[Music] all right so i think everybody can see my stuff um so i really appreciate um y'all joining me today while we review a little bit about spinal cord injury management this is going to cover both acute and long-term issues with spinal cord injury and some of these things will relate directly to surgery of the spine but a lot of them are also perioperative in nature so i hope that you'll bear with me as we talk about that i really believe that all these things are really important and caring for people with spinal cord injury so um i think it bears a little bit of discussion i don't really have any relevant disclosures but for completeness take i've listed all of my financial relationships here and leadership relationships um so we'll talk about five main domains of spinal cord injury management tonight the first four are in the more acute and subacute phases the last one is primarily regarding long-term management of people with spinal cord injury and i'll talk about um some of my favorite kind of surgery to do so you'll get to see a little bit of that the first concept to introduce in spinal cord injury management is the concept of primary versus secondary injury the primary injury is the trauma sustained by the spinal cord whether that is a fall a motor vehicle accident or whatever that happens to the you know to is what happens to the spinal cord at the moment of injury and it can include mechanical forces like compression distraction or other non-physiologic forces that the spinal cord is really not designed to withstand those forces directly disrupt neural pathways and vascular supply and primary injury can't really be reversed so the main focus you know for public health measures is in prevention of this such as you know removing lap belts from the back seats of cars and replacing them with shoulder seat belts although you can sometimes actually affect primary injury severity by surgically removing points of anatomic compression on the spinal cord in a timely fashion the secondary injury refers to cellular biomechanical biochemical or even molecular changes that continue neurologic injury after the moment of the primary injury and while we generally think of these as acute processes they can last into the chronic phase of recovery and we'll talk about a couple of those um secondary injury can include inflammatory responses hypoperfusion oxidative damage and ultimately these changes result in histologic remodeling of the spinal cord and as we'll see preventing secondary injury is a huge part of spinal cord injury management which we largely do through medical not surgical means so all spinal cord injuries are generally going to be traumas so while atls is outside the scope of this talk i do think it's important to emphasize that you want to always treat these traumas just like every other trauma you use the abcdes of trauma and you can see those here and of course atls has excellent interactive courses on this in order to be certified in this care and basically a is for airway and b is breathing and ventilation c is going to be for circulation and hemorrhage control d is disability and that includes your neuro exam right there and then e is exposure um including uh looking for other injuries that may be associated and immobilization is a central part of not causing more primary injury to the spinal cord because in a highly unstable spine manipulation of the spine can cause ongoing or even new and worsening injury to the spinal cord immobilization is done in the field usually through a philadelphia collar and a backboard by ems for transport into the emergency room and one of the important atls directives of course is to remove people from the backboard as soon as possible to avoid pressure sores but that's always done via log rolling and spine precautions are always maintained cervical immobilization needs to be paramount especially when a person is suspected to have a cervical spinal cord injury in order to prevent further cord injury from a highly unstable spine and this is done through a variety of cervical collars or braces in some cases a halo may even be needed but in general if they're that unstable in our practice my institution would generally just operate urgently and while my talk focuses mainly on the management of spinal cord injury not the workup i think that it's important to briefly hit on imaging because imaging is also in part a management decision ct of the entire spine is the standard imaging modality for people suspected of having spinal cord injury it's quick and it has excellent ability to detect spinal fractures remember that you would want to image the entire spine with ct if you suspect a spinal cord injury because having one fracture somewhere in the spine makes it more likely to have additional spinal fractures that may be a cult and pan scanning is generally kind of baked into trauma protocols at most level one trauma centers and it happens quickly and efficiently for patients with a neurologic finding you should also consider an mri but you would want to tailor this to the selected level of injury based upon neurologic exam and ct scan findings because you definitely can't image the entire spine with mri in a timely fashion at most centers and then you also want to consider concomitant injuries such as vascular injuries and consider things like ct angiogram for that and many centers actually have protocols for this as well since traumas are extremely protocol driven which is a best practice to ensure that every patient gets the right care now after workup and stabilization in the emergency room all spinal cord injury patients should be managed in the icu that is primarily to prevent that secondary injury that we talked about and also the biggest thing to remember over here is you still go abcs of trauma airway breathing circulation just like any other trauma patient you don't want to get distracted by the spinal cord injury and forget the basics the absolute primacy of those abc's really can't be overstated um