Traumatic Spinal Cord Injury

Question 1

What are some common etiologies of traumatic spinal cord injury?

Answer 1

Motor vehicle accidents, falls, animal-animal encounters, malicious abuse, penetrating missiles

Question 2

What are some types of vertebral Column Injury?

Answer 2

Fracture/luxation, acute disc herniation, soft tissue injury, contusion/laceration, nerve root injury, entrapment

Question 3

What is a primary vs secondary lesion?

Answer 3

Normal - mechanical impact - primary injury (contusion/concussion) and secondary injury (ischemia, neuroinflammation, edema)

Question 4

What kind of forces can act on the axial skeleton?

Answer 4

Bending (dorsoventral and lateral), Torsional, Shear, Axial loading (compression and tension)

Question 5

What part of the spine resists bending and axial loading?

Answer 5

Vertebral Body

Question 6

What part of the spine resists all forces?

Answer 6

Articular facets

Question 7

What is the most important stabilizer against lateral bending and torsion?

Answer 7

Intervertebral discs

Question 8

Where are many spinal injuries located region wise?

Answer 8

Cranicervical junction, cervicothoracic junciton, T-L junction and L-S Junction (more in the rear)

Question 9

What is the goal of treating a traumatic spinal injury?

Answer 9

Don’t make it worse, support the animal

Question 10

What are the goals of your exam?

Answer 10

Don’t make it worse, establish severity, determine what other injuries are present

Question 11

After a traumatic spinal injury what should you do when you first asceses the animal?

Answer 11

ABC- airway, breathing and circulation
Evaluate for concurrent injury (Cardiothoracic, appendicular fracture, soft tissue trauma, head traum and urinary tract injury

Question 12

How should you perform your neurologic exam?

Answer 12

Restrained and in lateral recumbency (Mention, body posture, CN, motor function in all limbs, reflexes in all limbs, perineum and CT, tail, conscious proprioception with deep pain

Tells you stability

Question 13

How do you grade severity of the spinal injury?

Answer 13

Modified Frankel Score (MFS) - 0-5
0 - normal
1-pain only
2- ambulatory parapersis and ataxia
3- non-ambulatory
4- paraplegia with deep pain preception
5 - paraplegia with absent deep pain
Pain preception = nociception

Question 14

What is the schiff-sherrington Phenomena/Posture?

Answer 14

extended front limbs and flaccid paralysis hind that can’t be moved normal
Spinal shock (thoracic lumbar lesion)

Question 15

Decerebrate Posture is?

Answer 15

Extension of all limbs
Brain stem and decreased concsiouness

Question 16

Decerebellate posture is?

Answer 16

Extension of thoracic and bent hind
Conscious

Question 17

What is the prognosis for traumatic spinal cord injury?

Answer 17

Cervical: 60-70% good if survive initial injury
T3-L3, L4-S2: 75-80% good with surgery, 60% with conservative
Cervial or thoracolumbar - no deep pain - grave/hopeless - euthanize

Question 18

How do we immobilize a patient?

Answer 18

Lateral recumbency (plywood, cardboard, stracher, cage, tape, cloth, dont let it prevent ventilation

Question 19

What does supportive care look like for a spinal injury?

Answer 19

Maintain perfusion - BP and Oxygen
Analgesics

Question 20

What type of analgesics are needed?

Answer 20

Parental narcotics - Full Mu-opiod agonsit (morphine)
Sedative, anxiolytic, NSAID

Question 21

How do we image spinal diseases?

Answer 21

Radiograph, CT, MRI

Question 22

Since radiographs are always indicated in traumatic spinal injury, how should they be taken?

Answer 22

Lateral recumbency

Question 23

How do you know if the injury is unstable?

Answer 23

Divide vertebrae in 3 compartments
-Disruption of 2/3 compartments = instability and dictates treatment

Question 24

Can you determine the degree of impairment from radiographs alone?

Answer 24

No, not unless it is a full displacement = poor prognosis

Question 25

What are indications for advanced imaging like MRI or CT?

Answer 25

No obvious rad lesion, rad lesion doesn't match clinical localization, surgical therapy indicated and evaluate integrity of the spinal cord

Question 26

What is treatment of the vertebral column driven by?

Answer 26

Stability and injury severity

Question 27

If the injury is stable what is the treatment?

Answer 27

cage rest and analgesics for 6 weeks

Question 28

If the injury is unstable what is treatment?

Answer 28

Surgical or conservative

Question 29

What are indications for conservative management?

Answer 29

Cervical fracture (death in surgery), Caudal lumbar or lumbosacral fracture with minimal neuro involvement, no significant concurrent injury, intact pain perception, client constrain, external coaptation

Question 30

How should external coaptation be fulfilled?

Answer 30

Make sure to immobilize high motion segments above and below the level of the lesion *DONT reduce fracture or luxation before putting a brace on, hard to reduce, labor intensive, multiple material

Question 31

How do you asses your conservative treatment?

Answer 31

Hospitalize 2-5 days Check BID (pain, neuro, bladder, tolerance of coaptation) Recheck weekly next 3 weeks (analgesia) Repeat rads 4 weeks

Question 32

What are indications for surgery and what are the goals?

Answer 32

Unstable injury and moderate to secer neurologic signs Reduce malalignments (decompression) Rigid fixation Decompress spinal cord

Question 33

When is additional decompression necessary?

Answer 33

Displaced fracture or fragment, disc rupture, compressive hematoma, penetrating missile

Question 34

What are the advantages and disadvantages of surgical treatment?

Answer 34

Advantage: strength against bend and torison, adaptable, no need to remove Disadvantage: low resistance to bending, implant failure or bone pull out

Question 35

What are things to strongly consider when thinking about Cervical vertebral trauma?

Answer 35

can lead to death if sever, canal:cord diamteter favorable, low incidence body fracture, high surgical mortality, conservative treatment 75% sucess, delayed referral worsens prognosis

Question 36

What should you consider with thoracolumbar injury?

Answer 36

surgery if unstable - hard to immobilize, decompensation bad, deficit common with conservative

Question 37

What should you consider with lumbosacral injury?

Answer 37

Mobile lumbar and imobile sacrum make more stess, nerve roots in caudal equina more injury tolerant than spinal cord, incontinence common

Question 38

What should you consider with Sacro caudal injury?

Answer 38

tail pull injuries - common in cat, rare dog - traction avulsion S1-S3 Sign: plantigrade with paraparesis, weak/paralyzed, flaccid tail, diminished perineal reflex/anal tine, tail pain, urinary and fecal incontencae Concurrent injury common Treat with cage rest, analesic and bladder management, tail amputation internal fixation ***Important presence of tail and perineal sensation, improve in 2 weeks, intact pain sensation urinary function return (75-100%), absence of tail sensation >30 days poor prognosis

Question 39

What are treatment complications for conservative treatment?

Answer 39

Failure - pain and instability Coaptation

Question 40

What are treatment complications for surgical treatment?

Answer 40

technical error, damage to spinal cord, concurrent injure, implant failure or infection