Steven Mardjetko M.D. A. Professor Rush University Dept. of
Orthopedic Surgery Illiniois Bone and Joint Institute
[email protected] PedSpine.com
Slide 2
Acute Spinal Cord Injury What 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
Slide 3
What Defines these injuries as Catastrophic? The Spinal
Cord!!
Slide 4
Spinal Cord Injury Incidence 50 injuries per million 32 per
million survive the first year Majority of mortality occurs en
route to hospital
Slide 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!)
Slide 6
SCI injury leads to irreversible functional loss
Slide 7
Spinal Cord Injury Acute 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)
Spinal Cord Regeneration Contused Rat Spinal Cords 5 to 6
months after injury Bomstein et al 2003
Slide 10
Rollover Truck Injury Fracture Dislocation C7-T1 Complete
Spinal Cord Injury: ASIA A
Slide 11
L-1 Burst Fracture Stable vs. Unstable (3/3 columns damaged)
Determined by integrity of the posterior Tension Band
Slide 12
52 yo fell from tree Burst Subluxation L-1 with Complete
SCI
Slide 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
Slide 14
Spinal Cord Injury Classification Frankel 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
Anatomic Alterations in SCI 50% of Complete Lesions have some
intact neural tissue
Slide 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!!
Slide 21
Spinal Cord Injury Improving 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
Slide 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
Slide 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
Slide 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!
Slide 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 No
Significant differences in Neural recovery, complications or Length
of Stay
Slide 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 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.!!
Slide 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
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C6-7 Fracture/Dislocation ultra-emergent Tx/Rdxn, Decompression
and PSFI ASIA A to ASIA D. Ambulatory w/o crutches! Unilateral UE
deficits
Slide 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!!!
Slide 32
Just a Routine Emergency Snake a tube down her nose and Ill be
there in 4-5 hours!
Slide 33
While You may be able to find many reasons not to get out of
bed in the Middle of the Nite!
Slide 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!
