Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
.pdf
9 Evaluation and Management of
Spinal Co rd Injury
9.1 General Considerations
I. In t r o d u ct ion .
A. App r ox im at e ly 1 2 ,0 0 0 t o 1 4 ,0 00 s p in al cor d in ju r ie s (SCIs) o ccu r in No r th
Am e r ic a p e r y e a r.
1. They most commonly occur in adolescent males.
2. Most are related to motor vehicle collisions.
II. Pr eh osp it al eva lu at ion p er iod .
A. Care of a ny t ra u m a p a t ie n t b e gin s w it h im m ob iliz at io n o f t h e sp in e at t h e s ce n e
of injury.
B. Am e r i c a n Co ll e ge o f Su r ge o n s m n e m o n ic fo r in - e l d m a n a g e m e n t o f a t r a u m a
patient:
1. A—airway.
2. B—breathing.
3. C—circulation.
4. D—disability.
5. E—exposure and environment.
C. All t ra u m a p at ie n t s s h ou ld b e i m m ob ilize d w it h a r ig id ce r vic a l o r t h osis a n d
transferred using lateral bolsters.
1. The patient should be placed on a long backboard secured with tapes or straps.
2. Helmeted athletes:
a. Helmet and shoulder pads should not be rem oved.
III. Em e rge n cy room m an agem en t .
A. Po lyt r a u m a p at ie n t s m a y h ave a n a lt e re d le ve l o f co n s c io u sn e s s a n d a re
vulnerable to further worsening of their neurological injuries.
B. On c e t h e ABCs h ave b e e n e st a blis h e d , a t h o r o u gh b u t fo cu se d p h ys ic a l
examination should assess the patient’s neurological function.
1. The entire spinal column should be palpated for “step-o ” or misalignment
of the spinous processes.
C. He a d t r a u m a :
1. Glasgow Coma Scale.
a. Total score can range from 15 (normal responses to stimuli) to 3 (no
response or comatose) (Table 9.1).
116
D. Eva lu at ion of air w ay an d breat hing:
1. Elective intubation should be performed in patients with severe head
injuries or w ho are unable to protect the airway becau se of a depressed level
of consciousness (Glasgow Coma Scale score < 8).
2. Patients with SCIs (particularly above C5) having di culty with respiration
should be considered for elective intubation.
3. Manual in-line stabilization of the cervical spine during orotracheal
int ubation minim izes mot ion of the unstable cervical spine.
9 Evaluat ion and Managem ent of Spinal Co rd Injury 117
Ta b l e 9 . 1 Glasg ow Com a Sca le
Ey e o p e n i n g S p o n t a n e o u s 4
Vo i c e 3
Pain 2
Non e 1
Ve r b a l r e s p o n s e Oriented 5
Co nfu se d 4
In ap p r o p ria t e 3
In co m p r e h en sib le 2
Non e 1
Mot or re s p on s e Ob eys co m m an d s 6
Lo c a l i z e d p a i n 5
Withdraws 4
Decorticat e 3
Decere b rat e 2
Non e 1
E. Ne u ro logica l e x a m in at io n (Fig. 9.1):
1. The American Spinal Injury Association (ASIA) standard of neurological
testing provides a concise and detailed method of evaluating spinal cord and
peripheral nerve root function.
a. Sensation is determined in all 28 dermatomes bilaterally by the patient’s
ability to detect the sharp end of a pin (Fig. 9.2).
b. Motor function is documented and graded 1 to 5 based on resistance to
physical manipulation or gravity (Table 9.1).
c. Based on both the m otor and the sensory exam ination, the patient is
furt h er classi ed or graded using the ASIA m od i cat ion of th e Fran kel
neurological classi cation system (Table 9.2).
F. S CI s :
1. Complete injury.
a. No functional motor (less than grade III motor strength) or sensory
activity below the zone of injury.
2. Incomplete injury.
a. Partial preservation of motor or sensory function below the zone of
injur y.
G. Im agin g evalu at ion :
1. Initial radiographs.
a. Standard anteroposterior/lateral views of the cervical, thoracic, and
lum bosacral spine.
(1) Ten to 15% of patients have noncontiguous spinal colum n fractures.
