Acute Spinal Cord Injury Emergent vs. Elective Surgical Management

1. Acute Spinal Cord InjuryEmergent vs. Elective Surgical Management Steven Mardjetko M.D. Professor Rush University Dept. of Orthopedic Surgery Illiniois Bone and Joint Institute StevenMardjetko@msn.com PedSpine.com

2. Acute Spinal Cord InjuryWhat is it? • Significant traumatic event: falls, MVAs, sports related • Structural spinal column damage with failure of bone, ligaments, disks results in acute spinal column Instability. • Acute Spinal Column Instability is defined as the INABILITY of the spinal column to protect the Nerves and Spinal cord from damage

3. What Defines these injuries as Catastrophic?The Spinal Cord!!

4. Spinal Cord InjuryIncidence • 50 injuries per million • 32 per million survive the first year • Majority of mortality occurs en route to hospital

5. The Christopher Reeve Story • Complete SCI at upper cervical level • Complete loss of motor severe loss of ventilatory function • Lived 9 years until his untimely death 2005. • Cost of care 400K/yr • Actually made 2 movies after injury (returned to Work!)

6. SCI injury leads to irreversible functional loss

7. Spinal Cord InjuryAcute Primary Pathophysiology • Immediate effect of mechanical deformation (100-200 ms) • Direct destruction of myelin tissue by compression, distraction, torsion, tension • Centrifugal evolution of hemorrhage (gray-white) • Decreased spinal cord blood flow (pCO2 autoregulation, hypotension)

8. SCISecondary Injury PathophysiologyHours to Days! • Edema • Immediate(vasogenic) • delayed(cytotoxic) Calcium effect • Cellular inflammation/lysosomal activity • Lipid peroxidation • Exogenous factors • ETOH (synergistic adverse effect) • Harmful Reparative Mechanisms (weeks-months) • Gliosis

9. Spinal Cord RegenerationContused Rat Spinal Cords5 to 6 months after injury Bomstein et al 2003

10. Rollover Truck InjuryFracture Dislocation C7-T1Complete Spinal Cord Injury: ASIA A

11. L-1 Burst FractureStable vs. Unstable (3/3 columns damaged)Determined by integrity of the posterior Tension Band

12. 52 yo fell from treeBurst Subluxation L-1 with Complete SCI

13. Classifying Acute Spinal Instability • Injury Classifications based on: • Clinical Assessment of Neural Injury • ASIA classification and ASIA scoring system • Structural damage to spinal column: force application and # of Columns injured: • Named Classification Systems • Cervical: Anderson, Effendi, Mechanistic(Allen/Ferguson) • Thoracolumbar: AO, Denis, Gaines, MacAfee • MRI based Spinal Cord Classifications

14. Spinal Cord Injury ClassificationFrankel System Adapted by ASIA • Complete- no motor, no sensory(ASIA/Frankel A) • Incomplete- • no motor, sensory spared (ASIA/Frankel B) • motor too weak to ambulate(ASIA/Frankel C) • motor weak, but ambulatory (ASIA/Frankel D) • motor normal, sensory normal (ASIA/Frankel E) • ASIA Motor Score- quantitative score based on 10 muscle groups

15. ASIA Functional SCI Classification

16. Spinal Cord Neuro-Anatomy

17. Classification of Incomplete SCI • Anterior spinal cord syndrome • Anterior spinal artery syndrome • Posterior column syndrome • Browne-Sequard(Hemicord) syndrome • Central Spinal cord syndrome

18. Spine TraumaDiagnostic Evaluation • MRI scan • Detects spinal cord abnormalities • Prognosticates neural recovery based on injury pattern • Identifies traumatic disc disruptions • Identifies ligamentous injury

19. Anatomic Alterations in SCI50% of Complete Lesions have some intact neural tissue

20. The Modern Level 1 Trauma Center has transformed care of acutely injured patients! • Team Approach: Trauma (general) surgeon, ER “SWAT” team (ER phyisicians, nurses, paramedical personnel) • Protocol driven care: ABCDEFs of Trauma Care • Immediate access to important diagnostic imaging: x-rays, CTs, MRI • Sub-Specialty and Consulting Services available 24/7/365 • Orthopedic Surgery, Neurosurgery, Neuro-Radiology • Spinal Trauma Surgeons: Orthopedic Surgeons and Neurosugeons who have attained additional training in the evaluation and management of the acutely unstable spine and can treat pathology from Occiput to Pelvis!!

