Neck and Spinal Cord Injury
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Transcript of Neck and Spinal Cord Injury
Neck and Spinal Cord Injury
Alpesh A. Patel MD FACSAssociate Professor
Chief, Orthopaedic Spine SurgeryCo-Director, Northwestern Spine Center
Director, Fellowship in Spinal SurgeryDepartment of Orthopaedic Surgery
Northwestern University Feinberg School of Medicine
Disclosures
ConsultingAmedica, Biomet, DePuy, GE Healthcare, Stryker Spine, Zimmer
Product Design/RoyaltiesAmedica, Ulrich Medical
Stock options/Ownership (<1%)Amedica, Trinity, Nocimed, Cytonics
BoardCervical Spine Research Society, Lumbar Spine Research Society, Indo-American Spine Alliance
Editorial BoardContemporary Spine Surgery, Surgical Neurology International
NMH Spinal Cord Injury Center
• RIC – Midwest Regional Spinal Cord Injury Center
• One of 14 national sites• NIH
Traumatic Spinal Cord Injury
• Cervical spine most common• 12,000 new cases
per year in U.S• Dramatic Injuries• Young, Fearless Population
SCI Grouped Etiology
1973-79 1980-84 1985-89 1990-94 1995-99 2000-04 2005-09 2010-120%
10%
20%
30%
40%
50%
60%
14.4% 14.2%10.2%
7.6% 7.0% 8.8% 8.0% 9.2%
Vehicular Accidents Falls Violence Sports
Year
Perc
enta
ge
Age at Injury and Gender
1973–1979 1980–1984 1985–1989 1990–1994 1995–1999 2000–2004 2005–201220
25
30
35
40
45
Males: 23,442 (80.7%) Females: 5,610 (19.3%)
203080 million people
20% of US population
Mortality
• Long-term– 23-66% @
1 year
Fasset JN Spine 2007Harris JBJS 2010
Falls and SCI
• Fall Risk– Propioceptive dysfunction– Neuropathy– Medications– Medical co-morbidities
• Pre-existing canal stenosis– Spondylotic disease– Asymptomatic
• 25-90% > 60 years old
Boden JBJS 1990Teresi Radiology 1987
Economic Costs
• >170 days of hospitalization - 1st 2 yrs• Direct costs – 12-14 billion US $ per yr• Indirect costs
– Lost wages– Caregivers– Lost productivity
What are the challenges facing spinal cord recovery?
The Acutely Injured The Chronically Injured
Historical Perspective
• Traction• Bedrest• Benign neglect
“One having a crushed vertebrae in his neck; he is unconscious of his two arms (and) his two legs, (and) he is speechless.
- Translation of the Edwin Smith papyrus, 3000 B.C.
an ailment not to be treated.”
Pathophysiology of Spinal Cord Injury
• Primary mediators:– Direct injury to
spinal cord tissue– Hemorrhage– Ischemia
IntactCord
Acute Spinal Cord Injury
MechanicalForces
PRIMARYINJURY
Acute Pathophysiologic Processes
+
SECONDARYDAMAGE
PRIMARY DAMAGESECONDARY DAMAGE
Goals of Treatment
Neurological Preservation
Spinal Stabilization
Neurological Regeneration
Evaluation• Standardized• Spinal Immobilization• Exam
– Neurological exam– Concomitant injuries
Current Interventions
• Surgical decompression• Optimizing spinal cord circulation• Steroids
Neurologic Recovery
LaterNow
When do we operate?
Timing of Surgery
Past – Timing of Surgery
• No urgency in treatment– “Early treatment” 3-5 days
• Early treatment = risk !– Neurological decline– Cardiopulmonary– Polytrauma
Marshall 1985, Vaccaro 1997, Mirza 1999, McKinley 2004…
Benefits of Early Surgery
• Neurological protection• Early stabilization• Quicker and safer mobilization• Decreased morbidity
– ICU stay– Pulmonary complications– GI complications
Schlegel, J. Orth. Trauma, 1996
Animal Data
• Primate– Kobrine et al 1978, 1979
• Feline– Brodkey et al 1972– Croft et al 1972
• Canine– Bohlman et al 1979– Delamarter et al 1995– Carlson et al1997, 2003
• Rats– Guha et al 1987– Zhang et al 1993– Dimar et al 1999
Human ModelsWe operated right awayand by the next morning
she was moving her legs!
The plural of anecdote is not evidence
• Multicenter, Non-randomized• 2002 to 2009• Acute Cervical SCI – 313 patients
– 182 Early (<24 hours): mean 14.2 hr– 131 Late (>24 hours): mean 48.3 hr
STASCIS
• SAFETY : Equivalent• RECOVERY (p<0.05)
1 GradeImprovement
2 GradeImprovement
*
**
LaterNow ?SCIEvidence
Current Interventions
• Surgical decompression• Optimizing spinal cord perfusion• Steroids• Hypothermia
Spinal Cord Circulation
Tator CH. Review of experimental spinal cord injury with emphasis on the local and systemic circulatory effects. Neurochirurgie 1991; 37:291-301. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg 1991; 75:15-26.
• Decline in Blood Flow After Trauma– Autoregulation disrupted by
trauma– Systemic hypotension
• Post-Traumatic Ischemia and Infarction– Microcirculatory changes– Blood flow drops to < 20
cc/100g/min within 2 hrs– Vascular congestion & vasogenic
edema– Neurogenic shock
Spinal Cord Perfusion
• PRESERVE cord perfusion• PRESERVE neuro function• AVOID
– Hypotension– Anemia
• No strong published guidelines
Spinal Cord Perfusion
• Mean arterial pressure >80– Optimize Volume (CVP)– Pressure support
• Hematocrit >30• Duration
– 3-7 days– ICU care
Steroids – Wonder Drug?
NASCIS II and III High Dose Methylprednisolone
IV bolus: 30 mg/kg Continuous infusion: 5.4 mg/kg/hr
If steroids given: Duration0-3 hrs post injury 24 hrs3-8 hrs post injury 48 hrs
Bracken, et al. JAMA 1997Bracken, et al. N Engl J Med 1990
NASCIS Limitations
• Methodology– Post hoc analysis– Arbitrary time cut-offs
• Transparency– Private data
• Objectivity– Drug sponsored studies– COMPLICATIONS
High Dose Steroids
• AVOID steroids in:– Neurologically intact– Nerve root injuries– Patients > 3-8 hours from injury– Gun shot wounds– Penetrating trauma– Elderly– Multiply injured– Dose >24 hours
Why do we use steroids?
• Therapeutic Benefit – 17%• Litigation – 70 %
Hurlbert et al 2002 and 2009
Neuroprotectives and Regenerative Strategies
Future Studies• Drug interventions
– TWO at Northwestern• Multi-center trials• IV treatments in patients with Cervical/Thoracic Acute
Spinal Cord Injury
Future Studies• Early detection
– Advance MRI studies: find patients at risk BEFORE they are injured
Right Now:
• Early Diagnosis and Comprehensive Treatment
Thank You