Spinal Cord Injury

1. Spinal Cord Injury Michael Ford MD FRCSC Sunnybrook HSC

2. Spinal Cord Injury Objectives Magnitude of the problem Patterns of injury Treatment options Literature review Future treatment paths

4. The Magnitude of the Problem

5. 250,000 in USA Paraplegic: 52% Quadriplegia: 47% New SCI/yr: 11,000 Male: 82% 16yr-30yr: 56% Causes MVA: 37% Violence: 28% Falls: 21% Sports: 6% Other: 8% 89%: D/C’d home SCI Statistics (2002)

6. Over 200.00/yr/taxpayer

7. Rick Hansen SCI Registry

8. RHSCIR

9. RHSCIR

10. RHSCIR

11. RHSCIR

13. Anatomy Review

15. Anatomy of the Spine

17. Patterns of Injury • Burst fractures • Dislocations • Fracture/Dislocations • Extension Injuries

24. Pathophysiology of Spinal Cord Injury • Primary injury Mechanical and initial ischemic injury • Secondary injury release of intrinsic factors which cause further injury

25. Treatment • The patient ABC’s • The spine and spinal cord

26. Treatment • The patient Avoid hypotension Maintain cord perfusion Watch for secondary neural mediated cardiovascular events….”neurogenic shock” Loss of sympathetic tone. Not to be confused with “spinal shock”

27. Treatment • The Patient Injuries at C5 and proximal results in diaphragmatic dysfunction and lack of intercostal muscle function. Ventilation dependant on the accessory muscles of respiration. Respiratory fatigue an inevitability

28. Treatment • The Spine and Spinal Cord Spinal precautions…”Do no harm” Basic principles Early and rapid reduction of deformity and malalignment in all cervical cases independent of neuro status….”indirect decompression” Early surgical stabilization of unstable fractures associated with reduced general complications, costs, ICU stay, ALOS.

29. Treatment • Indirect decompression….Gardner Wells tongs or halo

32. Treatment • Direct decompression Risk vs Benefit analysis Who benefits? Who doesn’t benefit?

33. Treatment • Best evidence Animal studies suggest that early decompression is of benefit but no clinical human series have demonstrated the utility of decompression especially in those patients with complete lesions. On an empirical basis most of us will decompress an incomplete cord lesion urgently accompanied by a stabilization procedure.

34. Treatment • There is very little justification for early decompression for complete cord lesions. “Why not decompress everybody…what have you got to lose?”

35. Treatment • Risks of decompression CSF fistula infection increased blood loss [especially if an anterior approach is utilized.]

36. Outcomes

38. Recovery After SCI • Most neurologic recovery occurs in the first 3-6 months after injury • Some lesser recovery may continue for up to 18 months to 2 years

39. Recovery of Walking • 90% of people with Brown-Sequard • 50% with central cord syndrome • Very few with anterior cord lesion • 70-90% if ASIA B + preservation of PP within first few weeks • Unlikely if ASIA B + preservation of LT but not PP

40. Recovery of Walking in Tetraplegia • Very likely if ASIA C/D and age < 50 • 40% if ASIA C/D and age > 50 • 46% of incomplete tetraplegics walk at 1 year • Poor prognosis if LE motor score ≤ 20/50 at 1 month • Good prognosis if LE motor score ≥ 30/50 at 1 month

41. Recovery of Walking in Paraplegics • More difficult to predict • Changes from 1 month to 1 year • 73% do not change NLI • 18% improve 1 level • 7% improve 2 levels

42. Recovery of Walking in Paraplegics • No neurologic recovery if complete injury above T8 • Some recovery of function • 15% of those T9 – T11 • 55% of those T12 and below • Incomplete paraplegia has the best potential for recovery

43. Prognosis Related to MRI Findings • Severe injury associated with • Intramedullary hemorrhage • Cord edema more than 1 segment • Residual spinal cord compression • Poor recovery associated with • Severe cord compression, swelling, abnormal signal on T1 and T2 images • No resolution of signal abnormalities

44. Prognosis Related to MRI Findings • 4 indicators for poor prognosis • Spinal cord hemorrhage • Length of hemorrhage • Length of edema • Spinal cord compression • CT spinal canal compromise by 25% or more correlates with compression on MRI

45. Prognosis Related to MRI Findings • No motor improvement if hemorrhagic lesion • 72% had some motor recovery if edema ≤ segment

46. Functional Outcomes by LOI • C1,2,3- power chair, ECU, ventilator • C5 - feeding • C6 - tenodesis grasp • C7 ** independent w/ most ADL’s • mobility - manual W/C, transfers • C8/T1 - bladder/bowel independence • L 2,3 - **Ambulation

47. Treatment • Secondary cord injury Methylprednisolone Neuroprotective agents Cooling

49. The Future Will there be a “cure”? ?

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