spinal cord injury management- neuro nurses perspective

1. Dr. M.Manoranjitha kumari MCh
Neurosurgeon
KIMS , Hyderabad
Spine injury and management
O-arm in spine fixation

2. Anatomy

3. Cervical Vertebrae
􀁺 Small vertebral bodies
􀁺 less weight to carry
􀁺 Extensive joint surfaces
􀁺 greater ROM

4. Thoracic Vertebrae
􀁺 Rib bearing vertebrae
􀁺 Designed to remain stiff
and straight

5. Lumbar Vertebrae
Weight bearing
vertebrae

6. Spinal ligaments

7. Spine trauma
• Incidence
• In the Indian setup,Approximate 20,000
new cases are added every year.

8. Mechanism

9. Suspect spinal injury with...
􀁺 Sudden decelerations (MVCs, falls)
􀁺 Compression injuries (diving, falls onto
feet/buttocks)
􀁺 Significant blunt trauma (football, hockey,
snowboarding, jet skis)
􀁺 Very violent mechanisms (explosions, cave-ins,
lightning strike)
􀁺 Unconscious patient
􀁺 Neurological deficit
􀁺 Spinal tenderness

10. Spinal stabilization and
management
􀁺 Protect spine at all times in patients with multiple
injuries.
􀁺 Up to 5% of spinal injuries have a second fracture
elsewhere in the spine.
􀁺 whole spine should be immobilized
1.Manually
2. A combination of semi-rigid cervical collar, side
head supports, long spine board and strapping.

12. System Oriented Approach
Airway
Breathing
Circulatory
Neurologic Classification
Spinal Imaging

13. Decision to Intubate
􀁺 Loss of innervation of the diaphragm
􀁺 Hypoventilation
􀁺 V/Q mismatch
􀁺 Secretion retention
􀁺 Associated injuries

14. Management of Breathing
Monitoring of SpO2, EtCO2
O2 therapy
Bronchodilators
Assisted ventilation
Positioning and mobilizing
Chest physio, Assisted Cough

15. Spinal Shock
Temporary suppression of
all reflex activity below
the level of injury
Occurs immediately after
injury
Intensity & duration vary
with the level & degree
ofinjury
Once BCR returns, spinal
shock is over
Neurogenic Shock
􀁺 Distributive shock
􀁺 The body’s response to
the sudden loss of
sympathetic control
􀁺 Occurs in people who
have SCI above T6
(> 50% loss of sympathetic)

16. Clinical Signs of Neurogenic
Shock
Clinical Triad
􀁺 Hypotension
􀁺 Bradycardia
􀁺 Hypothermia

17. Treatment
􀁺 First Line:
• Volume Resuscitation (1-2 L)
􀁺 Second line:
• Vasopressors-
counter loss of sympathetic tone
provide chronotropic support to heart

18. • Hemodynamics and Cord Perfusion
Maintain MAP 85-90mmHg for first 7 days if
possible

19. Bradicardia
􀁺 Avoid vagal stimulation
􀁺 Hyperventilate and hyperoxygenate
prior to suctioning
􀁺 Pre-medicate patients with known
hypersensitivity to vagal stimuli
Treatment of Symptomatic Bradycardia:
Atropine 0.5 - 1.0 mg IV

20. GI Intervention
• 􀁺 Minimizing Risk for Aspiration:
Nasogastric tube
• 􀁺 Minimizing Risk of Gastric Ulceration:
IV Ranitidine 50mg IV q8h

21. Pharmacological
Pain Management
• IASP Proposed 2 Broad
Types:
Musculoskeletal
Visceral
Responds well to opioids
and NSAIDS
Methylprednisolone
If initiated < 3hrs continue
for 24 hrs, if 3-8 hrs after
injury, continue for 48hrs
morbidity higher - increased
sepsis and pneumonia

22. Cervical traction
To realign and stabilize the spine
Fastest method of increasing the diameter
of the spinal canal
Muscle relaxants and the reverse
Trendelenberg position.
• Absolute contraindications:
Occipitoatlantal dislocations
Concomittant open skull fracture

23. Indications for surgery
• 􀁺 Deformity correction
• 􀁺 Stabilization of the spine
• 􀁺 Decompression of neurologic elements

24. PROGNOSTIC FACTORS for
recovery
• 􀁺complete cervical injuries that remain complete
within the first 24 hours of admission are unlikely
to regain significant ambulatory function (1% to
3%)
• 􀁺 Cervical injuries recover better than thoracic
or thoracolumbar injuries
• 􀁺 Younger age group
• 􀁺 Intermedullary hemmorrhage signifies a worse
outcome.

25. O arm
• 3D navigation- of cone-beam CT enabled
multiple fluoroscopic image acquisition by
a device that rotated isocentrically around
the patient- more accurate

26. Multiplanar imaging
• Axial, sagittal and coronal images
• Multiple level imaging without moving the
machine in a single sequence
• Imaging of the cervico dorsal junction and
upper thoracic spine

27. Cervico dorsal junction

28. Percutaneous fixation of D6 fracture

29. OR set up with O arm

30. O arm in spine surgery
• 3D view
• navigation
• Accuracy is excellent
• Less incidence of failure and second
surgery
• minimally invasive spine surgery

32. THANK YOU