Spinal Cord DisorderMichael H. Wilhelm, CRNA, APRN

Acute Spinal Cord InjuryTrauma is the leading cause of injury

1.5% to 3.0% cervical spine injury in major trauma4% to 5% have injury to upper cervical spine C1-

C3Injury can also occur at thoracic and lumbar

spinal area

Clinical ManifestationDepend on the extent and level of the injury

InitiallyFlaccid ParalysisLoss of Sensation below level of injuryClassified by the terms of the American Spinal Injury

Association

ASIA Classification System

Physiological EffectsDepends on Level of Injury

More severe at cervical level and less sever caudallyReduction of blood pressure

Loss of sympathetic nervous system activity and a decrease in systemic vascular resistance

Bradycardia resulting from loss of T1-T4 sympathetic innervation to the heart

Can be seen in Thoracic or Lumbar Injury but more common with Cervical Injury

Another Term for these findings is spinal shock Lasts 1-3 weeks

With Cervical and Thoracic InjuryMajor cause or morbdity

Alveolar hypoventilation Inability to clear secretionsMore respiratory muscle impairment with cervical

injuryAspiration of gastric contentsPneumoniaPulmonary Embolism

Do we always need an x-ray?

Well Stoelting talks about how x-rays are over used, pt can be evaluated on the following five criteriaNo midline cervical spine tendernessNo focal neurologic deficitsNormal sensoryNo intoxicationNo painful distracting injury

Anesthesia ManagmentAirway Management

Special Care with Direct LaryngoscopyNeck movement minimizedIf collar in place have another provider maintain C-

Spine immobillization with their hands, document appropriately

If no collor on trauma pt, ensure clearance from trauma team is noted in the chart

Avoid HypotensionMaintain Spinal Cord Perfusion

More Airway TipsOther options to Direct Laryngoscopy

Glidescope Awake Fiberoptic Laryngoscopy

Pt must be cooperativeCan have visualization problems with blood, secretions and

anatomic deformitiesCoughing can be detrimental to the pt

Awake TracheotomyOnly used as a last resort and for the most challenging

airways (i.e. facial fractures, deformities)

No matter what method you use always have manual in line stabilization in place

Systemic SystemsAbsence of compensatory sympathetic nervous

systemDrastic drop in blood pressure can be noted

Changes in body position, blood loss, or positive pressure ventilation

Liberal Intravenous Infusion of crystalloid solutionFill the intravascular spacesAcute blood loss should be treated rapidly

EKG changes are common especially with a cervical spine injury

Breathing best managed by ventilatorLoss of accessory muscles

Body Temperature should be maintained and monitoredPts become poikilothermic below level of injury

GA can be done with anesthetic gases or TIVACaution with Nitrous Oxide as it can expand gas in

closed spacesEspecially in Basilar Skull Fractire of Rib FractireCan worsen a pneumocephalus or a pneumothroax

Arterial hypoxemia is commonMonitor Pulse Oximetry and Oxygen

Supplementation

Muscle Relaxation?Base decision on location of operative site and

the level of spinal injuryPancuromium

Sympathomimetic effectsSuccyncholine

No excess potassium release seen with an initial spinal cord injury after a few hours

Chronic Spinal Cord Injury Anesthesia Focus should be to prevent Autonomic

Hyperreflexia Non-Depolarizing Muscle Relaxant Drugs are the drug of choice

Depolarizing Muscle Relaxants will provoke hyperkalemia Particularly for the initial 6 months after the injury Do not use after 24 hours of injury

May see varying of heart rate and blood pressures Chronic immobile patients should always have a high suspicion

of pulmonary thromboemolism Intercostal Muscle impairment can lead to difficulty in extubation

Impaired Cough and Excessive Secretions Continue Baclofen and Benzodiazepines to prevent withdrawal

symptoms

Autonomic HyperreflexiaAutonomic Hyperreflexia Syndrome

Associated with the body’s resolution of the effects of spinal shock

Commonly associated with injuries at or above T-6Presentation

Sudden hypertensionBradycardiaPounding headacheBlurred visionSweating and flushing of skin above the point of

injury

How do we treat it?Patients at risk should be treated to prevent

stimulation below the lesion, even though no prior history all spinal cord patients are at risk.

Prior to intiating a surgical stimulusGeneralNeuraxialRegional

Use short acting vasodilators to treat hypertention

Autonomic Hyperreflexia

Spinal Cord TumorsAnesthesia Management

Area of tumor and size with resulting neurological compromise can vary the treatment needed

Airway ManagementCervical Tumors may obstruct the view of the airway

Severe movement can cause further damageAvoid hypotension and anemia

Supplemental OxygenMaintain spinal cord perfusion and oxygenation

Caution in use of depolarizing muscle relaxants

Intervertebral Disc Disease

Cervical Disc DiseaseLumbar Disc Disease

Questions