Avoiding Spinal Cord Disasters The Key is Early Recognition J. Stephen Huff, MD, FACEP University of...

Avoiding Spinal Cord DisastersThe Key is Early Recognition

J. Stephen Huff, MD, FACEPUniversity of Virginia

Departments of Emergency Medicine and NeurologyJune 25 - 27, 2009

Spinal Cord DisastersThe Key is Early Recognition

• Injury patterns

• Differential diagnosis

• Cases

• Pitfalls

• Pearls

Spine or Spinal Cord?

Spinal Cord Syndromesand Injury Patterns

• Complete

• Incomplete– Anterior– Posterior – Central Cord– Brown-Sequard– Cauda equina lesion– Conus medullaris lesion

Spinal Cord Syndromesand Injury Patterns

• Complete– Transverse sensory pattern– Transverse motor pattern

• What’s the level?

Motor levels

• C4 level – quadriplegia

• C5 level + deltoid, biceps

• C6 level + wrist extensors, brachioradialis

• C7 level + triceps

• T1 level + finger abductors

Motor levelsT2 – T12 paraplegic

• L1 intact – Iliopsoas (hip flexion)

• L2 + hip adductors

• L3 + quadriceps

• L4 + tibialis anterior (dorsiflexion)

• L5 + hamstrings

• S1 + gastrocs (plantarflexioin)

Motor

• Weakness

– Sudden or progressive

• Fatigability

• Clumsiness

• Atrophy / fasciculations

Patterns of sensory loss

• Bilateral segmental loss

• Pinprick loss alternating with position & vibration loss

• Sacral sparing

• Sacral loss

Reflexes

• Reflex assessment may be unreliable in acute lesions

• Autonomic reflexes

• “Spinal Shock”

Pitfalls

• Time constraints

• Incomplete history

• Incomplete examination

• Unusual presentations

“Levels”

• Vertebral

• Cord

• Disability

• Function

• => say what you mean…

Imaging

• Plain radiography

• CT

• MRI

• Myelography

Case 1 - multiple trauma

• Unrestrained driver

• Head injury

• Intubated at scene

• Immobilized / IV’s

Case 1 - arrival

• Intubated / unresponsive

• Hypotensive

• Stable chest

• Rigid abdomen

Case 1 - Management

• Airway verified

• Resuscitation continued

• Examination

• Ancillary tests

Case 1 - Pressure problems

• Hypotensive…

• No fractures on early xrays

– CXR

– Pelvis

• Peritoneal lavage negative

• ? Why hypotensive?

Neurogenic Shock

• “Vasogenic shock”– Diagnosis of exclusion– Fluids– Pressors

• Not “spinal shock”

Pitfalls – complete lesions

• Failed recognition

• ABCD

• Attributing hypotension to the spinal cord injury erroneously

• Steroid stumble

Case 2 - football player

• Tackling injury

• Ambulatory after accident

• Immobilized

• Helmet on….

Case 2 - football player

• Awake, alert

• Strength exam normal

• Severe pain upper extremities

• Grip good

Central Cord Syndrome

• Upper extremity symptoms

• Lower extremities intact

• Variable sensory findings

• Variable bladder dysfunction

Central Cord Syndrome

• “Burning Hands” in football players with spinal cord injuries….

• Cord at risk

• Narrow canal – etiology?

• Advanced imaging

• Restriction of play?

Case 3 – chest pain

• 53 year-old man with chest pain and upper back pain

• Left-sided, sharp, + movement

• Hx COPD, sarcoidosis, CHF, pulmonary embolism, diabetes

• On prednisone, metformin, diuretic

• Wheelchair at times, active

Case 3 – chest pain

• Afebrile

• CXR, CT-PA obtained

• WBC 23,000

Case 3 – chest pain

• Leukocytosis attributed to steroids

• Pain medications, discharged

Case 3 – Clinical course

• Returned 48 hours with leg weakness

• Blood cultures + Staph aureus

• MRI- epidural fluid collection

Sensory

• Paresthesias-positive

• Negative symptoms

• Pain – Local pain– Radicular pain– Diffuse burning/aching

Compressive lesions

– Spinal epidural hematoma– Spinal epidural abscess– Disciitis– Disc– Neoplasm– Metastatic tumors– Primary CNS tumor

Spinal Epidural Abscess

• Acute, sub-acute, and chronic

• Thoracic location more common

• Extends 4-5 levels

• Triad– Back pain– Fevers– Progressive neurologic dysfunction

Spinal Epidural Abscess

• Risk factors– Intravenous drug abuse– Diabetes– Chronic renal failure– Alcoholism– Immunosuppression– Instrumentation

Spinal Epidural Abscessdiagnosis

• MRI diagnostic test of choice

• ESR elevated

• LP relatively contraindicated

Spinal Epidural AbscessTherapy

• Surgical decompression

• Antibiotics*– Staph coverage– MRSA

• Prognosis related to pre-op state

Compressive lesions

– Treatment generally similar…– Diagnosis…

• Exclude remedial causes…

– Steroids … – Decompression…– XRT for tumors…

• “the only XRT emergency….”

Case 4 – crack in neck

• Awakened with severe neck pain

• Became weak on way to ED

• Right-sided weakness– No facial droop – No speech difficulty

Case 4 – crack in neck

• At arrival, weak right arm and leg

– 4/5

– Left side normal

• Additional history– Strong family history of stroke– No medical history other than mild

hypertension

Spinal Epidural Hematoma

• Sudden, severe back pain

• Radicular component

• Progressive neurologic deficits

Spinal Epidural Hematoma

• Anticoagulant use

• Thrombocytopenia

• Liver disease / alcoholism

• Instrumentation

• MRI imaging modality of choice

Case 5

• 16 year old

• Abrupt inability to walk

Case 5

• Awake, alert

• Sitting on side of bed

• Lifting legs with arms

• Sensory level at umbilicus

Case 5

• Normal tone

• Normal reflexes

• “Don’t worry about me…”

“Hysterical paraplegia”

• Untenable patterns

– Sensory loss

– Motor loss

• Normal muscle tone

• Normal reflexes

• No bladder dysfunction

“Hysterical paraplegia”

• Beware diagnosis

• Positive findings…

• Ask for help…

• Lumbar puncture?

“Stable” vs. “unstable”

• Mechanical

• Deficit

• General condition

Low lesions

• Conus medullaris lesion

• Cauda equina lesion– Overlap / coexist– Sphincter involvement– UMN vs. LMN– Bilateral vs. unilateral

Nontraumatic etiologies of spinal cord dysfunction

• Demyelination– Multiple sclerosis / Transverse myelitis– Stroke

• AVM / SAH– Syringomyelia– Traumatic– Tumor

• Idiopathic spastic paraparesis– HIV myelopathy– Other myelopathies

• Compressive lesions

THINK REVERSIBLE

Avoiding Spinal Cord DisastersThe Key is Early Recognition

J. Stephen Huff, MD, FACEPUniversity of Virginiajshuff@virginia.edu