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Against All Odds Maximizing Outcomes in SCI

Against All Odds Maximizing Outcomes in SCI. Mary Kay Bader RN, MSN, CCNS, FAHA, FNCS, CCRN, CNRN Neuro Critical Care CNS Mission Hospital Badermk@aol.com. Disclosures. American Association of Neuroscience Nurses Immediate Past President Medical Advisory Board Brain Trauma Foundation

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Against All Odds Maximizing Outcomes in SCI

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  1. Against All OddsMaximizing Outcomes in SCI Mary Kay Bader RN, MSN, CCNS, FAHA, FNCS, CCRN, CNRN Neuro Critical Care CNS Mission Hospital Badermk@aol.com

  2. Disclosures • American Association of Neuroscience Nurses • Immediate Past President • Medical Advisory Board • Brain Trauma Foundation • Neuroptics • Honorarium • Bard • Neuroptics • The Medicines Company

  3. Epidemiology • Causes • MVAs 42% • Interpersonal violence 24% • Falls 27% • Acts of violence (15%) • Sports 8% • (diving=cervical vs parachuting = thoracolumbar) • Industrial (crush) 2% • Location • majority c-spine • thoracic-lumbar 20-30%

  4. Epidemiology • Incidence: 12,000/year • 50% age 16-30 mean (age 40) • 81% male • Alcohol intoxication present 17-19% • Prevalence • 259,000 survivors in US • Average life expectancy • High tetraplegics 36 years after injury • Low tetraplegics 40 years after injury • Paraplegics 45 years after injury

  5. Factors that Impact Outcome • Age at time of SCI • Level of injury • Grading of Injury (ASIA) • Increased mortality • Higher lesions • Advanced age

  6. Description • Primary Injury • A temporary or permanent loss of function as a result of injury produced from compression, tearing, lacerations or ischemia • Secondary Injury • Further compromise to cord function • spinal cord edema • hemorrhage • Results in a decrease in perfusion to cord

  7. Vertebral Column

  8. Spinal Cord Meninges

  9. Vertebral Column • Ligaments • Anterior support • ant. long lig • post. long. lig • Posterior support • interspinous • supraspinal • cruciform

  10. SCI: Degree of Stability • Stable • Unstable - ligamentous injury

  11. Intervertebral Discs • Ruptured discs can manifest motor/sensory or both

  12. Blood Supply to SC • Anterior and posterior spinal arteries • Radicular arteries

  13. Spinal Cord • C1-L2 • max movement C5-6 • greatest flexion L4-5 • Gray matter: cell bodies/dendrites • White matter: myelinated axons

  14. Etiology • Causes • MVAs 44% • Interpersonal violence 24% • Falls 22% • Sports 8% • Location • majority c-spine • thoracic-lumbar 20-30%

  15. Hyperflexion Hyperextension Compression Rotation Penetrating Mechanism of Injury

  16. Characteristics of Injury • Rotational Injuries • caused by extreme lateral flexion or twisting of neck • tears posterior ligamental structures causing dislocation and instability

  17. Soft Tissue Injury

  18. Vertebral Trauma • Simple-single break • Usually spinous/transverse processes, pedicles or facets • Compression: cause flattening/wedging of VB • wedge, burst or teardrop (hyperextension) • Amenable to orthosis • Dislocation • ligaments damage Crush injury

  19. Atlas and Axis Injuries C1 burst: disruption of ant and post arch of C1. Results from force to vertex of head/rarely causes neuro injury. Usually managed with external orthosis. http://www.google.com/url?sa=i&rct=j&q=spinal+cord+hangmans+fracture&source=images&cd=&cad=rja&docid=t1ZbAjMq9m0oEM&tbnid=Itidkkw8ILzSyM:&ved=0CAQQjB0&url=http%3A%2F%2Fdermatologic.com.ar%2F4.htm&ei=8cBYUeDZNJGu8QTurICoCg&bvm=bv.44442042,d.dmQ&psig=AFQjCNFQbyZny2YNQztNSvOlBeULzzAAvg&ust=1364857224911192

  20. Type II dens fracture Type II dens fracture Types of C2 Fractures 1: usually stable Usually involves ligament. Stable. May be ass. with antlanto-occipital dislocation 2. Transverse or oblique fX thru dens: Unstable Often displaced anteriorly or posteriorly. Associated with high nonunion rate when managed conservatively 3. Base of Dens: May require light traction for initial reduction with Halo

  21. Atlas and Axis Injuries Hangman’s Fracture Fx through bilateral pedicles Separates C2-C3 and posterior elements

  22. CT Spine Floating Dens (C2) Anterior C1 Posterior C1

  23. Chance Fractures • Mechanism • a flexion-distraction injury (seatbelt injury) • may be a bony injury • may be ligamentous injury (flexion-distraction injury) • more difficult to heal • middle and posterior columns fail under tension  • anterior column fails under compression • Associated injuries  • high rate of gastrointestinal injuries (50%)

  24. Chance Fractures • Result from hyperfexion of the spine around an anterior fulcrum in combo with a posterior vertical distraction force • Horizontal fractures of the pedicles with extension through vertebral body • Associated with visceral injuries

  25. Fracture-Dislocations

  26. Subluxation Rotary sublux: caused by abnormal rotation at C1-C2; Seen on CT; exhibit torticollis Sublux: facet malignment; may be no bony fx, only ligament –unstable; aka locked, perched, jumped facets.

