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Spinal Cord Injuries: Gabriel C. Tender, MD
Spinal Cord Injuries: Gabriel C. Tender, MD
Gabriel C. Tender, MD
Assistant Professor of Clinical Neurosurgery, Louisiana State University in New Orleans Staff Neurosurgeon, Touro Infirmary and West Jefferson Medical Center
What are the clinically important ascending tracts and where do they cross over?
What are the clinically important descending tracts and where do they cross over?
At what level does the spinal cord end and why is it important?
What are the differences between UMN and LMN? (e.g., cauda equina vs. myelopathy)
SPINAL TRAUMA
Terminology
Plegia = complete lesion Paresis = some muscle strength is preserved Tetraplegia (or quadriplegia)
Injury of the cervical spinal cord Patient can usually still move his arms using the segments above the injury (e.g., in a C7 injury, the patient can still flex his forearms, using the C5 segment)
Paraplegia
Injury of the thoracic or lumbo-sacral cord, or cauda equina
Hemiplegia
Paralysis of one half of the body Usually in brain injuries (e.g., stroke)
What are the important vegetative functions and when are they affected?
Reflexes
Deep Tendon Reflexes
Arm
Bicipital: C5 Styloradial: C6 Tricipital: C7
Leg
Patellar: L3, some L4 Achilles: S1
Pathological reflexes
Babinski (UMN lesion) Hoffman (UMN lesion at or above cervical spinal cord) Clonus (plantar or patellar) (long standing UMN lesion)
Sensory level = the last level with preserved sensation Radiographic level = the level of fracture on plain XRays / CT scan / MRI
NB: spine level does not correspond to spinal cord level below the cervical region
Case scenario
25 y/o white male Fell off the roof (20 feet) Had to be intubated at the scene by EMS Consciousness regained shortly thereafter Could not move arms or legs Could close and open eyes to command Not able to breathe by himselftotally dependent on mechanical ventilation
Case scenario
19 y/o white male Diving accident (shallow water) No loss of consciousness Could not understand why he could not move his legs, forearms and hands (he could shrug shoulders and elevate arms) BP 75/40, HR 54/ Had difficulties breathing and required intubation a few hours after the accident
Neurogenic shock
Seen in cervical injuries Due to interruption of the sympathetic input from hypothalamus to the cardiovascular centers Hallmark: hypotension (due to vasodilation, due to loss of sympathetic tonic input) is associated with bradycardia (not tachycardia, the usual response), due to inability to convey the information to the vasomotor centers in the spinal cord
Case scenario
22 y/o Hispanic female Motor vehicle accident (hit a pole at 60mph) + for ETOH and THC Short term loss of consciousness (10) Not able to move or feel her legs DTRs 2+ in BUE, 0 in BLE No bladder / bowel control or sensation Sensory level at the umbilicus
Case scenario
22 y/o African-American female Motor vehicle accident Not able to move or feel her legs below the knee Could flex thighs against gravity DTRs 2+ in BUE, 0 in BLE No bladder / bowel control or sensation Sensory level above the knee on L, below the knee on R
What is the difference between cauda equina and conus medullaris syndrome?
Brown-Sequard syndrome
Initial Management
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
Foley
Urinary retention is common
Methylprednisolone (Solu-Medrol)
Only if started within 8 hours of injury Exclusion criteria
Cauda equina syndrome GSW Pregnancy Age <13 years Patient on maintenance steroids
CT scan
Good in acute situations Shows bone very well Sagittal reconstruction is mandatory Soft tissues (discs, spinal cord) are poorly visualized Do NOT give contrast in trauma patients (contrast is bright, mimicking blood)
MRI
Almost never an emergency
Exception: cauda equina syndrome
Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan May be used to clear c-spine in comatose patients
Lumbar Puncture
Sedate the patient and make your life easier Measure opening pressure with legs straight Always get head CT prior to LP to r/o increased ICP or brain tumor
CT and/or MRI is necessary if the patient is comatose or has neck pain Subluxation >3.5mm is usually unstable
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
Gardner-Wells tongs
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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