118
9 Evaluat ion an d Managem ent of Spinal Cord Injury
Fi g . 9 . 1 Clin ical m a n ife st at io n s o f sp inal co rd in jur y a cco rd in g t o le vel o f in ju r y.
9 Evaluat ion and Managem ent of Spinal Co rd Injury 119
Fi g . 9 . 2 Am e r ic a n Sp i n a l In ju r y As s o c ia t io n sp in a l c o r d in ju r y a s s e s s m e n t fo r m . (Fr o m t h e Am e r ic a n
Spinal Inju r y Asso ciat ion. Int ern at io na l Standard s fo r Neuro lo g ical Classi cat ion o f Spin al Cord Inju r y.
Re v is e d 2 0 0 2 . Ch i c a g o , IL: Am e r i c a n Sp in a l In j u r y As s o c i a t i o n ; 2 0 0 6 . Re p r o d u c e d w it h p e r m i s s i o n . )
b. Always visualize the alignment of the cervicothoracic junction.
c. Computed tom ography (CT):
(1) Used to further delineate bony anatomy.
(2) Helpful in visualizing the cervicothoracic (C7–T1) junction.
(3) A CT scan must be obtained if C7–T1 is not visible on lateral
radiographs.
(a) Most traum a centers have now begun routinely obtaining CT
scans of the cervical spine as the gold standard for cervical spine
clearance, obviating th e need for plain radiographs.
d. Magnetic resonance imaging:
(1) Used in all cases of neurological comprom ise.
(2) Useful for visualizing soft tissue anatomy and disruption.
H. Treat m ent:
1. The severity of the initial impact on the spinal cord is typically re ected by
the patient’s initial neurological presentation.
2. The extent of the patient’s neurological recovery is not solely dependent on
the primary injury.
a. Secondary injury to the spinal cord results from a physiological cascade.
(1) Initial hem orrhage followed by in am m ation, m embrane hydrolysis,
ischem ia, calciu m in u x, and cellular apoptosis.
120
9 Evaluat ion an d Managem ent of Spinal Co rd Injury
Ta b l e 9 . 2 Am e r ic a n Sp i n a l In ju r y As s o c ia t io n (ASIA) Cla s s i c a t io n Sc a l e
1. Determine if patient is in spinal shock.
– Check bulbocavernosus re ex.
2. Determine neurologic level of injury.
• Lowest se gm ent with int act sensation and antigravity (3 or m ore ) m uscle funct ion
strength.
• In regions where t here is no m yot om e t o test, the mot or level is presum ed t o be
the same as the sensory level.
3. Determine whether the injury is COMPLETE or INCOMPLETE.
• COMPLETE de ne as ASIA A
– no volunt ary anal contract ion (sacral sparing) AND
– 0/5 dist al mot or AND
– 0/2 d istal sensory scores (no perianal sensat io n) AND
– bulbocavernous re ex pre sent (pat ient not in spinal shock)
• INCOMPLETE de ne d as
– volunt ary anal contract ion (sacral sparing)
– sacral sparing critical to determine com plet e vs. incom p let e
– OR palpable or visible m uscle contract ion below injury level OR
– perianal sensat ion present
4. Determine ASIA Impairment Scale (AIS) Grade:
ASIA Im p a ir m e n t Sc a le
AComplete No motor or sensory function is present in the sacral segments S4–S5.
BIncompleteSensory function preserved but no motor function is preserved
below the neurological level and includes segments S4–S5.
CIncompleteMotor function is preserved below the neurological level, and
more than half of key muscles below the neurological level have a
muscle grade less than 3.
DIncompleteMotor function is preserved below the neurological level, and
at least half of key muscles below the neurological level have a
muscle grade of 3 or more.
EIncompleteMotor and sensory function are normal.
Sou rce: Kirshblum SC, Burns SP, Biering-Sore nsen F, et al. Inte rnational st andard s for
neurological classi cation of spinal cord injury (Revised 2011). J Spinal Cord Med
2011;34(6):535–546. Used with permission.
3. Pharmacological intervention:
a. The most commonly used agent is methylprednisolone. However, the
extent of recovery in terms of improved functional ability and the risk to
the patient have been extensively debated.
(1) National Acute Spinal Cord Injury Study (NASCIS) guidelines are most
com monly used.
