A 27-year-old male was brought to the ICU following a motorcycle crash resulting in bilateral open femur fractures, grade IV splenic laceration, and traumatic spinal cord transection at T3.
Which of the following is NOT an expected disease-related physiological change?
Correct Answer: C
SCI can lead to neurogenic shock, which consists of bradycardia and severe arterial hypotension. It is due to autonomic nervous system malfunction and is caused by the lack of sympathetic activity, through loss of supraspinal control and unopposed parasympathetic tone via intact vagus nerve. Lesions between T1-T4 interrupt the cardiac accelerator fibers resulting in significant bradycardia along with hypotension, decreased vascular tone, and venous pooling.
Lesions at or above T7 cause impaired functioning of intercostal muscles, which causes reduction in VC and expiratory reserve volume, leading to hypoventilation and hypoxia. Disruption of the sympathetic nervous system due to SCI also results in impaired thermoregulatory function secondary to interruption of signal transmission to the hypothalamic temperature regulating center. This leads to hypothermia, which is characteristic of neurogenic shock.
A 17-year-old football player presents to the ED with acute onset paraplegia after colliding head-on with another player during a training session. He is awake, alert, and oriented; has stable hemodynamics; and is in no respiratory distress with an oxygen saturation of 100% on room air. Neurological examination reveals lack of sensation below T8 and muscle weakness involving all flexors and extensors. CT scan and MRI examination of the spinal cord is negative for any acute pathology. Over the course of next few hours, his motor strength starts improving.
What would be the next course of treatment?
Correct Answer: D
This patient has most likely suffered spinal cord concussion (SCC), which is a variant of mild SCI, clinically designated as transient paraplegia or neurapraxia, and characterized by variable degrees of sensory impairment and motor weakness that typically resolve within 24 to 72 hours without permanent deficits. Many patients show signs of recovery with the first few hours after injury and completely recover within 24 hours. Spinal cord injuries are classified as concussions if they met three criteria:
SCC is predominantly a sport-related injury occurring in a wide variety of contact sports in adult and pediatric athletes including wrestling, hockey, gymnastics, and diving, but most commonly in American football. Because the injury is self-resolving, no further treatment is needed. There is, however, controversy over whether players who suffer SCC have a higher likelihood of sustaining SCI in future and whether they should be cleared for return-to-play.
Which of the following injuries is LEAST likely to result in spine instability?
Spinal cord instability results when at least two of the three spinal columns (anterior, middle, and posterior) are disrupted. The most common mechanism of injury is blunt force involving acceleration-deceleration; these patients should be approached with a high degree of suspicion until injuries have been ruled out radiographically. Injuries to the thoracolumbar region are common in the setting of flexion forces and typically involve T11-L3. Bilateral calcaneus fractures typically result from high impact forces and are also associated with an increased incidence of spinal fractures and require a thorough thoracolumbar evaluation. In contrast to blunt spinal cord trauma, penetrating injuries are less likely to result in spinal instability and may not require placement of c-collars and immobilization. Damage caused by penetrating injuries occur at the time of the initial trauma making the risk of subsequent exacerbation less likely than with blunt spinal cord trauma.
A 88-year-old female presents to the ED after tripping over her cat and landing on her back. She sustains injury to her cervical spinal cord, which is immobilized with a cervical collar, and she is admitted to the ICU.
Which of the following interventions are more likely to improve her neurological outcome?
SCI results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, maintaining adequate spinal cord perfusion using blood pressure (BP) augmentation has been advocated. Spinal cord perfusion pressure (SCPP) is the difference between the diastolic blood pressure (DBP) and Intraspinal pressure (ISP) or intracranial pressure (ICP). [SCPP = DBP−ISP/ICP]. Increasing the DBP, potentially increases the SCPP, thus improving perfusion to the injured spinal cord. Current recommendations according to the guidelines of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Spine and Peripheral Nerves advise correcting hypotension and maintaining a MAP goal of 85 to 90 mm Hg for 7 days postinjury.
The use of methylprednisolone after acute SCI is debatable, and there is unclear evidence about the efficacy and clinical impact of methylprednisolone in recovery from SCI. Consensus statements consider methylprednisolone as a treatment option for acute SCI, but not a standard of care based on available evidence. SBP or CVP has limited impact on improving spinal cord perfusion.
A 40-year-old male is admitted to the ICU after being stabbed in the back during a bar fight. Neurological examination reveals loss of all sensation at the T8 level, loss of proprioception and vibration below T8 on one side, and loss of pain and temperature sensation below T8 on the other side. Motor strength is impaired on the same side as loss of proprioception and vibration.
Which of the following syndrome best describes the findings on neurological examination in this patient?
Correct Answer: A
Incomplete SCI is defined as partial injury to the cord that results in varying degrees of residual sensory and motor function. The site of the injury dictates the findings on neurological examination. BSS or lateral hemi-section syndrome represents a spinal cord hemisection in its pure form. It involves injury to the dorsal column, corticospinal tract, and spinothalamic tract unilaterally, which results in weakness, loss of vibration, and proprioception ipsilateral to, and loss of and temperature sensation contralateral to the injury. Sensory loss of all modalities at the level of the lesion is often seen. BSS is usually secondary to penetrating SCI but can be rarely seen from transverse myelitis after influenza vaccination or a ruptured pheochromocytoma. Management is conservative with aggressive early rehabilitation. Surgical intervention is indicated in the presence of cerebrospinal fluid leak, persistent spinal cord/root compression, or progressive deterioration. BSS demonstrates a favorable prognosis compared with other types of incomplete spinal cord injuries.
Central cord syndrome is the most common of the clinical syndromes, often seen in individuals with underlying cervical spondylosis who sustain a hyperextension injury (most commonly from a fall) and may occur with or without fracture and dislocations. This clinically presents as an incomplete injury with greater weakness in the upper limbs than in the lower limbs.
The anterior cord syndrome is a relatively rare syndrome that historically has been related to a decreased or absent blood supply to the anterior twothirds of the spinal cord. The dorsal columns are spared, but the corticospinal and spinothalamic tracts are compromised. The clinical symptoms include a loss of motor function, pain sensation, and temperature sensation at and below the injury level with preservation of light touch and joint position sense.
Complete SCI would lead to complete paralysis and absence of sensation below the level of the injury.
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