adequate perfusion and oxygenation of the spinal cord are really key here to maximize recovery and so even brief periods of hypoxia can trigger that secondary injury which will ultimately increase morbidity mortality and decrease chances of improvement neurologically icu management for patients with spinal cord injury is important because the patients frequently will experience things like hypotension arrhythmias hypoxia and airway compromise and that hemodynamic instability and ventilatory failure can even occur in a delayed fashion even if the patients appear stable right after the injury this happens as their respiratory function worsens to do the secondary injury or as their chest wall muscles tire out and all these things can impact outcomes so that's why we monitor these patients in the icu you also want to avoid further secondary injury from common icu events that would otherwise maybe be well tolerated and focused without sti but patients with spinal cord injury will worsen neurologic outcomes so examples of that include fever and hyperglycemia fever increases metabolic demand and hyperglycemia exacerbates neural injury so um avoidance of these secondary issues really just hinges on excellent icu care you know treating fever early treating hyperglycemia early so when you're all um interns remember that that's really important spinal cord ischemia is a common cause of secondary injury and so that implicates you know the vasculature at the spinal cord level direct injury to the micro circulation will result in vasospasm and loss of autoregulation which alters the spinal cord blood flow and at the more systemic level of course acute spinal cord injury is often associated with hemodynamic instability which can affect perfusion this is particularly more common in cervical and complete spinal cord injuries hypotension in the setting of spinal cord injury and a trauma can have multiple ideologies and you want to consider all of these in dealing with a patient with spinal cord injury and the first thing you want to consider is just plain old blood loss or hypovolemia just like all of the trauma patients you never want to fail to consider that possibility but in spinal cord injury you also need to consider loss of sympathetic vascular tone which can cause hypotension typically hypotension related to hypovolemia is associated with tachycardia whereas hypotension seen with severe spinal cord injury is usually coupled with bradycardia and hypotension in the setting of spinal cord injury regardless of you know that cause is going to worsen that cord ischemia and and worsen that secondary injury so it needs aggressive treatment um the first line treatment is going to be volume resuscitation but it might not be enough and so the second line treatment is usually vasopressors there are blood pressure treatment guidelines for the acute phase of spinal cord injury based upon you know the evidence that we have correction of hypotension which means a systolic blood pressure less than 60 or 90 that's that's hypotension is very strongly recommended but then it's also recommended to maintain a mean arterial pressure of 85 to 90 for seven days after a spinal cord injury and that is thought to improve spinal cord perfusion and and ultimately potentially neurologic outcome many institutions employ this recommendation as well and that is our institutional protocol as well for for cervical cord injuries at wvu and we keep people in the icu for seven days for map pushes respiratory complications are also a major cause of morbidity mortality in patients with spinal cord injury respiratory failure is common in spinal cord injury patients and again it's it's more common in cervical and complete spinal cord injury the two phases of respiration which are inspiration and expiration are both affected after spinal cord injury inspiration requires contraction of the diaphragm and the intercostals and these are controlled at the c three through five spinal cord segment levels so injuries above c3 essentially always require immediate ventilatory support or they will die in addition even with lower levels of injury the loss of the abdominal wall function and spinal cord injury leads to a decrease in expiratory force and that can impair the ability to cut off and clear secretions all these changes combine to lead to relative hypoxia and they can exacerbate the spinal cord ischemia that happens after the acute injury therefore it's really important to identify patients at risk for respiratory failure and complications the altered mechanics of respiration lead to a pattern of shallow breathing which can be initially compensated for by increasing respiratory rate however that doesn't last long because it doesn't work to adequately oxygenate the patient and so the overall result is a higher work of breathing but also decreased gas exchange and then can lead to respiratory failure approximately one third of patients with cervical spinal cord injury will require intubation and you need to carefully monitor those patients and consider early intubation if they're starting to struggle generally icus will have protocol for this but in general a decrease of fec to less than a liter or increasing the respiratory rate or pco2 or good indicators that you need to intubate patients with thoracic spinal cord injury are also more at risk for respiratory complications and that may not just be relating to neurologic compromise and alter breathing dynamics but also may relate to just the overall force needed to cause a thoracic spinal cord injury and so they may have a lot of concomitant other injuries as well like fractures and a significant proportion of the respiratory morbidity and mortality and spinal cord injury is actually also attributable to pneumonia including ventilator-associated pneumonia and those patients have like anywhere from i think a one to three percent chance per day of getting a pneumonia okay skipped forward quite a bit so when we talk about pharmacotherapy and spinal cord injury our