Spinal cord trauma: Difference between revisions

Revision as of 20:13, 13 July 2011

Background

Surgical intervention indicated for:
- Progressive neurologic deficits
- Spinal instability
Penetrating injury
- GSW
  - Most are stable injuries and only require supportive orthosis, analgesia
  - Give Abx if GSW traversed the abdomen before injuring the cord
  - Bullet removal does not improve neuro status for stable cervical and thoracic lesions
  - Bullet removal may improve neuro status for thoracolumbar region injury (T11-L2)
- Stabbing
  - Vertebral instability is generally not an issue
  - Delayed deficits are rare
    - If do occur related to retained fragment of blade within spinal canal

Peds

In pts <10yr spinal injury occurs mainly in upper cervical vertebrae
In pts >10yr majority of injuries occur in lower cervical spine, similar to adults
Odontoid fractures are among most common cervical spine injuries in children

.49 These fractures must not be confused with the normal anatomic variations in the odontoid due to synchondrosis between the body of the axis and the odontoid, which may be seen in children up to 7 years of age

cord injury without radiologic abnormality, or SCIWORA, refers to the lack of evidence of vertebral fracture or malalignment on plain radiographs and CT in a patient with spinal cord injury. It is more common in younger children and occurs most frequently with cervical spine injuries. SCIWORA has been reported in up to 55% of thoracolumbar injuries in the pediatric population.51 Despite the lack of findings on radiography or CT, MRI has shown significant pathology in many of these patients

Delayed onset of neurologic damage is usually apparent within 48 hours. Numbness, paresthesias, or "shock-like" sensations in the extremities are suggestive of SCIWORA, and should be expeditiously evaluated for evidence of spinal cord injury

Transient quadriparesis (referred to as "Stinger") is seen relatively frequently in children, most often in young boys after sports injuries. Clinically, there are paresthesias or weakness of the extremities, lasting from seconds to minutes, with complete recovery within 48 hours. No radiologic abnormalities are found

Consider intubation for pt w/ injury at C5 or above
Steroids are no longer recommended
Complete lesion means absence of sensory and motor function below level of injury
- May be confused w/ spinal shock
Anatomy
- Doral columns
  - Proprioception, vibration touch
  - Decussation at medulla
- Corticospinal Tract
  - Voluntary motor
    - Upper extremity fibers more central, lower extremity fibers more lateral
  - Decussation at medulla
- Spinothalamic
  - Pain, temp, touch
  - Decussates one level above entry point to spinal cord

Spinal Cord Syndromes

Complete Transection

Higher lesions are a/w spinal shock and autonomic dysfunction
Priapism implies a complete injury
Sacral sparing excludes complete transection
- Perianal sensation, rectal tone, bulbocavernosus/cremasteric reflexes

Anterior Cord

Etiology
- Direct anterior cord compression
- Flexion of cervical spine
- Thrombosis of anterior spinal artery
Symptoms
- Complete paralysis below the lesion with loss of pain and temperature sensation
- Preservation of proprioception and vibratory function
Prognosis poor

Central Cord

Etiology
- Hyperextension injuries
- Disruption of blood flow to the spinal cord
- Cervical spinal stenosis
Symptoms
- Quadriparesis (greater in upper extremities than lower extremities)
- Some loss of pain and temperature sensation also greater in the upper extremities
Prognosis good

Brown-Sequard

Etiology
- Transverse hemisection of spinal cord
- Unilateral cord compression
Symptoms
- Ipsilateral spastic paresis
- Loss of proprioception and vibratory sensation
- Contralateral loss of pain and temperature sensation
Prognosis good

Cauda Equina

Etiology
- Peripheral nerve injury
Symptoms
- Variable motor and sensory loss in the lower extremities
- Sciatica
- Bowel/bladder dysfunction
- Saddle anesthesia
Prognosis good

Source

Tintinalli's

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
+*Surgical intervention indicated for:
+**Progressive neurologic deficits
+**Spinal instability
+*Penetrating injury
+**GSW
+***Most are stable injuries and only require supportive orthosis, analgesia
+***Give Abx if GSW traversed the abdomen before injuring the cord
+***Bullet removal does not improve neuro status for stable cervical and thoracic lesions
+***Bullet removal may improve neuro status for thoracolumbar region injury (T11-L2)
+**Stabbing
+***Vertebral instability is generally not an issue
+***Delayed deficits are rare
+****If do occur related to retained fragment of blade within spinal canal
+==Peds==
+*In pts <10yr spinal injury occurs mainly in upper cervical vertebrae
+*In pts >10yr majority of injuries occur in lower cervical spine, similar to adults
+*Odontoid fractures are among most common cervical spine injuries in children
+.49 These fractures must not be confused with the normal anatomic variations in the odontoid due to synchondrosis between the body of the axis and the odontoid, which may be seen in children up to 7 years of age
+cord injury without radiologic abnormality, or SCIWORA, refers to the lack of evidence of vertebral fracture or malalignment on plain radiographs and CT in a patient with spinal cord injury. It is more common in younger children and occurs most frequently with cervical spine injuries. SCIWORA has been reported in up to 55% of thoracolumbar injuries in the pediatric population.51 Despite the lack of findings on radiography or CT, MRI has shown significant pathology in many of these patients
+Delayed onset of neurologic damage is usually apparent within 48 hours. Numbness, paresthesias, or "shock-like" sensations in the extremities are suggestive of SCIWORA, and should be expeditiously evaluated for evidence of spinal cord injury
+Transient quadriparesis (referred to as "Stinger") is seen relatively frequently in children, most often in young boys after sports injuries. Clinically, there are paresthesias or weakness of the extremities, lasting from seconds to minutes, with complete recovery within 48 hours. No radiologic abnormalities are found
+*Consider intubation for pt w/ injury at C5 or above
+*Steroids are no longer recommended
 *Complete lesion means absence of sensory and motor function below level of injury
 **May be confused w/ spinal shock
@@ Line 16: / Line 58: @@
 ==Spinal Cord Syndromes==
 ===Complete Transection===
-*Higher lesions a/w spinal shock and autonomic dysfunction
+*Higher lesions are a/w spinal shock and autonomic dysfunction
-*Sacral sparing (perianal sens, rectal tone, or toe flexor) excludes complete transection
+*Priapism implies a complete injury
+*Sacral sparing excludes complete transection
+**Perianal sensation, rectal tone, bulbocavernosus/cremasteric reflexes
 ===Anterior Cord===
@@ Line 61: / Line 105: @@
 *[[Neurogenic Shock]]
 *[[Cord Compression]]
+*[[C-spine (NEXUS)]]
 ==Source==