Spinal cord injury

SPINAL CORD INJURY (SCI)

An insult to the spinal cord

resulting in changed
neurological function
Motor
Sensory
Autonomic

May be temporary or permanent

Injuries tend to be physically,
emotionally and financially
devastating

CLASSIFICATION

Tetraplegia: (quadriplegia)
Cervical region injury
Loss of muscle strength to all four extremities
Most critical: support respiratory function

Paraplegia
Injury to the spinal cord in the
Thoracic
Lumbar
Sacral segments

T12 and L1 are the most common level

MECHANISM OF INJURY
In the United States:
Automobile accidents

High speed
Ejection. rollover
Falls

Greater than 4.5 meters/15 feet (or 3x height)

Slip and fall: rare except in elderly
Diving into shallow pool
Violence

Blunt
Penetrating
Sports

SITE OF INJURY AND

NEUROLOGIC LEVEL
C5 Most
common site of
injury

T12 / L1 most
common injuries

PRIMARY AND SECONDARY

SPINAL CORD INJURY

Primary Spinal Cord Injury

Initial physical damage to spinal cord or
its structures
Physical cord damage due to mechanical
insult
Neurons passing through injury site are
physically disrupted and exhibit
diminished myelin thickness

PRIMARY AND SECONDARY INJURY

Secondary Spinal Cord injury:
Progressive pathological responses to initial injuries
Hemorrhage into cord compartments
Inflammatory response to initial insult
(Biochemical cascade, progressive edema and
cell necrosis)
Hypoxia due to local and systemic
hypoperfusion
Systemic hypotension from other injuries
(bleeding) or neurogenic shock
Collectively damage intact neighboring tissue
Symptoms: paralysis and loss of sensation to areas
innervated below the general level of the injury

Mechanisms of Spinal
Injuries
Extremes of motion
Hyperextension
Hyperflexion: Kiss the Chest
Excessive Rotation
Lateral bending
Axial Stress
Axial loading
Compression common between T12 and L1
Distraction
Combination
Distraction/Rotation or compression/flexion
Other MOI
Direct, Blunt or Penetrating trauma
Electrocution

Pathophysiology of Spinal Injury

(3 of 14)

Bledsoe et al., Essentials

of Paramedic Care:
Division 1II
2006 by Pearson

Spinal Column Injures

Movement of vertebrae from normal position
Subluxation or Dislocation
Fractures
Spinous process and Transverse process
Vertebral body
Ruptured intervertebral disks
Common sites of injury
C-1/C-2: Delicate vertebrae
C-7: Transition from flexible cervical spine to
thorax
T-12/L-1: Different flexibility between
thoracic and lumbar regions

Spinal Cord Injuries

Concussion
Similar to cerebral concussion
Temporary and transient disruption of cord
function
Contusion
Bruising of the cord
Tissue damage, vascular leakage and
swelling
Compression
Secondary to:
displacement of the vertebrae
herniation of intervertebral disk
displacement of vertebral bone fragment
swelling from adjacent tissue

Spinal Cord Injuries continued

Laceration

Causes

Bony fragments driven into the vertebral

foramen
Cord may be stretched to the point of
tearing

Hemorrhage into cord tissue, swelling

and disruption of impulses

Hemorrhage

Associated with contusion, laceration, or

stretching

SPINAL CORD INJURY UNTIL PROVEN OTHERWISE IF:

Significant mechanism of injury

high speed motor vehicle collision
Fall from a height
Diving accident
Electrocution
Direct neck trauma

Head or Neck pain associated with trauma

Motor or sensory deficits
Altered Level of Consciousness
Distracting Injury

Spinal Clearance Protocol

Bledsoe et al., Essentials

of Paramedic Care:
Division 1II
2006 by Pearson

Primary and Secondary Surveys

Primary Survey Assess for life

threatening injuries, if identified, stop
immediately and address before
moving on
Airway with Spinal Cord Precautions
Breathing and Ventilation
Circulation
Disability mental status
Exposure

Primary and Secondary Surveys

Secondary Survey
Complete head to toe and focused
assessment
History
Everything else

Primary Survey

AIRWAY AND SPINAL PROTECTION

Airway with simultaneous spinal

protection
Manually hold head/neck in line

Inspect the airway using jaw thrust (if

able)
Tongue, secretions, blood, vomit,
edema, foreign body, retropharyngeal
hematoma
Gentle, frequent suction (avoid vagal
stimulation and hypoxia)

AIRWAY WITH SPINAL STABILIZATION

Oxygen
Oral-tracheal intubation with in-line
stabilization is the preferred method
Any episode of hypoxia can lead to
cord ischemia and further injury
Plan for: rigid C-collar (if able), head
supports, long board, log roll patient
Minimal movement/manipulation of
spine!