main discussion is going to be about methylprednisolone which is a form of steroid and this is going to be a very controversial topic the clinical practice with regards to steroids for spinal cord injury has changed a lot over the years we used to give it almost always but now do it either not at all or in very limited protocol driven circumstances the reason for this is debate over the true clinical benefit which is questionable and also over the side effects which are significant and they're very well characterized and each subsequent trial of steroids has shown less convincing evidence of benefit and more convincing evidence of harm randomized trials of steroids for the treatment of acute spinal cord injury have possibly shown some improvements in motor function in terms of the level of recovery however this effect even if it's there may not result in significant functional clinical recovery so if you think um about gaining one motor level of function in certain instances that is very beneficial to the patients but not necessarily worn out in terms of the evidence that we see in this studies and the most recent study actually also showed evidence of a rise in mortality due to pneumonia and respiratory symptoms and patients also had a increased risk of gi complications and wound infections so essentially all of these are known issues with high doses of steroids and contributes to the overall morbidity after spinal cord injury for patients that receive steroids so it's still somewhat controversial um and when surgeons are surveyed they often list litigation as a risk um as sort of the driving factor for whether or not they give steroids but interestingly um that is the reason given as both the reason to not give steroids and also to give steroids so so everyone's afraid of being sued essentially um but in recent years it seems that the most common practice has been to avoid steroids although some institutions will give it to patients who have no risk factors for the complications noted in the previous studies and because of the conflicting data it's beneficial to have a strict protocol for centers that are still using steroids and really only give it in the setting of that protocol those protocols will consist of patients who are very young without any comorbidities without multiple injuries and without a coincident aspiration pneumonia but saying no to steroids because of the previous evidence is also very appropriate so now that we've talked about some of the really important medical management and spinal cord injury let's talk about some of the surgical stuff um surgery does have a role in most but not necessarily all spinal cord injury and many of these will be associated with a fracture and for purposes of this i will include certain you know closed reduction procedures like traction and with the classification of surgery because it does have similar goals basically for surgery you have two goals the first is to decompress the spinal cord remember that that can affect primary injury of the cord particularly if it's done in a timely fashion after injury and you also want to stabilize the fracture sometimes decompression is done surgically but sometimes just traction can decompress the cord and there are some benefits to that which i'll list in a bit so this set of imaging is from a really great textbook by bob heary um and it demonstrates one of the main indications for closed reduction which is traction okay and that is bilateral jump facets and you can see the jump facet here and you can see it here they're not overlapping like they're supposed to um and you can imagine that the spinal cord is getting squished right here because the space right here is so much narrower than the space above and below that area so the spinal cord is getting squished right in front of you so um by using traction you can distract the facets enough to reduce the fracture and remove that ongoing compression from the spinal cord and the awesome thing is that you can actually do this while the patient is awake so you have a second by second neurologic exam to know if you're hurting them or not that's the decompression and then in the bottom pane you can see the final stabilization is done surgically through an acdf in this particular patient um so that demonstrates some of the aspects we're going to you know aim for surgically and how traction can help and you can see here these are the x-rays taken during traction you can see the um the fracture dislocation here and then you can see that it's being distracted here um and reduced and then they remove some of the traction here it looks like and it's it's sitting back in its normal position in order to apply traction you have to have something to pull against and so that's usually going to be inserting gardner wells tongs or a halo ring on the patient's head um you can apply a decent amount of traction we generally say that you can apply up to 10 pounds per cervical level um so that can be a lot you know if you're talking about a c67 fracture dislocation that's like 70 pounds of weight um and so you you can put a lot of weight on there and you can see in this diagram that you you hang the weight off of this pulley and you can direct the vector of the pole based upon the angle of the pulley so some of the benefits of traction as i said previously are that you can do it in an awake patient which allows you to know instantly if they have any neurologic changes and you can reverse whatever you have just done if they have a neurological change you know you take the weight off or whatever and that basically is never possible in the operating room under anesthesia there's always going to be a delay and you're never going to quite know what you're doing to the patient it can also be done faster than you know going to the operating room you just have to bring your materials and set up in the in the icu room that the patient is in and you can almost instantly decompress the core and allow for later less urgent surgical stabilization