TRAUMA TO SPINE ROLE OF ANAESTHESIOLOGIST

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TRAUMA TO SPINE ROLE OF ANAESTHESIOLOGIST

• Speakers Ranju Gandhi
• KalaiSelvan
• Moderator Dr Bhalla

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
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Role of Anaesthesiologist

• Acute phase
• Resuscitation in emergency department
• Airway management
• Administration of anaesthesia for acute
  decompression of spinal cord to preserve or
  improve function
• Administration of anaesthesia for surgical
  treatment of associated injuries
• II. Chronic phase

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Pharmacological Agents for spinal cord injury
Agent Mechanism of action
Methylprednisolone (MPS) Mem stablization by ? lipid peroxidation, prevention of inflammatory cascade
Tirilizad mesylate Same as MPS, lacks glucocorticoid activity
GM1 ganglioside Augmentation of neuronal regeneration
Naloxone Blocks endogenous opioids that cause local systemic hypotension spinal cord ischaemia
Thyrotropin releasing hormone Same as naloxone
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Recommendations of three NASCI studies for MPS in
treatment of acute spinal cord injury

• Methylprednisolone bolus, 30 mg/kg,then infusion
  at 5.4mg/kg/hr
• Infusion for 24 hr if bolus given within 3 hr of
  injury
• Infusion for 48 hr if bolus given within 3-8 hr
  after injury
• No benefit if MP started more than 8 hr after
  injury
• No benefit with naloxone
• No benefit with tirilazad

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Goal of treatment of spinal cord injuries

• Protect spinal cord from further damage
  (secondary injury)
• Maintain alignment of bony structures to allow
  maximum recovery in incomplete leisons
• Achieve stability of bony column to allow
  rehabilitation

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Management techniques for spinal injuries

• Can be nonoperative or operative
• Non operative management consist of
  immobilization that is well tolerated, permit
  timely mobilization allow for healing within a
  reasonable period
• Cervical spine injury Cervical traction with
  head halter, tongs or a halo ring or cervical
  braces(CO low high CTOs)

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Management techniques for spinal injuries

• Full contact TLSO is currently most effective
  orthosis for management of patients with
  thoracolumbar es
• Below L4 Spica TLSO with 15-30 deg hip flexion
• Above T8 Spica TLSO with custom moulded cervical
  extension
• Special beds For optimal reduction prevention
  of 20 complications
• egg crate mattress special rotating beds
  (Stryker bed Rotorest frame)

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Surgical management of cervical Thoracolumbar
injuries

• Principal goal is adequate decompression of
  neural elements to allow maximal restoration of
  neurologic function
• Optimal timing of surgery early vs late is
  controversial
• Only absolute indication for immediate or
  emergency surgery is progressive neurologic
  deterioration in patients with incomplete or no
  neurologic deficit or other life-threatening
  conditions, unrelated to cord injury

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Anaesthetists concerns in Acute phase
(Preoperative assessment)

• CVS Spinal shock, Baseline HR, BP, Arrhythmias,
  need for inotropic support
• RS Respiratory insufficiency, chest infection
• Mid to low cervical spine injuries (C4-C8) spare
  the diaphragm- intercostal abdominal muscles
  may be paralysed.This leads to inadequate cough,
  paradoxical rib movement on spontaneous
  ventilation, ? VC by upto 50 (redn in IC to 70
  ERV to 20), ? in FRC to 85 0f predicted,
  loss of active expiration.
• Manel et al.Respiratory complications
  management of spinal cord injuries. Chest 97
  1446-52.
• OPTIMIZE RESPIRATORY FUNCTION BY TREATING ANY
  REVERSIBLE CAUSE, INCLUDING INFECTION, WITH
  PHYSIOTHERAPY NEBULIZED BRONCHODILATORS

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Anaesthethists concerns

• CNS Level of injury, complete or incomplete
• Airway unstable cervical spine, potential for
  difficulty if leison at cervical or upper
  thoracic spine
• Immobilization devices
• Increased risk of venous thromboembolism
  Initiate LMWH or mechanical prophylaxis with
  pneumatic boots or compression stockings
• Delayed gastric emptying
• Impairment of thermoregulation
• Investigations Routine hematological, Cervical
  spine X rays, CXR, ABG, Spirometry, ECG