(2) Methylprednisolone: bolus dose of 30 mg/kg of body weight over
15 minutes, followed by a 45-minute pause, and then a 23-hour
contin uous infusion of 5.4 m g/kg/h if the patient presents < 3 hours
after injury.
9 Evaluat ion and Managem ent of Spinal Co rd Injury 121
(3) If the patient presents bet ween 3 and 8 hours after injury, the steroid
infusion is continued for a total of 48 hours.
b. The NASCIS II Trials advocated for the administration of high-dose
steroids within 8 hours of injury if the follow ing contraindications are
absent:
(1) Cauda equina syndrome.
(2) Nerve root injury.
(3) Life-threatening patient status.
(4) SCI secondary to gunshot.
(5) Pregnancy.
(6) Patient younger than 13 years of age.
(7) Substance addiction.
(8) Chronic steroid use.
c. Numerous authors have questioned the validity of the study design and
have refuted the ndings of the NASCIS trials.
d. In 2013, the Congress of Neurological Surgeons and the American
Ass o ciat io n o f Ne u r o lo gica l Su rge on s r eco m m e n d e d a g a in st t h e u s e o f
steroids following an SCI.
(1) Lack of evidence that dem onstrates bene cial outcom es.
(2) Greater risk of potential side e ects (gastrointestinal bleeding,
infect ion, avascu lar necrosis of the fem oral head).
4. Surgical timing:
a. Data from the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)
trials suggest that early intervention with decompression and stabilization
may potentiate better neurological recovery following an SCI.
(1) Primary injury from physical compression or contusion.
(2) Secondary injury from the dow nstream cascade of events that result
follow in g t h e p r im a r y in su lt :
(a) Neuroprotection involves the prevention of secondary injury
with the expeditious decompression of neural elements.
(b) The poten tial for neuroprotect ion varies inversely w ith tim e.
(3) Decom pression within 24 hours of injury results in im proved
neurological outcomes at 6-month follow-up.
Sugg este d Reading
Aa r ab i B, Ha dle y MN, Dh a ll SS, e t al. Ma n age m e n t o f a cu t e t r au m a t ic ce n t r a l co r d syn -
drom e (ATCCS). Neu rosurger y 2013 ;72 (Suppl 2):1 95– 204
Fe h li n gs M G, Va cc a r o A, W ils on JR, e t a l. Ea rly ve rs u s d elaye d d e c o m p r e ss io n fo r t r a u m a t ic
cervical spinal cord injury: results of th e Su rgical Tim ing in Acu te Spinal Cord Injury
St udy (STASCIS). PLoS ONE 2012;7(2):e32 037
Halpern CH, Milby AH, Guo W, Sch u st er JM, Gra cias VH, Stein SC. Clearan ce of t h e cervical
spine in clinically unevaluable traum a patients. Spine 2010;35(18):1721–1728
Ro w l a n d JW, Ha w r y l u k GW , Kw o n B, Fe h li n g s M G. Cu r r e n t s t a t u s o f ac u t e s p i n a l co r d i n -
jury pathophysiology an d em erging therapies: prom ise on the h orizon . Neurosurg
Focu s 20 08;25(5 ):E2
10 Cervical Spine Trauma
10.1 General Considerations
I. In t r o d u ct ion .
A. Fift y t h o u sa n d ce r vica l sp in al colu m n o r co rd in ju rie s a r e r e p or te d ye a r ly in t h e
Un it e d St a t es.
B. Mo st sp in a l c o lu m n o r co r d in ju r ie s o cc u r in m a l e s b et w e e n t h e a ge s o f 1 5 a n d 2 4 .
C. Me ch a n is m :
1. Motor vehicle accidents are the most common cause (40–56%) (Fig. 10.1).
2. Falls (20–30%).
3. Gunshots (12–21%).
4. Sports (6–13%).
D. Th e m id cervical sp ine (C4–C6) is th e m ost com m only a e ct ed an atom ical
region.
II. Pat ie n t eva lu at io n .
A. A d et aile d h is t o r y, in clu d in g t h e m e ch an is m o f in ju r y a s w ell a s a ss ocia t e d
injuries, is required.
