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Current Update in

Spinal Cord Injury


Yudha Mathan Sakti
Galih Prasetya Sakadewa

Orthopaedic and Traumatology


FKKMK Universitas Gadjah Mada – RS
DR Sardjito
Yogyakarta,
10/03/2018 Yogyakarta, Indonesia
S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)

5 jam SMRS saat pasien sedang menebang kayu, kayu terjatuh dan
mengenai punggungnya. Pasien kemudian mengeluhkan tidak bisa
menggerakkan kedua kakinya.
S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)
Traumatic Spondylolisthesis of 1st lumbar spine with Neurologic Deficit TLICS 8
with Spinal Cord Injury of 11th thoracic spine (ASIA-A)
S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)
Traumatic Spondylolisthesis of 1st lumbar spine with Neurologic Deficit TLICS 8
with Spinal Cord Injury of 11th thoracic spine (ASIA-A)

Decompression, Deformity correction, and Stabilization


S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)
Traumatic Spondylolisthesis of 1st lumbar spine with Neurologic Deficit TLICS 8
with Spinal Cord Injury of 11th thoracic spine (ASIA-A)

Decompression, Deformity correction, and Stabilization

How far have we done in helping


the patient?
Is this the current management ?
Objective

• Know what is spine trauma and SCI


• Know how to identify and diagnose SCI
• How to manage SCI
• Know the current management of SCI
What is Spine Trauma and SCI

• A spinal cord injury (SCI) is damage to the spinal cord that


causes changes in its function, either temporary or
permanent.

• These changes translate into loss of SC function (respiratory,


motoric, sensory and autonomic) in parts of the body served
by the spinal cord below the level of the lesion.

• Mainly resulted due to spine fracture and trauma


 KNOWN as a catastrophic injury
What is Spine Trauma and SCI
• The Edwin Smith papyrus, an ancient Egyptian physician textbook, described, in
1700 BC, Spinal Cord Injury (SCI) as an ‘‘ailment not to be treated’’ (Porter, 1996).

• United States who currently have around 253,000 cases with 11,000 new cases/
year  devastating disabilities

• ± 4000 years later, the treatment of SCI remains largely palliative  patient
support and managing disability

• There is no treatment available that restores the injury-induced loss of function


to a degree that an independent life can be guaranteed.

• Ongoing advances and research will hope to change this paradigm


curative interventions?
Pathophysiology
Anatomy of Vertebra

Function:
Support the axial musculature and protect the spinal cord and nerve root
Respect the structure Disruption creates instability
BIOMECHANICALLY  SC injury

 The anterior column is composed of the anterior


longitudinal ligament, anterior half of the vertebral
body, and anterior half of the disc

 The middle column is composed of the posterior


half of the vertebral body, the posterior half of the
disc, and the posterior longitudinal ligament

 The posterior column includes the pedicles, facet


joints, lamina, and posterior ligament complex
Respect the structure Disruption creates instability
BIOMECHANICALLY  SC injury
Pathophysiology

Anatomy of Spinal Cord


The spinal cord is 40 to 50 cm long and
1 cm to 1.5 cm in diameter.

Ascending tract:
• Dorsal column: deep touch,
proprioception, vibration
• Lateral spinothalamic: pain,
temperature
• Ventral spinothalamic: light touch

Descending tract:
• Lateral corticospinal: main voluntary motor
• Ventral corticospinal: voluntary motor
Pathophysiology
• When the spinal cord is lacerated or macerated by a
sharp penetrating force, contused or compressed by a
blunt force (DeVivo et al., 2002):
• Primary injury  mechanical injury
• Secondary injury (Response following injury) 
cascade of biological event

(1911) Recognizing the inflammatory that help in


healing followed with cytokines and ROS , free radical
formations, mediator excitotoxicity, apoptosis and
vascular changes
white matter demyelination, gray matter dissolution,
reactive gliosis that lead to glial scar formation

 Related with local cellular capability following the


trauma

Schematic representation
adapted from Yiu and He (2006).
Identification and Diagnosis
Identification and Diagnosis
Identification and Diagnosis

Immobilize the skull proximally


(Anterior : mandible, chin; posterior:
occiput around to below ears)
and distally (clavicle and/or thorax)
Maintain the spinal
alignment and evaluate
with Logroll maneuver

Patient in the neutral position

Spinal protection should be


maintained until a spine injury is
excluded
Logroll and spine board placement
1. Manual immobilization to
head and apply a semirigid
cervical collar
2. Straighten arms and legs
3. Reach across and grasp
shoulder, wrist, and hip
4. Logroll towards assistant
5. Place the spine board and
carefully logroll the patient
back
Neurogenic shock occurs
secondary to sympathetic
outflow disruption (T1-L2)
with resultant unopposed
vagal (parasympathetic)
tone.
Spinal Shock
Spinal shock is defined as spinal cord dysfunction based on physiologic rather than
structural disruption. Resolution of spinal shock may be recognized when reflex
arcs caudal to the level of injury begin to function again, usually within 24 hours of
injury.