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Preparation Premedication

• Explanation of awake intubation, Wake up test,
  need for post op ET
• High spinal cord leison or FOI
• anticholinergic atropine or glycopyrrolate
  (200-400µg iv or im)
• Antiaspiration prophylaxis
• H2 receptor antagonist, or a proton pump
  inhibitor, with sod. citrate

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Induction

• Can be very challenging, particularly with
  unstable cervical spine es incomplete
  neurologic deficit
• Maintaining alignment of cervical spine during
  intubation is vital in preventing neurologic
  deterioration
• Awake fibrescopic intubation is safest
• (if surgery is non urgent)
• Use nebulized lidocaine rather than cricothyroid
  inj or admn of local anaesthetic through
  fibre-optic scope

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Induction

• IV or inhalation guided by patients condition
  ease with which trachea may be intubated
• Preoxygenate
• Hypoxia or manipulation of larynx or trachea can
  cause profound bradycardia
• All drugs given slowly by titration because of
  cardiovascular lability
• Succinylcholine can be used in first 48 hours
  again 9 months after injury (Hambly et al.
  Anaesthesia 1998)

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Intubation
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Review of literaure

• McCoy laryngoscope significantly improves view at
  Lscopy (Gabbot et al Anaesthesia 1996)
• Bullard Lscope may be useful adjunct to
  intubation of patients with potential cervical
  spine injury when time to intubation is not
  critical (Andrew et al Anaesthesiology 1997)
• Intubating Laryngeal Mask RSI in patient with
  cervical spine injury (Schuschnig et al
  Anaesthesia 1999)
• Awake tracheal intubation through ILMA in a
  patient with halo traction (Bengi et al CJA 2002)

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Review of literaure

• Upper airway obstruction by retropharyngeal
  hematoma after cervical spine trauma. Report of a
  case treated with Percutaneous Dilational
  Tracheostomy(Mazzon et al J of Neurosurgical
  Anaesthesio 1998)
• Use of ILMA to facilitate awake orotracheal
  intubation in patients with cervical spine
  disorders ( Wong et al J Clin Anesth 1998)
• Anesthetic management of a patient in prone
  position with a drill bit penetrating the spinal
  canal al C1-C2, using LMA (Valero et al Anesth
  analg 2004)
• Trauma in pregnancyanaesthetic management with
  awake FOI with unstable cervical spine (
  Kuczkowki et al Anaesthesia 2003)

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Intraoperative monitoring

• Routine ECG, HR, SpO2, NIBP/IBP,
• Et CO2, Temp, UO, NM,
• AWP, CVP
• Special Neurophysiological
• Wake up test
• SSEP
• MEP
• ICP Associated head injury
• PAC Spinal shock
• Prone position TOE, CVP or PAOP misleadng
  indicators of aequate cardiac filling

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Positioning A delicate endeavor

• Depends on level of spine to be operated on
  nature of proposed Sx
• Peripheral nerves, bony prominences eyes are
  protected padded
• Proper positioning of upper extremity
• Avoid displacement of unstable es
• Logrolling from trolley to table
• Compression stockings on lower extremities
• Thoracolumbar surgery
• Anterior approach right decubitus position, may
  require DLT
• Posterior Sx Prone with free abdomen
• Disc Sx Knee-chest position

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Positioning

• Cervical Sx Anterior approach
• Feet close to anaesthetic machine for surgical
  access to head neck
• Extensions needed to breathing circuits iv
  lines
• Tracheal tubes carefully secured without
  impinging on surgical field
• Reinforced tube
• Head supported on padded head ring or Horseshoe
  of Mayfield NSical OT attachment axial traction
  with head halter or skull tongs traction
• Shoulders retracted distally secured with
  longitudinal tape to facilitate radiographic
  access
• Reverse trendelenberg minimizes venous bleeding
  provides counter traction for weight attached to
  head

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Posterior approach to cervical spine

• Patient turned prone with longitudinal chest
  rolls
• Turning can be facilitated with Stryker frame
• Head supported on gel-padded horseshoe of
  Mayfield table attachment or skull clamp
• Orbits, superior orbital nerve skin over
  maxilla at risk of ischaemic injury
• VAE is a risk