but there are risks of course as well as important contraindications and also understanding the mechanisms of injury can be helpful in reducing the fracture because you'll be able to understand what needs to occur anatomically to re-establish alignment now there is a debate about getting an mri before versus after traction there's a small but real risk of displacing or dragging disk material posteriorly into the spinal canal with any method of reduction possibly causing neurological compromise an mri before traction can alert you to that possibility and might possibly cause you to just go straight to surgery instead but there's also a likelihood that the actual traction reduction itself can create a new disc herniation as you drag the bone back with the traction and so you wouldn't necessarily know that if you got at the mri beforehand and it's not necessarily reasonable to get an mri before and after traction so in my practice i tend to get the mri after traction not before because the patient exam in my mind is better than the mri before traction and here's a brief list of tips and protocols for um cervical traction of another good textbook and so we'll just go through each um thing briefly to explain it so first you want to rule out skull fractures um that's because you don't want to put the pins directly into the brain so that's that's important um and then you know particularly for halo the second one is mainly for a halo but you want to always place the pins with the eyes closed because you put them just lateral to the eyes and if the patient's eyes are open you can pin the eyes open and that's that's sub-optimal um again closed reduction is contraindicated if you get an mri before traction you see a big disc herniation i usually use the exam for that and then occasionally depending on the type of fracture you either want to pull the patient in axial traction and flexion or axial traction and extension and so that you actually do that um relevant to the external autoimmunitis so if you want to do traction and extension you're going to put it a little bit anterior to the external auditory meatus so that they lift their chin up if you want to put an extension you're going to put it a little bit behind the extra auditory medius to put the chin down and then when you're starting the weight you start with a very low weight and you obtain an initial x-ray and that initial x-ray is making sure that you don't have any atlanta occipital dislocation or anything like that and then you increase your weight for each weight increase you check an x-ray so when you're a resident you want to have the x-ray machine in the room you don't just want lateral films you want the x-ray machine right there so they can take repeated x-rays for each weight increase and then once the ejection reduction is achieved you generally will leave the patient in traction until definitive treatment is done that's usually going to be b surgery and then you want to stop your reduction if you if you reduce it you want to stop it if you get distraction of the atlanta survey or the occipital cervical junction or if any disc disc height is greater than 10 millimeters that's over distraction or if you have any neurological changes it would be unusual to have sscps or meps during um you know closed reduction in an awake patient maybe some centers do it but you can just follow the exam for those patients and we usually think of traction in the cervical spine because closed reduction will be really difficult in the thoracic or lumbar spine just because the amount of force required you know if it takes 70 pounds to reduce a c67 dislocation it's going to take up almost non-physiologic loads to reduce something in the thoracic spine but we do use some of the same principles and other spinal cord injuries and spinal fractures you can see that this person going back to our goals of decompression and stabilization this person definitely needs decompress they've got canal a bone in the canal here so you need to remove that to remove the ongoing compression of the thoracic cord but this is also an extremely unstable um spinal fracture called a fracture dislocation and unfortunately spinal fractures are classification is kind of outside the scope of this talk it's one of my favorite things to talk about um but we obviously definitely with this thing these two disarticulated ends of the spine need to be stabilized and so you need um a very structurally solid stabilization here to keep the ends of the spine from moving around here's another less dramatic example this is a coconus level spinal cord injury and you can see again the two ends of the spine are disrupted this is again a fracture dislocation and so we really need to realign the spine which will remove the compression so you need to push this part forward through various means and then stabilize through fixation and here's another really extreme example of a fracture dislocation you can imagine here potentially that um just traction or or that sort of thing is not going to work we actually had to do some some significant bone removal to to achieve reduction of this of this unfortunate person and so again um the goals of surgery are to decompress the spinal cord restore normal alignment and balance and restore stability to the spine and that is generally going to be done through instrumentation and in many cases certainly the ones i just showed you you want to abide by principles of fixation that include multiple fixation points which are usually pedicle screws or lateral mass screws usually longer constructs and some other principles which are really excellently addressed by the ao which is another great international organization this image is from their surgery reference which is available online i believe for free to everybody and the overall goals for for timely decompression and stabilization ultimately are to allow maximum recovery okay maximum neurologic recovery in terms of recovery of function but also to encourage the next stage of