Spinal shock should be distinguished from neurogenic shock, which refers to


hypotension associated with loss of peripheral vascular resistance in spinal cord
injury.
Neurogenic Shock Hypovolemic Shock
BP Hypotension Hypotension
Pulse Bradycardia Tachycardia
Reflexes /
Bulbocavernosus Variable/independent Variable/independent
Reflex

Motor Variable/independent Variable/independent

~48-72 hours
Following excessive
Time immediately after
blood loss
spinal cord injury

Disruption of
autonomic pathway
Decreased preload
leads to loss of
Mechanism leads to decreased
sympathetic tone and
cardiac output.
decreased systemic
vascular resistance.
Treatment
of neurogenic shock is pharmacologic intervention to augment
peripheral vascular tone.
Physical Examination in Spine
• Know the mechanism of injury (low, moderate or high)
• Evaluate injuries to the head, chest, abdomen and pelvis
• Special precautions
(awareness of other injury, e.c calcaneus fracture, thoracal and
abdominal injury, ‘paper bag phenomen’)
Physical Examination in Spine
• Assess the patients symptoms
• Perform logroll  Look, Feel and Move
• Look for malalignment/ step off
• Look for tenderness
• Check the neurologic function (ASIA American Spinal lnjury Association/ ASIA
Score)
• Make the spine fracture diagnosis (in trauma settings)
Identification and Diagnosis
(Spinal Cord Injury)

Spinal Shock
Spinal shock is defined as spinal cord dysfunction based on physiologic rather than
structural disruption. Resolution of spinal shock may be recognized when reflex
arcs caudal to the level of injury begin to function again, usually within 24 hours of
injury.

 The bulbocavernosus reflex refers to contraction of the anal


sphincter in response to stimulation of the trigone of the bladder
with either a squeeze on the glans penis, a tap on the mons pubis,
or a pull on a urethral catheter.

 The absence of this reflex indicates spinal shock.


Identification and Diagnosis
(Spinal Cord Injury)
Identification and Diagnosis
(Spinal Cord Injury)
Identification and Diagnosis
(Spinal Cord Injury)

Complete spinal cord injury is defined by the total absence of sensory and motor
function below the anatomic level of injury in the absence of spinal shock

Incomplete spinal cord injury is present when residual spinal cord and/or nerve
root function exists below the anatomic level of injury
Identification and Diagnosis
(Spinal Cord Injury)

Spinal Cord
Injuries

Complete Incomplete
Injury Injury
Incomplete Spinal Cord Injury

Conus Medullaris Syndrome


• T12-L1 injuries
• Loss of voluntary bowel and bladder with
preserved lumbar root function
• Bulbocavernosus reflex may be permanently
lost
Cauda Equina Syndrome
• Multilevel lumbosacral root compression
within the lumbar spinal canal
• Saddle anesthesia, bilateral radicular pain,
numbness, weakness, hyporeflexia/areflexia,
loss of voluntary bowel or bladder function
Identification and Diagnosis
(Spine Fractures)

Spine Fractures

Stable Unstable

Vertebral components
Significant risk of
will not be displaced
displacement and
by normal
neural tissue damage
movements
Identification and Diagnosis
(Spine Fractures)
Identification and Diagnosis
(Spine Fractures)

We need to see the


structures with supporting
exam X Ray, CT or MRI ?
Identification and Diagnosis
(Spine Fractures)
Identification and Diagnosis
(Spine Fractures)
Identification and Diagnosis
(Spine Fractures)
CLEARING the SPINE
• A cleared spine in a patient implies that diligent spine
evaluation is complete and the patient does not have a
spinal injury requiring treatment.

Criteria for clinical spine clearance are


1. No posterior midline tenderness
2. Full pain-free active range of motion
3. No focal neurologic deficit
4. Normal level of alertness
5. No evidence of intoxication
6. No distracting injury

Clear X Ray evaluation


Management

• Started since we meet the patient

• Clear the ATLS procedure


• The specific shock management  vasopressor?