BREATHING/VENTILATION
Assess patients respiratory status

Spontaneous? Need for assistance?

Rate and rhythm
Equal chest rise and fall
Use of accessory muscles
Vocalizations
Skin signs
Is the patient tiring? Assist
Trauma patient, look for: chest wall stability
and penetrating injuries
The higher the injury, the higher the risk for
respiratory failure

CIRCULATION
Bleeding? Control it
Skin signs

Hypovolemia: pale, cool, diaphoretic

Neurogenic shock: warm, dry
Palpate central pulses
Hypovolemia: tachycardia
Neurogenic shock: bradycardia
May be taking medication that affects heart
rate, especially the elderly
Compare pulses
Intravenous access x 2
Bradycardia may require atropine or pacing

DISABILITY

What is the patients mental status?

Altered?
Intoxicated?
Distracting Injury?
Significant Head or Neck Trauma?
Check pupils

DISABILITY/MENTAL STATUS

DISABILITY/MENTAL STATUS

Alert
Verbal
Pain
Unresponsive

EXPOSURE
Dont miss other injuries!
Uncover the patient. Significant mechanism of
injury means high risk for other trauma (thoracic,
abdominal, pelvic, long bone fractures,
head/brain trauma)
Log Roll Patient. Palpate and inspect entire spine
and paraspine for tenderness, deformity, bruising,
step-offs and widening of the vertebral spaces
Sphincter tone and Priapism
Keep warm. Recover. Patient may have no
thermoregulation

SECONDARY SURVEY

Patient on the monitor

Full set of vitals
Full Head to Toe
Dont miss other injuries!

Full History
Mechanism is important!
As much information as possible from the
patient, the family, the paramedics

Minimal movement of spine!

Consider removing back board.

BLOOD PRESSURE
Check Blood pressure: any episodes of
hypotension increase the risk of ischemic
injury.
Maintain a Mean Arterial Pressure of 8590mmHg
Hypotension: 2 potential causes
1. Hypovolemia
Is the patient bleeding
Dont miss an injury.
Patient needs fluids/blood
2. Neurogenic Shock
lack of sympathetic innervation.
May need dopamine and atropine.
Caution not to fluid overload causing further cord edema and
damage to brain and lungs

FULL NEUROLOGICAL ASSESSMENT

What hurts? What can you feel/move?
Check motor, sensory, proprioception
What can you move?
What can you feel?
Distal to proximal
Pain point of pin
Pressure head of pin
What toe am I moving and in which direction?
Document using established scales
Dermatomes
American Spinal Injury Association

Neurological Assessment
Unresponsive patient:

flaccid?
Diaphragmatic breathing?
Loss of grimace/withdrawal response?
Sphincter tone?
Priapism?
Distended bladder/abdomen?
Hypotension?
Hypothermia?

American Spinal Injury Association

Scale to describe the extent of the

injury

A = Complete:
Complete loss of motor and sensory function in sacral segments S4-S5.

B = Incomplete:
Sensory function preserved preserved below site of injury
Loss of motor function below site of injury

C = Incomplete:
Motor function is preserved below the site of injury
More than half of key muscles below site of injury have a muscle
strength less than 3.

D = Incomplete:
Motor function is preserved below site of injury
At least half of key muscles below site of injury have a muscle strength
of 3 or more.

E = Normal: motor and sensory function are normal.

AMERICAN SPINAL INJURY ASSOCIATIOTION

Scale for assessment of motor

strength
0 No contraction or movement
1 Minimal movement
2 Active movement, but not against
gravity
3 Active movement against gravity
4 Active movement against resistance
5 Active movement against full
resistance

AMERICAN SPINAL INJURY ASSOCIATION

Sensory Scale
Both sides of the body
Distal to proximal
Pain and Pressure

0 Absent
1 Impaired
2 Normal
NT Not testable

PAIN CONTROL
Hypersensitivity above level of injury
Tend to have extreme pain with even light pressure

Balance needs
Pain relief
Need to maintain adequate perfusion
Need for ongoing neurological assessments
Opioids
positioning
Assisting with traction

Devastating injury. Include the Patients

Family

REASSESSMENT

Serial assessments are critical!