recovery which includes aggressive rehabilitation and rehabilitation includes mobilization and so that really requires us a stabilized spine prior to starting and once you're able to mobilize that patient um you know respiratory wise everything gets better um some of the late complications that i'm going to talk about are are decreased and so mobilization is really really key for these patients and for that it really is about timely surgery one of the main reasons we mobilize in spinal cord injury is to avoid complications like this venous thromboembolism or vte and pressure ulcers vte includes both deep venous thrombosis as well as pulmonary embolism and it's a leading cause of morbidity and mortality following spinal cord injury and having a trauma greatly increases the risk of dbt and pe because of immobility as well as inducing a hypercoagulable state the risk for vte in patients with spinal cord injury is considered to be greatest during the first 12 weeks after injury again due to those factors of immobility and hypercoagulability and that hypercoagulability will start within a couple hours after trauma and persist for at least two to three weeks therefore we try to start prophylaxis for thrombosis as soon as possible after injury ideally within 72 hours and some patients like those with intracranial bleeding or other active hemorrhage you have to wait to give them medical prophylaxis but you can use mechanical forms of prophylaxis as soon as the patient is admitted in most cases and by that i mean like phenodines or stds it's recommended to continue vte prophylaxis for at least three months from the time of spinal cord injury or for as long as the inpatient rehab period lasts pressure ulcers are another really dangerous condition that people with spinal cord injury are at risk for without proper complication avoidance effective pressure ulcer management requires consideration of a bunch of factors and usually it's a comprehensive multidisciplinary approach many pressure ulcers are preventable if we use appropriate interventions such as padding turning and mobilization so again that's the important importance of surgery you also want to modify as many medical risk factors as possible including poor nutrition which can be common physical occupational and other rehab specialists will develop sort of individualized plans and that generally is best done through a protocolized plan that is optimized with each particular hospital so each hospital is going to have a different protocol for this but the important thing is that you have a protocol with initial mobilization of people with spinal cord injury they will often have something called orthostatic hypotension which is when they drop their blood pressure with reconditioning and mobilization the symptoms of orthostatic hypertension will usually improve but some patients will have to have lifelong problems with it and need medication for it or other interventions like wrapping the legs to prevent venous pulling opposites of the orthostatic hypotension some individuals with injuries above t6 can experience significant episodes of hypertension known as autonomic dysreflexia these episodes are really unpredictable and really severe and they can actually be life-threatening autonomic dysreflexia is manifested by episodic headaches um really severe increases in blood pressure and can even result in cerebral hemorrhage from that high blood pressure and most episodes of autonomic dysreflexia can be managed by figure out figuring out what precipitates them there's always going to be something that incites them to happen that can be a full bladder constipation needing to change positions or other things like that but sometimes it can just be completely random and the patients may even need pharmacologic interventions or hospitalization to to manage those things now i think it's important to comment on issues of equity and disparity whenever we talk about any particular medical condition and spinal cord injury has been studied a bit in this regard race and ethnicity are related to differences in outcomes with respect to well-being and community participation after spinal cord injury but differences in all domains of spinal cord injury have not been characterized and it is recognized that the reason for this is subject non-participation and follow-up that is more pronounced in certain groups and so we are not even collecting that data in some cases and that is important because it likely indicates that those more vulnerable patients are unable to access specialized care this has been specifically assessed and verified in certain subspecialty care for instance obesity treatment in patients with chronic spinal cord injury another aspect of care that creates disparities is inequitable access to rehabilitation services based upon insurance status now i hope i've impressed upon you the importance of rehab um in west virginia medicaid used to just not cover inpatient rehab for patients with spinal cord injury so they would go come into the hospital get their surgery then they would either just go home or go to a nursing home even if they were you know 20 and that worsened their outcomes and it increased the acute care hospitalization costs to the state which we've previously characterized in our group and thankfully that situation is now rectified but it really demonstrates um the the disparate care that is received based upon insurance status in some cases and i also think it's important to recognize that because of mobility impairments when our patients sustain a spinal cord injury they have now entered a more vulnerable group with less access to care as a direct result of the sci and this is especially notable in rural areas such as west virginia and efforts have been made to sort of ensure that patients with spinal cord injury get more equitable access to primary care and other you know just normal aspects of health care which may not be accessible to them as indicated in the article that i picture here so moving