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Maintenance

• Stable anaesthetic depth
• 60 N2O isoflurane lt .5 MAC, opioid
• Recommended to keep MAP between 80-90 mm Hg (to
  maintain adequate SC perf)
• Warming of all IVF warm air mattress device
• Sudden cardiovascular instability-
• SC BS reflexes, mediastinal distortion bcoz
  of surgical manipulation or blood loss

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Blood Loss

• Depends on number of spinal levels operated, body
  weight, Preop Hb (Zheng et al Spine 2002)
• Raised IAP in prone position
• Associated with increased operative time, delayed
  wound healing, wound infections, increased
  requirement of BT associated risks
• Can be minimized by careful patient positioning,
  good surgical technique, controlled hypotensive
  anaesthesia use of antifibrinolytics(aprotinin,
  tranaxemic acid, EACA)
• Autologous blood Pre-deposit autologous
  transfusion, ANH, intraoperative RBC salvage

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Intraoperative Spinal cord monitoring

• Ankle clonus test
• Performed during emergence
• SCI Complete absence
• Hoppenfeld et al. J Bone Joint Surg Am 1997
• Reported 100 sensitivity 99.7 specificity
• Can be performed intermittently absence can be
• due to inadequate or too great anaesthetic depth

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Stagnara wake-up test

• Simple, cost effective reliable test
• Evaluates gross functional integrity of motor
  pathways
• Preoperatively, need for test is explained
• Limitations Doesnt evaluate sensory function
  PROVIDES NO INFORMATION REGARDING SPECIFIC ROOT
  INJURY
• Disadvantages
• Requires patient cooperation
• Poses risks to patient tracheal extubation
• Requires considerable operator skill
• Doesnot allow continuous IOM of motor pathways
• Risk of VAE

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Somatosensory evoked potentials

• Elicited by stimulating electrically a mixed
  peripheral nerve, recording responses from
  electrodes at distant sites cephalad to level at
  which surgery is performed.
• Functional integrity of somatosensory pathways is
  determined by comparing amplitude change
  latency change of responses obtained during
  surgery to baseline values.
• Reduction in amplitude of response by 50
  increase in latency by 10 is considered
  significant.

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Postoperative care

• Close monitoring of vitals, neurologic function,
  any worsening suggestive of epidural haematoma
• Observation of upper airway for local edema,
  wound haematoma esp after anterior cervical spine
  injury
• Use of orthotic devices further restricts
  excessive spine motion, allows for soft tissue
  healing, decreases pain
• Initiate DVT prophylaxis (mechanical )

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Postoperative analgesia

• Multimodal approach recommended
• Combination of NSAIDs, opioids and regional
  anaesthesia techniques where appropriate
• Reuben et al . J Bone Joint Surg. 2005 . Effect
  of COX-2 inhibition on analgesia spinal fusion
• Parenteral opioids mainstay of analgesia via
  im,iv ( continuous infusion PCA devices with or
  without background infusion), intrapleural,
  epidural, intrathecal routes

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Gunshot wounds of spine

• Patient evaluation
• ABC
• General description of weapon (handgun, rifle,
  assault weapon)
• Examination of entrance exit wounds
• Palpation to assess presence of crepitation
  general turgor of tissue

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Radiographic examination

• Fracture type degree of bone comminution
• Bullet in torso extent of bullet fragmentation
• CT scan extent of spinal injury degree of
  spinal canal encroachment by bone or bullet
  fragments
• MR scans not routinely performed
• If projectile is ferromagnetic, there may be
  further local tissue damage.

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Treatment of Gunshot wounds of spine

• Wound care
• Exploration of wounds of neck, chest abdomen
  only in patients with specific warning signs of
  serious injury
• Minimally invasive surgery with arteriography
  use of intravascular hemostatic coils has changed
  indications of em exploratory surgery
• Use of steroids is contraindicated

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Treatment of Gunshot wounds of spine

• Wound cultures should be taken from bullet tract
• Uncontaminated spinal injuries 3 days of
  treatment with parenteral antibiotics
• Contaminated wounds 7-14 day antibiotic regimen
  recommended
• Rarely require operation for establishing
  stability.