• Immobilize and manage the spine trauma


• Transportation and mobilization  spine stretcher

• Manage the SCI


Management
Spine alignment is crucial
Management
•Immobilize and manage the spine fracture
• Transportation and mobilization
Management
•Immobilize and manage the spine fracture
• Transportation and mobilization
M, 36 y.o,
Unilateral facet joint dislocation of the 3rd until 4th cervical spine without neurologic deficit SLICS 5
Close reduction under fluoroscopy, immobilization with Gardner Wells Tong
Management
Management
Year Study Result
1984 National Acute Spinal No neurologic benefit to methylprednisolone at 6
Cord Injury Study months
(NASCIS)
1990 NASCIS II Result failed to demonstrate the benefit of MP
compared to placebo.
Post-hoc analysis  significant improvement in MP
treatment within 8 hours (flaw)

1997 NASCIS III No significant result of motor scores.


Post hoc analysis  patients treated between 3-8
hours showed significant improvement (flaw)

2002 Congress of Neurological Published joint guideline  MP is a treatment


Surgeons (CNS) and option for acute SCI
American Association of
Neurological Surgeons
(AANS)

2011 ATLS Insufficient evidence to support the routine use of


steroids in SCI
2013 Follow up to CNS and MP is not recommended (lack of evidence)
AANS guideline
Management
• High-dose MP cannot be recommended as a standard of care in Acute SCI,
but it remains an option until there is a standardized therapy based on the
evidence-based (Bydon, 2014)

• It is not that the RCTs conclusively demonstrate that steroids do not work
in SCI. It is that there is no RCT data suggesting that steroid is effective in
SCI (Cheung et.al., 2015)

• Many promising therapeutic agents and strategies being studied in ongoing


trials. Combined stem cell treatment with pharmacologic
manipulation may be another possible answer to improve patient
outcome and alter the poor natural history of SCI (Karsy, 2017)
Management
The development of surgical procedure is great
 biomechanical improvement and surgical technique
Current Management
Current Management
The stem cell
• Stem cells proliferate, migrate, and differentiate to form
organisms during embryogenesis

• Characterized by self-renewal and their ability to become


any cell in an organism  different level of potency

• A greater potency indicates a larger number of cells that


can be derived.

• Can be directed to differentiate into neurons or glia in


vitro

• Can function in replacement of neural cells, give


neuroprotective and axon regeneration-promoting effects
(positive milieu)
The stem cell
• Zygote is a totipotent cell it can become any cell type
present in an organism (placenta cell or an embryonic cell)

• Inner cell mass (blastocyst) as embryonic stem cells (ESCs)


are pluripotent  ecto, meso and ecto derm

• Undifferentiated cells can be found among differentiated


cells of a specific tissue after birth known as adult stem
cells (somatic stem cell ≈ present in children and umbilical
cords)
 multipotent (become particular cell lineage within its
own germ layer)

big interest and application can be harvested


without destruction of embryo
The stem cell
• Undifferentiated cells can be found among differentiated
cells of a specific tissue after birth known as adult stem
cells (somatic stem cell ≈ present in children and umbilical
cords)
 multipotent (become particular cell lineage within its
own germ layer)

big interest and application can be harvested


without destruction of embryo

Primum non nocere that


means "first, do no harm."
The stem cell
Cell type Potency Proliferation Rejection Ethical
Zygot Totipotent Differentiates to any cell type present in an organism +++
(placenta and embryo)
Embryonal Stem Pluripotent Differentiates to any cell type present within a germ +++ + +
Cells (ESCs) layer (ecto, meso and endo)
Mesenchymal Multipotent Differentiates into cells of a particular cell lineage (in a ++ - -
Stem Cells germ layer)
(MSCs)
Progenitor cells Unipotent Differentiates into only 1 type of cell + - -
Induced Pluripotent Differentiates to any cell type present within a germ +++ - -
Pluripotent layer (ecto, meso and endo)
Stem cells (IPCs)
Stem cell in SCI
The function of stem cell :
1. Neuroprotective to limit secondary tissue loss
and the loss of function
2. Replace and restore of damaged axon and glia
3. Creates favorable microenvironment
Type Function