into sort of the chronic aspect of things um persisting pain is one of the commonest and most disabling um consequences of spinal cord injury aside from the inability to ambulate and bowel and bladder dysfunction chronic pain is the most disabling aspect of spinal cord injury when you ask patients there's also a strong association between pain and psychological well-being in addition the pain intensity is strongly correlated with sleep disorders fatigue and and social disability spinal cord injury associated pain can be um somatic visceral neuropathic or combination of any of those and it can be treated with medications physical and occupational therapies psychologically based treatments or surgery and generally the treatment is going to be multimodal and may include components of all those but it's pretty hard to treat post-spinal cord injury pain until world war ii severe spinal cord injury was almost universally fatal everybody died in the initial two years following injury mainly as a result of you know not good rehab options and so the development of specialized spinal cord injury centers has really dramatically improved the survival rates and the health and also the functional outcomes of people with spinal cord injury spinal cord injury rehab is ideally delivered in an interdisciplinary nature that is going to focus on achieving and maintaining good health maximizing the function and promoting good quality of life for these patients and that's going to be a core that's that's really multi-disciplinary so physical therapy will be part of this occupational therapy vocational therapy in some cases rehab psychology social work case management it's it's a really a complex team because the needs really span the entirety of the patient's life their entire life has changed it doesn't matter if they get really good inpatient physical therapy if they don't have wheelchair access into their own house so all those things are things that are important following a spinal cord injury the presence of lower extremity impairments often necessitates that individuals compensate by using their arms for instrumental adls and mobility like transfers and wheelchair propulsion and over time increase in repetitive use of the upper extremities can lead to overuse syndromes which obviously are primarily the purview of physical medicine and rehabilitation but spinal spine surgeons should also be aware of these things in their role as a patient advocate shoulder pain is one of the most common upper extremity complaints following a spinal cord injury and that's from chronic use during reaching and transfers and often leads to asymmetric wear and tear on the shoulders partial or full thickness tears the rotator cuff can be common but there are numerous other shoulder pathology issues that can occur more commonly in patients with spinal cord injury other commonly encountered sites of pain in the arms can include elbow wrists and hand issues the reported prevalence of carpal tunnel following spinal cord injuries up to 66 percent of patients which is crazy high number um management of carpal tunnel can include steroids or even surgery and it's important to know that splinting is tends to not be as effective in this group because they use their hands for so much and so the cornerstone of managing overuse syndromes is reduction of those repetitive activities and incorporation of adaptations that really minimize the associated stress so so minimizing overhead reaching incorporating assessment devices and ergonomics and and proper seating positioning so so little things really matter a lot um in the in the downstream effects on patients with spinal cord injury going further out into the chronic complications of spinal cord injury the prevalence of risk factors for coronary artery disease increases after sci and those specific risk factors can include things like hyperlipidemia glucose intolerance and lower physical activity levels and cardiovascular morbidity mortality occurs earlier and more often in patients that have spinal cord injury than those without um and in fact cid is the leading cause of death amongst people with with spinal cord injury in the chronic phase spinal cad can also be asymptomatic in patients with spinal cord injuries so the visceral afferent fibers to the heart enter the spinal cord at t1 through t4 so people with a cervical cord injury can actually have no symptoms of cardiac pain which means that you have to be really vigilant in considering this as a physician treating these patients heterotopic ossification is a condition that's characterized by the formation of ectopic bone in the joints where it shouldn't be in the setting of spinal cord injury that always occurs below the level of injury and the most common side is the hips and severe cases can lead to a loss of range of motion or even joint ankylosis where the joint autofuses most cases are going to be asymptomatic but loss of hip range of motion can interfere with the seated posture independence and transfer so it's something that you want to look out for osteoporosis following spinal cord injury is also a significant source of morbidity and mortality we call it uh sublesional osteoporosis when it occurs below the neurological level of injury um and almost half of patients with chronic spinal cord injury may sustain fragility fractures which are usually going to be in the leg because of these long-term issues long-term follow-up is really essential to maintain health and prevent complications preferably with someone who is familiar with these sequelae now spasticity is again one of the late complications after spinal cord injury it can cause jerky movements of the extremities and painful muscle spasms very painful for patients and it impairs the range of motion the legs which can lead to joint contractures in the long term it also interferes with adls and transfers and sleep almost 80 percent of patients who um have an sti will develop spasticity um and those patients who have a complete spinal