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Spinal Cord Injury

Incidence
8,000-10,000 per year

Mechanisms
MVC 48% Falls 21% Assaults 15% Sport-related 14% (majority diving)

Incidence
50% involve cervical spine (C5-6)
40% lead to quadriplegia

Co-morbidity
Limb fractures - 67% Intrathoracic - 53% Head injury - 33%

Anatomy

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

Spine stability dependents


bone
ligaments joints applied force

axial

extension
rotation

Pathophysiology
Initial insult to cord Local deformation Energy transformation

ASIA Score
Based on key muscle strength & key sensory points Useful for following improvement or deterioration

Spinal shock:
transient flaccid paralysis areflexia (incl. lack of bulbocav. reflex) while present (usu <48 h), unable to predict

recovery

Classification
Complete absence of sensory & motor function in lowest sacral segment Incomplete presence of sensory & motor function in lowest sacral segment (indicates preserved function below the defined neurological level)

Incomplete Syndromes

E. Posterior Cord Syndrome

Frankel Classification
Grade A: Absent motor and sensory function

Grade B: Absent motor function, sensation

present Grade C: Motor function present, but not useful (2 or 3/5), sensation present Grade D: Motor function present and useful (4/5), sensation present Grade E: Normal motor (5/5) and sensory function

Xrays
Cervical
neck tenderness, intoxication, abnormal neuro

exam, distracting injury, difficult clinical exam


Thoracolumbar
spine tenderness, MVC ejections, falls > 10 ft,

neurologic deficit, difficult clinical exam

Spine Instability
Indicators of instability on plain radiographs > 5 mm subluxation bilateral jumped facets burst fractures with bone fragments in canal widening of interspinous space fractures of posterior element Columns - 2 of 3 damaged Flexion/extension plain radiographs - no pain & active full motion

Treatment
Immobilization

Drug Therapies
Steroids GM-1 Gangliosides

Surgical management Rehabilitation

Steroids
Standard of Care
National Acute Spinal Cord Study within 8 hours of injury methylprednisolone 30mg/kg load, 5.4 mg/hr x23 hrs. result: slight but significant improvement in motor function and sensation at 6 months NASCS 2nd trial some benefit of 48hrs of steroids, but significant morbidity (severe sepsis and pneumonia)

Surgical Management
Subluxation/angulation
immobilization with traction not recommended with fractures

Braces
Halo brace Minerva jacket/vest

Surgical Management
C1 rotatory subluxation- after reduction treatment

with Halo 3 months


C1 fx (Jefferson) - usually stable treat with hard

collar (ligament injury- Halo)


Odontoid fx - depend on type
Type I and III usually hard collar/halo 3 mos Type II - young (halo) and older (ORIF)

C2 fx (Hangmans) - Halo at least 3 months

Surgical Management
Lower cervical
fracture/dislocation - posterior ORIF with/without collar

compression/burst - anterior ORIF or halo

Thoracolumbar
compression without subluxation usually stable require

brace only severe subluxation/retropulsion bone fragments require ORIF

Complications
*Cardiovascular
hemodynamics sinus bradycardia

*Venous Thromboembolism *Pulmonary problems Skin breakdown

(most avoidable) Autonomic Hyperreflexia (usually above T6) Muscle spasiticity (trial of baclofen)

Rehabilitation
Begins immediately

Objectives
maintain full range of motion of joints use of orthotics to prevent contractures muscle strenghtening patient education self-range techniques activities of daily living

Prognosis
Depends
severity and location of injury age comprehensive rehab facilities

Mortality
Early mortality < 50 = 11%
> 50 = 39%

Quadriplegia - 15-37% die within first year

Prognosis
Cause of death
pulmonary - 21% 20% who require vent assistance die within 3 mos cardiovascular - 15% accidents, poisoning, or violence -10%

infections - 9%

Prognosis
Up 7% have progressive decrease
neurologic function develop painful dysesthesias syrinx - fluid in injured necrotic cavity compress surrounding tissue

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