Spinal Cord Injury 2

How would you acutely manage a 20 year old male with a C4 ASIA A SCI from snowboarding?
• Decompression within 24 hours may improve neurologic recovery, but data inadequate
• High dose steroids called into question: may cause infection or bleeding
• Avoid hypotension, can try abdominal binders, lower limb compression, oral vasopressors (midodrine)
• Autonomic dysfunction is common: bradycardia, neurogenic shock, autonomic dysreflexia (after spinal shock over)
• Spinal shock: loss of reflex neurologic activity in spinal cord (loss of reflexes)
• Neurogenic shock: hypotension of neurogenic origin --> need volume resuscitation and vasopressors
• Bradycardia may occur due to unopposed vagal tone --> usually self-limited but can use atropine
• “quad fever” without identified source can occur in early weeks
• Anticoagulation for DVT or IVC filter within 72 hours
• High risk of stress ulcers --> should start PPI for 4 weeks

What physiatric interventions in acute care can prevent complications in this patient?
• Early ROM, especially in shoulders
• Splinting and orthosis to preserve joint ROM in hands and feet
• Bowel program after starting enteral feeding
• Can remove Foley when patient no longer requires IV fluid --> avoid cath volumes greater than 500 cc
• Pulmonary complications at all levels
• Clearance of secretions: difficult with weak abdominal muscles, manual assisted cough better at clearing secretions than suctioning (hands placed over lower rib cage), mechanical insufflators-exsufflator is effective
• Atelectasis present in 60% of SCI patients on admission, support of use of high tidal volumes
• High rate of dysphagia, especially in patients with C-spine surgery, trachs, prolonged intubation, halo, TBI
• Pressure ulcers: early most common in sacrum, heels, and occiput --> minimize time on backboard, use pressure-relief beds, routine turning q2hrs

How is neurologic recovery prognosticated in SCI?
• Exam at 72 hours better than at 24 hours for prediction
• Most UE recover occurs in first 6 months, mostly in first 3 months
• Most patients recover 1 root level of function with cervical lesions
• UE motor recovery twice as great in incomplete tetraplegia --> more favorable if pinprick spared
• 80% of patients with incomplete paraplegia regain antigravity hip flexors and knee extensors
• 6% of ASIA A convert to ASIA B and none developed volitional motor below injury
• Spinal shock: worse prognosis
• Crossed adductor response to patellar tendon taps is highly predictive of functional motor recovery
• Normal cord on MRI is positive predictor for recovery

What is the acute evaluation of a 30 year old woman with profound and rapid onset of nontraumatic incomplete tetraplegia?
• DDx: Myelopathy, motoneuron disease, MS
• MRI for MS very sensitive but nonspecific
• Spinal angio for diagnosis of spinal cord AV malformations
• CT for bone mets
• CSF: diagnosis of inflammatory disorders
• Labs: test for Lyme, syphilis, HIV, DM, APA