cord injury be more likely to have it in a very severe fashion and our current strategies to treat that include physical therapy to improve range of motion oral medications like baclofen injections and surgery such as intrathecal pumps like baclofen pumps for for medication delivery and specificity can actually be useful for mobility and transferring so often the management of spasticity in patients with spinal cord injury requires a careful balance in order to avoid you know too much spasticity but also not letting the lower extremities get too loose so that they can still be used and some of the anti-gravity power of the lower extremities can be utilized for transfers ceringomyelia is another late sequel of spinal cord injury patients with post-traumatic syringomyelia usually present with pain but motor deficits and sensory loss can also be common and there's a classic sort of dissociated sensory loss which is loss of pain and temperature but preservation of light touch that reflects intact dorsal columns and that's considered to be characteristic of a syrinx and more common than a complete sensory loss where there's just a sensory level of all modalities and motor symptoms may reflect injury to the lateral cortical spinal tract and there are other less common symptoms that can include hyperhidrosis autonomic dysreflexia horner's syndrome respiratory issues if you're going up into the cervical spine or even cranial nerve involvement if you're going up into the medulla you can see here this person has most likely a high thoracic cord injury and you can see this hearing is just going all the way up almost into the into the brain stem you can see here as well now sometimes these can be surgical um the goal of surgical treatment for for post-traumatic steering should be disease stabilization um but importantly that doesn't always mean an improvement in neurologic function or pain it just means preventing it from getting worse we hope there are a couple different ways to deal with these those include simple spinal decompressions percutaneous drainage serum shunting lysis of adhesions expansion duroplasties and core de-tethering but it's important to recognize that these all have kind of a limited utility um and so you need to really carefully uh balance the morbidity of surgery with the potential benefits because these surgeries are not all that satisfying and and often the symptoms will recur now shunting um in a post-traumatic series will either be um include taking that fluid and putting it into the subarachnoid space which is a cyringo subarachnoid shunt or into some other low pressure cavity like the pleural cavity or the peritoneal cavity and that can be effective but again there's generally re-scarring of the arachnoid and so that has limited durability and so again you want to carefully consider that and so the way i can sort of demonstrate that is this isn't just a searing problem you can see here this this fluid inside the spinal cord you can also see there's sort of anterior tethering um and so that indicates that there's some csf hydrodynamic changes here that we don't completely understand but we do know that it's not necessarily as simple as just you know draining it into another space but um since cerringo subarachnoid chanting is pretty rare um it's an interesting procedure and it's kind of hard to conceptualize if you can't see a picture of it so i've included this diagram to kind of explain the procedure so this is a view of the cervical spine where um a laminectomy has been done this is the dura and you can see they've opened the dura here and what they're doing with this scalpel is they're actually opening the spinal cord and so they're opening the spinal cord into the searing cavity and then they insert this little long shunt okay it's a tiny cylastic tube sometimes it's a t-tube shape so it's shaped like this and you put the the top part of the t inside the spinal cord and the other part sort of sticks out um and what that's supposed to do is is sort of make this space communicating so the fluid inside the spinal cord can get out of the spinal cord then you sew everything back up that can work um it tends to have maybe less enthusiasm now than it did when it was first um sort of invented because we know that those things kind of scar down uh might work for a little bit and then and then you're back where you started um shortly thereafter so not necessarily the great procedure that we maybe hoped it was when it was first first sort of invented now sharko spine is again a relatively rare complication and a very late complication after a spinal cord injury the pathogenesis of the deformity is likely due to lack of sensory input to the spine below the level of injury which leads to abnormal motions and stresses on the spine and that will cause progressive destruction of cartilage and subchondral bone damage and it actually creates a false joint somewhere along the spine always distal to the level of injury um and sarcospines can present very very late as late as you know 30 years after after injury and because sharko spines are an interest of mine and present in a really interesting you know surgical problem that's very sort of distinctive i'm going to go a bit in depth into their management here as a late sequal of spinal cord injury just because i think that they're cool and i enjoy managing them so you can see here are some of the main characteristics of a shark spine so this is a sagittal view so this is um belly this is the back these are the two disarticulated ends of the spine okay um these will often rub together and create an audible funk that the patient can hear or feel as they move around and you can also see this sort of copious fluid here produced by the process sometimes this can either mimic an infection or actually become infected since it's just this you know inert fluid um that's sitting there and so it's just asking to get infected and so ruling out infection is an important part of the management of these and sarcoid