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Associated viscus injuries

• If bullet first penetrated pharynx, esophagus or
  colon before entering spine, extra precautions
  taken to prevent spinal infection
• Em surgery for repair of viscus broad spectrum
  antibiotics

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Bullet in disc space

• Indications of surgery
• Patient likely to develop lead poisoning
• Disc extrusion causing significant neural
  compression which is symptomatic
• Bullet in spinal canal
• Surgery indicated
• All patients with cervical injuries
• Documented compression of neural elements by
  bone, disc, bullet or haematoma
• At 7-10 days unless deemed urgent

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Complications of gun shot injury to spine

• Neurologic injury
• CSF fistulas
• Subarachnoid pleural fistula
• Spinal infections
• Chronic dysesthetic pains

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Chronic phase

• Preoperative evaluation Problems
• CVS Autonomic hyperreflexia, ? blood volume,
  orthostatic hypotension
• RS Muscle weakness, ? cough ability,
• retention of secretions, atelectasis
• Neuromuscular Proliferation of EJ Ach
  receptors, spasticity
• Genitourinary Renal Recurrent UTI, altered
  bladder emptying, VUR, Early nephrolithiasis

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contd

1. GIT Gastroparesis, ileus
2. Skin Decubitus ulcers, difficult venepuncture
   (skin atrophic, ?BF)
3. Hematologic Anaemia, DVT (25)
4. Bone Osteoporosis, hypercalcemia, muscle
   calcification, hypercalciuria
5. Nervous system Chronic pain
6. Metabolic Glucose intolerance, insulin
   resistance, high i of atherosclerosis (? HDL
   increased TGL)
7. Impaired thermoregulation

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Types of Sugeries

• Urological procedures
• Pressure sores
• Orthepedic surgery for spinal fixation
  treatment of fractures
• Neurosurgery Insertion or removal of
  intrathecal baclofen infusion apparatus,
  insertion of SC stimulators phrenic n pacing
• Msc Coincidental SX

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Autonomic dysreflexia

• 3-6 weeks after SCI-------12 years
• Characterized by extreme autonomic responses
  after stimulation of nerves below level of spinal
  cord leison (rectal, urological, peritoneal)
• Vasodilation in areas above the leison
  vasoconstriction below.
• Prevalance of 60-80 in leisons above T6
• Results from disorganized connections b/w
  pre-synaptic afferent terminal buttons
  interneurons within SC which synapses with sym
  efferents
• Increased sensitivity to exogenous vasopressors
• Adverse sequealae Myocardial ischaemia, ICH,
  Pulmonary edema, seizure, coma, death

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Management of autonomic dysreflexia

• Removal of precipitating stimulus
• Exclude bladder distention fecal impaction
• Pharmacological interventions
• (Alfa 1, alfa 2, ß) Blockers, labetalol,
• CCBs, ganglion blockers, nitrates,
  hydralazine, reserpine, Magnesium
• Perioperative Autonomic dysreflexia (Laurie et al
  Anaesthesiology 2004)
• Preanaesthetic history of AD if ve, greater
  chance of developing intraop.
• Frequency of AD during CNB low, compared to GA
• During general anaesthesia increase
  anaesthetic depth

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Regional anaesthesia in autonomic dysreflexia

• Spinal anaesthesia recommended
• Cardiostability in various studies
• Does not affect neurological outcome
• Epidural opioids (pethidine) to prevent autonomic
  dysreflexia
• Epidural analgesia, CSEA during labor
• SAB, EPIDURAL, GA for LSCS
• Brachial plexus block for UL Sx

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Chronic pain after SCI

• 2 types of neuropathic pain
• Segmentally distributed pain at leison (n root
  entrapment or direct segmental deafferentation)
• Pain in body below leison, late onset
• Shoulder pain in tetraplegia (incidence 70 -
  Spinal Cord 2006)
• Partial spinal leisons, specially cervical more
  prone to produce pain than complete leisons

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Chronic pain after SCI

• Treatment
• Analgesic effect of iv ketamine lidocaine on
  pain after SCI ( Acta Anaesthesiolog Scand 2004)
• The efficacy of intrathecal morphine clonidine
  in treatment of pain after SCI (Anesth Analg
  2000)
• SSRI, Gabapentin, Amitryptiline, Carbamazepine,
  Baclofen
• Interventional spine therapy
• Dorsal root entry zone (DREZ) leisoning procedure
  under intramedullary electrical guidance
  improves pain outcomes in patients with traumatic
  SCI ( J Neurosurg 2002)
• TENS, Acupuncture, SC stimulation
• Cognitive behavioural rehabilitation

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