21. Spinal Cord InjuryImproving Natural History • Decreasing incidence of complete SCI • 1972 - 62% • 1986 - 21% • Increased survival of high level quads due to better medical care • Better training of paramedical personnel • Airbags and Seatbelts

22. Defining Emergent, Urgent, and Elective timelines for SCI • Ultra-Emergent: within 8 hours upon arrival to ER, usually includes initial treatment such as closed and/or Open reduction immediately after patient is stabilized and diagnostic tests are completed! • Emergent: within 24 hours, often performed after other life saving treatments • Urgent: 24 to 36 hours • Elective: after 36 hrs to 6 weeks

23. Polytrauma with Spinal Cord Injury • Concept of “Early Total Care” Priority List • Emergent life and limb saving interventions: vascular, chest, visceral • Brain trauma management • Spinal Instability/SCI management • Musculoskeletal Injuries • Total management within 72 hours of injury will decrease mortality in patients with significant Head Injury and Polytrauma

24. Literature Review on SCI recovery and time to Treatment • STASCIS -Surgical Trial in Acute Spinal Cord Injury Study (Wilson, Fehlings AO Study Group) • Incidence 42/million, 5% of all Level 1 Trauma patients • 4 Billion/yr spent on acute and chronic care of SCI patients in USA. • Surgical intervention in first 24 hours: 24 % in Canada, and 52% in Europe • Questionaire to all spine surgeons: 80% preferred to decompress and stabilize within 24 hours, and if there was an incomplete SCI the desire was to decompress emergently, within 6 hours!

25. Vaccaro AR, Daugherty RJ, Sheehan TP, et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine 1997 • RCT with acute SCI and spinal injury • Two groups: OR < 72 hr, >72 hr • No Significant differences in Neural recovery, complications or Length of Stay

26. STASCIS Study Results (preliminary)Fehlings et. Al.(Neurotherapeutics, 2011) • RCT with 2 groups: decompression and stabilization before or after 24 hours post injury • 24% of those in the <24 hour group showed recovery of 2 ASIA grades on average • 20% lower medical complication rate • 4% of those in the > 24 hour groups showed improvement of 2 ASIA grades • A 2 Grade improvement means you can usually stand and walk with assistive devices!! So 1 in 5 patients will regain this ability in the <24 hr treatment group vs 1/25 in those treated >24 Hr.!!

27. Emergent Reduction of Cervical Spine Dislocation • Indicated for dislocations and subluxations • Pre-op MRI to rule out disc herniation • application of Gardner-Wells cranial tongs • gradual increase in traction weight with careful neural and radiographic evaluation • may decrease weight once reduction is achieved • urgent surgical stabilization

30. C6-7 Fracture/Dislocation ultra-emergentTx/Rdxn, Decompression and PSFIASIA A to ASIA D. Ambulatory w/o crutches! Unilateral UE deficits

31. Decreasing secondary Injury Effect! • Methylprednisolone protocol (NASCIS-Bracken) • SYGEN Study- RCT with GM-1 Gangloside- no efficacy at 6 months • Spinal Cord cooling- systemic and local (Barth Green and the Miami Project, Dimar/Louisville) • But the #1 way to decrease further injury to the spinal cord is to decompress and stabilize the unstable spine ASAP!!!

32. Just a “Routine Emergency”Snake a tube down her nose and I’ll be there in 4-5 hours!

33. While You may be able to find many reasons not to get out of bed in the Middle of the Nite!

34. It is now clear that to “do no Harm” you must Get your Butt OOB and decompress and stabilize SCI patients as soon as they are medically cleared!

35. Thanks You For Your Attention! Illinois Bone & Joint Spine Institute