Embryonal (ESCs) pre-differentiation protocol is remyelination and functional recovery Liu et al., 2000; McDonald
et al., 1999
performed (neurons,oligodendrocytes
progenitor cells )
Concern: ethical, safety (report on teratoma (Li et al., 2008).
Mesenchymal (MSCs) Isolated from bone marrow, adipose, 43 studies analyzed ± 50% of the experimental studies (Tetzlaff et al., 2010).
umbilical cord (Wharton's Jelly) origin  SCI models led to motor improvements. The potential
transdifferentiation into neurons and mechanism unknown

glia cells
No serious complications were reporte(Geffner et al., 2008; Sykova´ et al., 2006a; Yoon et al., 2007)
Stem cell in SCI
The function of stem cell :
1. Neuroprotective to limit secondary tissue loss and the loss of
function
2. Replace and restore of damaged axon and glia
3. Creates favorable microenvironment
Type Function

Neural stem cells Isolated from embryonic or adult spinal cord and multipotent cells with the ability to
(NSCs) brain (dentate gyrus and subventricular zone), differentiate into neurons, oligodendrocytes, and
astrocytes.

Limitation in translational studies  practical issues hindering their isolation and ethical concerns
Induced Pluripotent pluripotent cells could be obtained from fibroblast Cell reprogramming by introduction
of 4 (Takahashi and Yamanaka,
Stem cells (iPS) by the introduction of 2006)
four genes into cells via retrovirus-mediated gene transcription factors,OCT3/4 (octamer-
transfer 4), SOX2 (sex-determining region
Ybox2),
KLF4 (Kruppel-like factor), and MYC
(+) They circumvent the ethical concerns associated with ES cells and allow autologous transplantations of pluripotent
cells
iPS and ESCs cells also share similar disadvantages such as the ability to form teratomas (Takahashi and Yamanaka,
2006).
3 months post

5 months post
• Male, 62 y.o
• DIAGNOSIS (2 years post injury and surgery)
• Spinal cord injury at the level of 2nd lumbar spine
• ASIA impairment scale A
Perkembangan Fungsi Motorik Paska
Injeksi Sel Punca Mesenkimal

4 4 4

3 3 3 3 3 3

1 1

0 0 0 0 0
C5 C6 C7 C8 T1 L2 L3 L4 L5 S1
Fungsi Motorik Baseline Fungsi Motorik Paska Injeksi
Current Management
• Another type of approach is tissue
engineering, using biomaterials to help
scaffold and rebuild damaged tissues.

• Biomaterials being investigated include


natural substances such as collagen or
agarose and synthetic ones like polymers
and nitrocellulose  vehicle for
delivering gene therapy to tissues

• Other approach is to aid in rehabilitation


using wearable powered robotic
exoskeletons  The devices, which have
motorized joints, are put on over the legs
and supply a source of power to move
and walk
Conclusion

• Spinal Cord Injury is a debilitating injury that should be approach


comprehensively

• Management should be started early (since we meet the patient)

• Further study is evolving and will give better future for the patients

• We all have our role in managing SCI


Thank You ^^
• 10. Define spinal shock and explain its significance after an acute spinal cord injury.
• Spinal shock refers to the period after spinal cord injury (usually 24 hours) when the reflex activity of the entire
• spinal cord becomes depressed. During this period the reflex arcs below the level of spinal cord injury are not
• functioning. The return of reflex activity below the level of a spinal cord injury signifies the end of spinal shock.
The
• significance of spinal shock lies in the determination of whether a patient has sustained a complete vs.
incomplete
• spinal cord injury. This cannot be determined until spinal shock has ended. Bulbocavernosus reflex is used to
assess
• the end of spinal shock.
• 11. What is the bulbocavernosus reflex? What is its significance?
• The bulbocavernosus reflex is a spinal reflex mediated by the S2 to S4 cord segments. It is tested by application
of
• digital pressure on the penis or clitoris or gently pulling on the Foley catheter to cause reflex anal sphincter
contraction.
• Absence of this reflex indicates spinal shock. Return of this reflex signifies the end of spinal shock. At this point,
the
• patient with complete loss of motor and sensory function below the level of injury and absence of sacral
sparing is
• considered to have a complete spinal injury.
• Treatment of spinal cord injuries starts with stabilizing the spine and
controlling inflammation to prevent further damage.

• Other interventions needed can vary widely depending on the


location and extent of the injury, from bed rest to surgery. In many
cases, spinal cord injuries require substantial, long-term physical and
occupational therapy in rehabilitation, especially if they interfere
with activities of daily living. Research into new treatments for spinal
cord injuries includes stem cell implantation, engineered materials
for tissue support, epidural spinal stimulation, and wearable robotic
exoskeletons

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