Vital Signs
Mental status
Work of breathing
Focal findings Motor, Sensory and Proprioception
Full care of patient in spinal precautions
Nausea and Vomiting!
Radiology May require serial images
Goal is best possible outcome for this
patient

STUDIES

X-Rays
Cheaper
Less radiation
Difficult to obtain 3 mandatory and adequate views
Must visualize down to T1
Computerized Tomography (CT)
Easier, faster, see more
Lots more radiation (especially for children)
Cant see soft tissue
Magnetic Resonance Imaging (MRI)
Long delay
Requires transport time
Difficult to monitor patient in MRI machine
Some patients unable to tolerate

National Emergency X-Radiography Utilization Study

Criteria

Canadian Criteria

Contoh kasus
Tn. D, usia 62 tahun, kedua tungkai
tidak dapat digerakkan setelah jatuh
terduduk 3 hari SMRS. Tidak bisa
merasa pada tungkai tersebut, tidak
menyadari BAB dan BAK, dan tidak
bisa ereksi. Riwayat demam tidak
ada, bengkak dan nyeri pada
punggug tidak ada. Keluhan muncul
setelah jatuh terduduk.

 Motor skor :
Kanan : 25 kiri : 25 total 50
Sensori skor :
Light touch dan pin prick
Kanan : 18 kiri : 18 total
36
ASIA impairment scale A
(complete)

PENATALAKSANAN SPINAL
CORD INJURY

Pemberian terapi
MP 30 mg/kgbb bolus, dilanjutkan 5.4
mg kg/bb selama 23 jam.
Perbaikan neurologi signifikan bia
diberikan pada 3-8 jam setelah
trauma.

Mekanisme Kerja Metilprednisolon

Menurunkan post traumatic SC
edema
Menghambat post trauma LP
Menghambat iskemik post trauma
Membantu metabolisme aerob
(reduksi laktat & meningkatkan ATP)
Memperbaiki ca ekstrasel
(menurunkan ca intrasel)
Mengurangi neurofilamen

MENURUT
NASCIS

NASCIS I (USA,
1984)
Prospektif
Metil prednisolon NASCIS II (1990)
(100 mg dan
Prospektif
1000 mg)
Metiprednisolon,
naloxone,
placebo
NASCIS III (1997)
Prospektif
Metilprednisolon
, tirilazad

NASCIS I

330 pasien
T/
100 mg bolus MP, kemudian 25 mg tiap
6 jam selama 10 hari
1000 mg bolus MP, kemudian 250 mg
tiap 6 jam selama 10 hari
Kesimpulan : tidak ada hasil
signifikan dari kedua grup diatas
Angka kejadian meningkat
terhadap luka infeksi (dosis tinggi)

NASCIS II

487 pasien dalam 1 tahun

Pasien yg meninggal dieksklusikan
Total 427 pasien
T/
MP 30 mg/kgbb bolus, dilanjutkan
5.4 mg kg/bb selama 23 jam.
Naloxone 5.4 mg//kgbb bolus,
dilanjutkan 4.5 mg/kgbb selama 23
jam
Placebo

NASCIS III
Prospektif
Tanpa placebo
499 pasien. Total pasien 439 pasien
setelah 1 tahun follow up.
Diberikan dalam waktu < 8 jam setelah
trauma
T/
MP 5.4 mg/kgbb/jam selama 24 jam
MP 5.4 mg/kgbb/jam selama 48 jam
Tirilazad 2.5 mg/kgbb tiap 6 jam selama
48 jam

 Mortalitas meningkat 6 kali pada grup yg

48 jam (respirasi) pneumonia dan
sepsis.
Pasien tsb dibagi dalam 0-3 jam setelah
trauma dan 3-8 jam setelah trauma.
Pada kelompok 0-3 jam tidak ada
perbaikan neurologi.
Pada kelompok 3-8 jam terdapat
perbaikan neurologi.