

Drugs to improve reflex contractions

Bladder Training • Bladder emptying by external pressure

-by straining (increase intraabdominal pr)

-by direct manual suprapubic pressure

• High residual volume predispose to reflux,back pressure on the kidneys,

persistent UTI and stone formation

• Keep a low residual urine volume ( 10% of the voided volume;actual volume 50 ml)

Bowel Training • A fixed time pattern instead of cerebrally monitored

urge

• Every-other day evacuation

• Time chosen for evacuation should take advantage of the post-prandial gastrocolic reflex

• A good diet with sufficient bulk necessary for the production of well formed stools

Bowel Training • Night-before laxatives or stool softener

• Defaecation reflex initiated by local anal stimulation using suppositories or rectal touch technique

• A satisfactory bowel habit by trial and error

• Avoid anything which may upset the habit such as change of diet,poor fluid intake

Sexual Function

• Sexual rehabilitation involves both patient and sexual partner

• Objective:to understand and manage sexual activity and reproduction • Dependent on level and completeness of lesion • In complete lesion: loss of psychic

erection,orgasm,effective ejaculation and seminal emission

• Lesion above conus:retain reflex erection to cutaneous stimulation of glans penis but no sensation with sexual intercourse

Sexual Function • In incomplete lesion:variable ability in

erection,ejaculation and orgasm • Usually male patients have adequate erection to

achieve satisfactory intercourse • Psychological factor of being able to satisfy the mate

more important than the genital sensation • Overall:erection 75%;coitus 35%;ejaculation 10%, less than 5% have children • Female much better off:satisfaction from the mind Fertility is unimpaired;pregnancy usually normal

Establishment of Spinal Cord Injury Rehabilitation Centre

One of the three Spinal

Cord Injury

Rehabilitation Centres in

Hong Kong

Physical Training

• Postural training

Physical Training

• Strengthening Exercise

Physical Training

• Passive stretching exercise

Physical Training

• Transfer

Physical Training

• Wheelchair Training

Physical Training • Mobility Training

Physical Training

• Balance

Physical Training

• Pressure relief

Physical Training

• Pain treatment

ADL Training

• Feeding

ADL Training

• Dressing

ADL Training • Cleansing

Establishment of Spinal Cord Injury Rehabilitation Centre

Equipped with the

most modernized

facilities and input

from multidisciplinary

specialists

09’ caseload:

26 admissions

ALOS: 91.03 days

Wheelchair Prescription

Assistive Devices

Splintage and Pressure Garment

Seat Cushion Prescription

Spinal Cord Injury Rehabilitation Centre

Transitional Residential Service

Providing a

supportive living

environment to

develop their skills

and competence

Facilitate to live

independently in the

community

Capacity: 20 beds

Maximum length of

stay: 12 months

Vocational Training

Transportation Training

Home Modification

Recreational Training

The END