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REHABILITATION OF SPINAL CORD INJURY  Neurologically complete injury

(SCI)  Poor self-related adjustment to


 “an ailment not to be treated” – earliest reference disability
to SCI in Edwin Smith Surgical Papyrus, 2,500-  Causes of Death
3,000 BC 1. Diseases of respiratory system -
 SCI is damage to the spinal cord due to trauma pneumonia (most common)
w/c usually results from a sudden traumatic blow  Tetraplegia
to the spine that fractures or dislocates vertebrae, 2. Heart disease
causing bruising or tearing of spinal cord tissue.  Paraplegia
 Injured for >30 years
EPIDEMIOLOGY OF TRAUMATIC SCI  Patients >60 y/o
 Incidence – 40 new cases/million 3. Septicemia (assoc. w/ pressure ulcers,
 Prevalence – 250,000 persons (US) urinary tract or respiratory infections)
 Age – young adults, 16 & 30  Paraplegia
o Average – 39.5 y/o 4. Cancer (most common in lung >
 Gender – Men > women, 4:1 ratio bladder > prostate > colon/ rectum)
 Etiology 5. Suicide – highest in younger patients
o Motor vehicle crashes (MVC) (42%)  Paraplegia
o Falls (27.1%)
o Acts of violence (15.3%) (gunshot ACUTE MEDICAL & SURGICAL
wounds [GSW]) MANAGEMENT
o Recreational sporting activities (7.4%)  Treatment – begins at the scene
 Associated injuries – most common:  Suspect SCI esp. if:
o broken bones (head, chest, ribs, long o suffers loss of consciousness,
bones) o major trauma
o loss of consciousness o any complaint:
o traumatic pneumothorax (more in GSW)  spine (pain, tenderness)
 Neurological Level & Extent of Lesion  spinal cord (sensory changes,
o most common – cervical lesions (50%) weakness, priapism)
> thoracic > lumbosacral lesions  All trauma victims – spine immobilized
o most common lesion level – C5 o w/ a rigid cervical collar
segment > C4, C6, T12, L1 o w/ supportive blocks on a backboard
o most frequent neurologic category at o w/ straps to secure entire spine
discharge from rehab: incomplete o transferred onto a firm padded surface
tetraplegia (34%) > complete paraplegia o maintaining spinal alignment to prevent
> incomplete paraplegia > complete skin breakdown
tetraplegia o via logrolling until spinal injury has been
ruled out
 Life Expectancy
o Mortality rates – higher during 1st year  Traditional CPR methods  jaw-thrust maneuver
after injury to access airway
 Complete injuries: higher in  Important after injury:
high tetraplegia (C1-3) o prompt resuscitation
o Predictors of mortality: o stabilization of spine
 Male gender o avoidance of additional neurologic
 Advanced age injury & medical complications
 Ventilator dependence  1st seconds after SCI  catecholamines  initial
 Injury by act of violence hypertensive phase  state of spinal shock
 High injury level (C4 or above) (flaccid paralysis & extinction of muscle stretch
reflexes below the injury level) o Noncontiguous fractures – when 1
 Neurogenic shock fracture is identified, careful inspection
o part of the spinal shock syndrome of the rest of the spine
o direct result of reduction in sympathetic o Stiff spine & midline tenderness –
activity below level of injury suspect fracture (esp. in spondylosis,
o Triad: hypotension, bradycardia, ankylosing spondylitis, or diffuse
hypothermia interstitial skeletal hyperostosis [DISH])
 Treatment of hypotension – fluid resuscitation  Objects embedded around spinal canal  left in
(1-2 L) – adequate urine output of >30 cc/h place w/ removal in the OR
o neurogenic shock, further fluid  IV methylprednisolone – adults after acute SCI
administration o MOA:
 proceed cautiously  improve blood flow to spinal
 risk for neurogenic pulmonary cord
edema  prevent lipid peroxidation
 vasopressors  free radical scavenger
o MAP at 85 mmHg during 1st week  anti-inflammatory function
post-injury  Anesthesia – avoid use of succinylcholine after
 Bradycardia – in acute period in cervical spinal 1st 48 hours postinjury – potentially fatal
level injury hyperkalemic response
o treated: <40/min or symptomatic w/ IV
atropine (0.1-1 mg) Spinal Stability & Principles of Spinal Stabilization
o prevented by: atropine prior to any vagal  Spinal instability
stimulation maneuvers (suctioning) o “the loss of the ability of the spine, under
o significant bradycardia  resolves w/in physiologic loads, to maintain its pattern
6 weeks of displacement so that there is no initial
o cardiac pacemaker implant to facilitate or additional neurological deficit, no
safe mobilization major deformity, & no incapacitating
 Respiratory assessment is critical pain” (White & Panjabi)
o ABG & FVC – assessment of respiratory o present if any 2 of the 3 columns are
muscle strength violated (“three-column theory” for
o VC <1 L – ventilatory compromise, thoracolumbar fractures by Denis)
requires assisted ventilation
 Maintain oxygenation w/ O2 per nasal prongs or
face mask & ET or nasotracheal intubation &
Ambu bag ventilation
 NGT – to prevent emesis & aspiration
 Foley catheter – for urinary drainage & accurate
assessment of UO until hemodynamically stable
 Emergency department
o baseline neurological examination,
maintaining spinal precautions
o Imaging studies
 assess spinal fracture,
instability, &/or spinal cord
pathology
 X-rays  Primary goal of surgical intervention in acute
 CT scan  C1 to C7 SCI  decompress neural elements either by
 MRI  neuronal structures anterior or posterior approach
 Postoperatively, or if surgery is not required – spine
orthosis maintained for 3 months o fall from a height
o conus medullaris &/or cauda equina
Specific Injuries to the Spine  Early spinal decompression w/in 8-24 hours
 Atlas fracture (“Jefferson” burst fractures) o may improve neurological recovery esp.
o fracture of the vertebrae of C1 in incomplete injuries
o stable injuries – Halo-vest orthosis  Early surgery:
o unstable injuries – posterior surgical o reduces LOS in acute hospital
stabilization o facilitates rehabilitation
 Odontoid fractures (Peg or Dens fractures) o decreases hospital costs
o Type I o reduces postoperative complications
 very rare  Current indication for emergent surgical
 fracture of odontoid process tip treatment – progressive neurologic deterioration
o Type II
 more common, in elderly
 fracture through base of the
odontoid process, at its junction
w/ C2 vertebral body
 internal stabilization
o Type III
 base of the odontoid into body
of C2 vertebra proper
 external orthosis for 3 months
 Pedicles of C2 fractures (“Hangman’s” fractures)
o bilateral & stable injuries
o abrupt deceleration injury
o external orthoses
 Pure bony injuries in the subaxial spine (C3-7)
o w/o substantial neurologic compression
– external orthosis alone
o ligamentous injuries – open surgical
intervention to decompress &/or fuse the
cervical spine
o most common burst fracture in the
cervical spine – C5 vertebra
 T12 vertebra fracture
o most common thoracic spinal injury
o Unstable injuries – stabilization & fusion
 Chance fracture
o horizontal splitting of vertebra extending
from posterior to anterior through
spinous process, pedicles & vertebral
body
o most common – thoracolumbar spine
(T12, L1, or L2)
o acute hyperflexion of the back (“seat-
belt” fractures)
 L1 burst fractures – most common in lumbar