B. Ea rly r e co gn it io n o f t h e in ju r y b e g in s in t h e e ld .
1. A cervical collar and spine board are applied to the patient.
2. The patient is transferred to an emergency department.
a. The trauma resuscitation team evaluates airway competency, breathing,
and circulation.
3. Anteroposterior and lateral radiographs of the entire spine can be obtained.
4. Computed tomography (CT) is the most sensitive and speci c imaging study
to diagnose cervical spine injuries (Fig. 10.2).
a. Intravenous contrast is useful to determine vertebral artery injury.
C. Ce r vi c a l sp in e t r a ct io n :
1. Indications.
a. Unstable fractures or fracture dislocations of the cervical spine with or
without neurological de cits.
b. Damage control therapy for cervical spine fractures while the patient is
being treated for other injuries.
2. Contraindications.
a. Complete permanent quadriplegia.
122
b. Unstable fractures with deteriorating neurological signs.
c. Stable fractures.
d. A patient who is not awake, alert, and cooperative.
3. Technique: Gardner-Wells tongs (Fig. 10.3).
a. The skin over the temporal fossa is in ltrated with a local anesthetic
agent. The pins are positioned 2 cm above the external auditory canal
and below the temporal ridge. The pins are tightened until the spring-
10 Cervical Spine Trauma 123
Fi g . 1 0 . 1 Me ch a n ism o f wh iplash in jurie s o f t h e h ea d an d n e ck.
loaded indicator protru des 1 m m above th e surface. Initially, 10 lb of
traction-weight is used. Weights are added at 10 lb increments every 20
minutes. Serial neurological exams are performed and radiographs are
taken after each weight is placed.
4. Complications.
a. Failure to reduce: a bilateral, irreducible facet dislocation is unstable and
should be treated with urgent open reduction after m agnetic resonance
im aging (MRI) is perform ed.
b. Change in the neurological status: with any change in the neurological
status of the patient, the weights should be rem oved imm ediately and an
MRI scan should be obtained em ergently.
124
10 Cervical Spine Traum a
a
b
Fi g . 1 0 . 2 ( a ) Sagittal computed tomographic
(CT) im ages of the cervical spine dem onstrating sp in al ste n o sis a n d spondylo sis. (b) Axial CT
im a g e s of th e ce rvical sp ine de m o n strat ing sp inal stenosis and spondylosis at the level of the
C3 ve rt eb ra e . (c) Axial CT images of the cervical
spine demonstrating spinal stenosis and spondy-
c
losis at t he le ve l o f t he C4 ve r t e b rae .
III. Up p e r ce r v ical in ju ries.
A. Occ ip it a l co n d yle fr a c t u r es .
1. Rare injury.
2. One-third occur in conjunction with atlanto-occipital dislocations.
3. Diagnosis is most commonly made incidentally with a head CT scan.
a. Ligamentous injury, intracranial hematoma, and neurological de cit may
accompany this injury.
4. Treatment:
a. Usually rigid orthosis or halo vest for 3 months.
b. A exion–extension lm is obtained at 3 months.
c. Occipital–cervical arthrodesis for resultant instability.
B. Occip u t– C1 d is lo ca t io n .
1. Unstable and almost always fatal.
a. Survivors usually have severe neurological de cits.
2. Violent, twisting, or exion-extension force on the head.
3. Disruption of all ligamentous attachments.
4. Radiographic diagnosis.
a. Harris radiographic lines.
5. Treatment.
a. Closed reduction.
b. Occipital-cervical fusion.
10 Cervical Spine Trauma 125
Fi g . 1 0 . 3 Ga rd n e r-We lls t on g s in p lace wit h t ra c t io n .
C. C1 – C2 s u b lu xa t io n .
1. More common in children than in adults.
2. Common complaints.
a. Neck pain with evidence of torticollis.
b. Suboccipital pain.
c. Limited cervical rotation.
D. May be associat e d w ith od on toid or at las fra ct u res.
1. Rupture of transverse ligament.
a. Anterior atlantodens interval (ADI).
(1) Three to 5 mm indicate rupture of the transverse and alar ligam ents.
(2) Seven to 8 mm indicate complete ligam entous disruption.
(3) Greater than 10 mm causes spinal cord compression.
Соседние файлы в папке Библиотека им академика М.И. Перельмана