Acute spinal cord injury: monitoring and anaesthetic implications

Abstract

The incidence of spinal cord injuries in North America is estimated to be 15-50 per million population. 1,2 In the U.S. this means approximately 12,000 new cases per year with a mortality approaching 50% and a prevalence of 200,000. I Most victims are young (15-24 yr) 2 and the survivors end up with debilitating neurological deficits although the development of regional spinal cord injury centres as well as improved treatment have reduced the incidence of complete lesions from 65% to 45%. 3 The major causes are motor vehicle accidents, falls, sports and recreational injuries, and other violent causes. Alcohol and recreational drug use are frequently contributing factors. Mechanism and classification of spinal cord injuryInjuries in the cervical spine are generally caused by (1) flexion, (2) flexion-rotation, (3) vertical compression (axial loading), (4) extension, (5) extension-rotation, (7) lateral flexion. 4 The mechanism of injury in the thoracolumbar spine is similar except that there is less mobility and injuries are more likely due to compression and rotational forces.The three-column concept 5 of the structure of the vertebral column helps to clarify the mechanism of injury. The posterior column is formed by the posterior neural arch, spinous process, facetal articular processes, and their corresponding posterior ligamentous complex. The middle column consists of the posterior one-third of the vertebral body and annulus fibrosus and the posterior longitudinal ligament. The anterior column comprises the anterior longitudinal ligament and the anterior two-thirds of the vertebral body and annulus fibrosus. Flexion injury causes disruption of the posterior column and extension injury causes disruption of the anterior column. If two or more columns are disrupted, then acute spinal instability exists and predicts the possibility of late instability. Spinal cord injuries most frequently involve the lower cervical spine and the thoracolumbar junction, the former because of its mobility, and the latter because it is the junction between the rigid thoracic spine and the flexible lumbar spine. The paediatric and the elderly spineUntil ten years of age the immature spine has increased physiological mobility due to ligamentous laxity, and incompletely ossified wedge-shaped vertebrae, which afford them some protection against spinal column injuries but at the same time increase the incidence of spinal cord injury without radiographic abnormality. 6-s The elderly patient, on the other hand, with the development of degenerative changes and osteophytes, and narrowing of the spinal canal, may develop spinal cord injury even with trivial trauma and the injury may be missed. 9Spinal cord injuries can be complete with loss of all motor and sensory function below the level of injury, or incomplete including the central cord syndrome, the Brown-Sequard syndrome, the anterior cord syndrome and the posterior cord syndrome. Normal physiology of the spinal cord Spinal cord circulationThe anterior two-thirds of the spinal cord are s...

Perioperative Care of the Pediatric Patient with a Spinal Cord Injury

“…Excellent reviews are available that discuss the care of a patient with an acute SCI and explore the specifics of anesthetic management. [1][2][3][4][5][6][7][8][9][10][11] Factors that Impact on a Pediatric SCI Patient Who Undergoes Surgery…”