  27. Spinal Cord Injury • Concussion • Transient loss of SC function • Contusion • Intramedullary hemorrhage & edema • Laceration • Cut in the cord

  28. Spinal Cord Injury • Transection • Complete cut through SC; very rare • Hemorrhage • Parenchyma of SC or within one of meninges (can lead to SC compression) • Vascular • Damage to vessels perfusing the cord lead to ischemia • Cellular Dynamics

  29. Complete Injury: Anatomical Levels http://www.google.com/url?sa=i&rct=j&q=spinal+cord+injury+assessment&source=images&cd=&cad=rja&docid=Jacvj9YwLVXwTM&tbnid=rgb8iZ7PUkifCM:&ved=0CAQQjB0&url=http%3A%2F%2Fwww.yourshealthy.com%2F&ei=IbpYUeOvGIuA9QSyo4CoCA&bvm=bv.44442042,d.dmg&psig=AFQjCNEy75p04w3B9O-NUeu-HR2uRK82Yg&ust=1364855704791603

  30. Cord Injury • Level of lesion and functional impairment • C 1-4 tetraplegia with loss of respiratory • C 4-5 tetraplegia with possible phrenic nerve • C 5-6 tetraplegia with gross arm/diaphragm • C6-7 tetraplegia with biceps intact • C7-8 tetraplegia with triceps, biceps, & w.e. • T1-L2 paraplegia with loss of intercostals and abdominal muscle function • Below L2: Cauda equina vs. conus medullaris

  31. Cord Injury • Level of lesion and functional impairment • Below L2: Cauda equina • Compression of lumbosacral nerve roots below L1 vertebrae • Variable motor loss • Absent Achilles reflex • Radicular pain • Variable sensory loss • Areflexive bowel and bladder • No upper motor neuron findings

  32. Cord Injury • Below L2: conus medullaris • Compression of conical termination of cord with damage to lower lumbar/sacral gray matter and nerve roots • Causes • Fractures • Disc herniation in the T12/Lumbar region of vertebral column

  33. Cord Injury • Below L2: conus medullaris • Urinary retention • Impotence • Constipation • Lax anal sphincter • Saddle anesthesia (variable) • Loss of anal/bulbocavernosus reflex • Minimal to no motor weakness – varies may have lower motor neuron impairment

  34. Cord Injury • Horner’s syndrome • Ptosis • Miosis • Anhidrosis on affected side • Associated with spine lesions above T1 that disrupts the cervical sympathetic chain or it central pathways

  35. Incomplete Injury • Central cord • Anterior cordsyndrome • Brown Sequard • ipsilateral loss of motor and position/vibratory sense • contralateral loss of pain and temperature

  36. Cord Injury • Pathophysiology • decreased blood supply to cord • progressive edema • decrease tissue oxygenation

  37. Cord Injury • Spinal shock –primary injury to cord • Areflexia • flaccid paralysis • loss of sensation • Loss of autonomic function • Loss of bowel/bladder function

  38. Cord Injury • Neurogenic shock –secondary to autonomic dysfunction especially injuries above T6 • Interrupts normal sympathetic outflow from T1-12 region of SC • Peripheral dilatation & unopposed vagal tone • S/S • hypotension/bradycardia • Hypothermia • lose ability to sweat below level of lesion

  39. Assessment • History • How did injury occur? • Remember your P’s • Pain • Paralysis • Paresthesias • Position • Ptosis • Points • Priapism

  40. Assessment Principles • Upon arrival • Rapid, thorough evaluation • Airway patency, ventilation, and circulation • Gross neurologic assessment • Repeat at regular intervals

  41. Assessment Principles • Why do patients deteriorate? • Early clinical deterioration (<24 hours) • Usually due to treatment • Application or removal of traction • Inadequate immobilization • Delayed deterioration (24 hours-7days) • Often associated with hypotension in patients with fracture dislocations • Late deterioration (> 7 days) • Associated with vertebral artery injuries

  42. Maintain neck in neutral position • Immobilization • ABC • Airway-Intubation and airway support • BP and Heart rate • Disability • GCS and pupils • Motor 0-5 scale • Sensory • Reflex

  43. Assessing Motor Function • Upper extremities • C5 Deltoids: Raise arms • C5-6 Biceps: Flexion of elbow • C6-7 wrist extensors: Extension of wrist • C7 Triceps: Extension of elbow • C8-T1 Hand intrinsics: • Finger flexion • Hand squeeze • Finger abduction

  44. Assessing Motor Function • Lower extremities • L2 Iliopsoas: Hip flexion • L2-4 Hip adductors: Adduct hips • L4-S1 Hip abductors: Abduct hips • L3-4 Quadriceps: Knee extension • L4-5 S1-2 Hamstrings: Dorsiflex foot • L5 EHL: Extend great toe • S1 Gastrocnemius: Plantar flex foot

  45. Assessing Sensory Function • Sensation: Sharp vs dull distinction in each dermatome • Lateral spinothalamic tract mediates pain and temperature • Tongue depressor (dull) and pin (sharp) • Compare side to side • Porprioceptioin (position sense) • Dorsal column • Toe and Thumb positions

  46. Sensory Dermatomes

  47. AANS Guidelines 2013

  48. Published 2013 by AANS/CNS

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