spines um you know present significant difficulty with respect to spinal reconstruction and successful fusion and thus they're you know interesting to me as a surgeon they have um large bony defects um and often present limitations in the fixation and reconstruction because um they've just have such a huge defect and they've often had numerous revision surgeries so it's really salvage surgery that we're doing with these and certain patients are at increased risk for this condition after having a spinal cord injury we think that patients who have a long segment fusion from their initial injury are at higher risk from this patients who have had a laminectomy patients who have excessive loading or like patients who do really intensive sports after their injury maybe increased risk because of all that loading and motion also obesity and sitting in balance can can predispose one to having these importantly these risk factors actually will be exacerbated sometimes after the initial surgery for a sarcospine and that may contribute to the high rate of recurrence which we see in these patients revision rates for hardware failure or of recurrent charcoal or non-union have been reported to range up to 75 after an initial surgery and in order to minimize the risk of failure or recurrence there are some best practices that have been delineated when doing um these surgeries um and so some of those include employing a lesional debridement so getting all of the stuff out a circumferential fusion so anterior and posterior fusion technique fusing down of the pelvis if you're going into the lumbar spine using four rod constructs or two rods on either side using bmp to create bone formation all of those things are considered best practices but even when you do that stuff the overall rate of revision due to hardware failure or recurrent shortcuts fine is still 35 so even if we do all those things so again this is a topic of interest to me and my partners and we do a fair amount of these surgeries no published techniques for salvage and the revision of charcoal surgery which is what these images are from so i'm just going to take you through this patient's imaging because it sort of details some common issues so this is a guy who had a high thoracic injury okay he actually had a mid thoracic charcoal spine that's this big destructive thing here and you can see the anterior cage placed and he had a long segment fusion after that to stabilize because you want multiple again multiple fixation points this is just like an initial trauma it's a disarticulation of the spine and so then you got another one um you can see this huge destructive process here and so again following best practices did the intra-regional debrief took out all that crap that's in there did anterior fusion at every level all the way down the pelvis four rod construct and then he got it again and it's like even bigger it's massive um and so again go back in debride everything um and and repair it and so our salvage technique in this case was actually to transect the fecal sac because he didn't have any functional neuro neural tissue um and then do a big anterior reconstruction and use a structural allograft this is a fibula in the actual spinal canal as a structural allograft so this technique of fecal transaction um is you know a salvage technique and we've published on this um in each of the patients where we've done this they have a chronic complete spinal cord injury when we transect the fecal sac there was no clinical sequela at all um and no functional or really even identifiable structures were encountered when we did the transaction um there was no spinal fluid encountered um nobody had the spinal fluid lake um and so you know that was helpful for us because we were able to use the canal as a fusion surface um and also we could do an easier intra-regional um debris because we have to work around the thickly sac and here's another one that we did um that was the same kind of thing so again thoracic cord level um then a upper lumbar charcoal spine had carried all the way down to the pelvis anterior fusion at each level um interlational debridement and then you can see it failed actually at s1 and so you can see this femoral ring here at s1 and it like fell out it fell out here and it's like now on its side in the pelvis and there's this huge defect here and so again revised it um did a fecal transaction and this is a femur it's a huge piece of bone that we put into this defect for a structural allograft as well as to encourage fusion so these are really big intense cases um definitely want to be at a specialized center to to do this kind of thing and um you know they're surgically very interesting but it really illustrates the fact that when you have a spinal cord injury you end up having issues that are going to require advanced medical care really for the rest of your life and so i hope that you can see from all these different topics that we've covered that the management of spinal cord injury is very complex it involves a multi-disciplinary team at all steps along the timeline of injury to address numerous known issues in these patients care because of the complexity of care it's best to work with specialized teams and from formal standard protocols such as this one that's been proposed different hospital environments will have different protocols depending on their organizational and practical structure but i think the main you know sort of essential take-home here is that there should be a protocol for dealing with these patients and i'm working within a team of people who are really passionate about that about you know sort of complex multi-disciplinary cutting-edge treatment for for people with spinal cord injury is also really fulfilling and inspiring and um it's a it's a really great way to provide and receive that care so um thanks a lot i'm happy to take any questions it looks like there's a couple things in the in the chat box so hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world