Spinal Cord Injury 1
Content
Spinal cord injury
Dr. R. Muthu Kumar
Definition
SCI (spinal cord injury ) defined as disruption of the normal spinal cord anatomy with neurological deficit may be traumatic or non - traumatic
Epidemiology
More common in males (80%) average age 31.4 years 10000 cases reported per year 2.25 to 2.28 lakh people in US are living with paralysis Most commonly injured regions Cervical 4 to 6 (51%) and thorocolumbar T12 to L1(34%)
Fourth leading cause of death next to IHD, cancer and CVA Annual cost in for caring these patients was 7.73 billion $
Etiology
Motor vehicle accidents (40-56%) Falls (20-25%) Recreational and sports (10-15%) Violence eg -gun shot wounds (10-15%) Other causes ( work related) [10-15%]
Frequency of SCI according to level of injury
Level of injury
Cervical spine C 4-6 Thoracic spine Thorocolumbar T 12 to L2 lumbosacral Sacral Multiple levels Associated head injury (mild) severe
Frequency in %
50-55 10-15 15 -20 10 < 10 20 40 -50 2-3
Pathophysiology
Primary SCI
Caused by mechanical forces Direct neuronal disruption, petechial hemorrhages, hematomyelia, vasospasm and ischemia
Histologically extravasations of proteins into central grey horn Cord edema leading to necrosis and scar formation
Pathophysiology
Secondary SCI
Complex cascade of events (biochemical, enzymatic and micro vascular)
Release of cytokinins and AA generates inflammatory cascade Leading to free radical formation, cellular edema and cellular apoptosis
Loss of vascular auto regulation Compounded by hypoxia, hypotension, and local cord edema causing destruction of axons
Anatomical correlates
Flexion injuries causes anterior column and vertebral injury Hyperextension mostly whiplash and posterior column Vertical compression burst # and ligamentous rupture Rotational facetal and peduncle # Combined Stable or unstable potential for further injury and failure to heal
Mechanistic classification of cervical spinal injuries
Allen and colleagues
Clinical presentation of SCI
Clinical syndromes
Key clinical features
Arm weakness in disproportion to legs Sparing vibratory and position senses Loss of fine vibration and positional senses Ipsilateral motor & touch and , contra lateral pain and temperature loss Flaccid areflexic parperesis or paraplegia
Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown -sequard syndrome Cauda equina syndrome
Conus medularis syndrome Deep tendon reflexes preserved. Areflexic bladder, bowel, legs Complete cord transection Complete loss of autonomic, sensory, and motor functions below
General measures in acute SCI patients
airway breathing circulation immobilization transportation
Careful oxygenation with attention to spine mobility Nasotracheal intubation and avoidance of neck extension Volume and vasopressors as needed Hard collars with block , sand bags and strapping Immediate transport to SCI centers < 4 hrs ASIA score
Clinical examination Radiological examination
X rays (5 views) CT and MRI
Immobilization and transportation
Moved by log roll technique Soft collars- 96% flexion, 73% extension & full lateral rotation Rigid collars ± (Philadelphia collar) 2 pieces- 30% flexion & extension and 45% lateral rotation
Easy to remove during intubation, easy to fix without lifting the head Sandbags and tapes -flexion & lateral rotation 5% , extension 35% Tong and Halo permits 4% flexion, 1% rotation and no extension So intubation is only fibroptic
Immobilization
A, Soft cervical collar B, Philadelphia-type reinforced cervical collar
C, halo brace.
Comprehensive neurological examination
Should be quick and efficient Assess consciousness and orientation Motor system assessment (grade 0-5) & Deep tendon reflexes Cerebellar function & cranial nerves examination in head injury Sensory system- light touch, pin prick, temperature, proprioception and vibration
Perirectal sensation , bulbo cavernous or anal cutaneous reflex {sacral sparing} favorable prognosis
Comprehensive neurological examination
Classification
Explanation
No motor or sensory function preserved in sacral segments Only sensory function is preserved below the neurological level including sacral segments Motor function preserved below the lesion & 50% and more of muscles have > grade 3 strength Motor function preserved below the lesion & less than 50% of muscles have > grade 3 strength Motor and sensory normal
Complete ASIA (A) Incomplete ASIA (B) incomplete ASIA (C) Incomplete ASIA (D)
Normal ASIA (E)
Radiological evaluation
Five views of cervical spine X ray ( visualized till C7)
Lateral - misses about 15 to 20% of CS # oblique Antero posterior Open mouth odontoid views Flexion & extension 93% sensitivity
Radiological evaluation
15 -20 % have to be evaluated with CT and MRI to rule out whiplash and ligamentous injury
SCIWORET- without radiological evidence SCIWBA- without bony injury (children) Widening of paravertibral space indicates unstable spine and airway problems
Radiological evaluation
1-anterior vertebral border 2-posterior margins 3-jn between lamina and spinous processes 4-Tips of spinous process 2 & 3 ± borders of spinal canal Lardotic alignment on 4 anatomical lines
Airway management
Urgency of airway intervention Associated facial, neck and soft tissue injuries Basilar skull fractures Awake or unconscious patient Skill of the operator
Airway management
Intubation worsens C ±spine injuries polytrauma are considered to have C spine injury unless proved Jaw thrust causes 5mm widening of disc space (aprahamain et al) Single handed Cricoid pressure causes 9 mm posterior displacement (Gabbot A .D et al )
No evidence to prove the efficiency of posterior support I-LMA and LMA causes posterior displacement @ C2-3
Wood P.R et al
Airway management
MILS reduces neck movement during intubation Axial traction causes subluxation and distortion Laryngoscopy (curved/straight) 3-4 mm widening @ C5-6 Maximal extension @ C1-2 & occipito-attlantal joint Bullard and glide-scope reduces movement @C2-5 <50% Blind nasal intubation -2 to 5mm subluxation @ C5-6
Hastings R.H et al
Blind nasal intubation
Advantages Minimal head movement Disadvantages Trauma to nasal passage and infections Can be done in spontaneously Longer time breathing Contraindicated in basal skull # and facial injury Needs expertise
Awake fibroptic
Advantages Least neck movement Patient need not be anesthetized and breathing spontaneous Disadvantages Need expertise only in non emergency Airway free of blood and aspirate only in non emergent situations Patient should be cooperative
Summary of airway control
There is no evidence that any particular airway management technique is either safe or dangerous in a patient with an unstable cervical Several retrospective studies have failed to demonstrate a higher incidence of neurologic injury in patients with cervical instability after trauma associated with intubation
The method for definitive airway control should be based primarily on the operator¶s skill and experience rather than on the fear of inflicting cervical cord damage
Cotrell and Young
Medical management of SCI
Cardiovascular system
Intense SNS activity immediately after injury Can cause MI, pulmonary edema, raised ICP Spinal shock ± 4 phases Hypo reflexive / flaccid paralysis / loss of DTR- 24 hrs Denervation super sensitivity ± return of initial reflexes Initial hyper reflexia after a week ± axonal growth Final hyper reflexia after a month of phase 3 ± soma growth
1. 2. 3. 4.
Cardiovascular system
Spinal shock ( neurogenic shock)- phase 1
Loss of SNS more with lesions above T6 Hypotension, vasodilatation, ventricular dysfunction and dysrhythmias Unopposed vagal tone with loss of T2 ±T5 fibers Reflex bradycardia and asystole during airway manipulation Relative tachycardia indicates hypovolumia
Treatment
Isotonic fluids and vasopressors to maintain cord perfusion PA catheter / CVP guided volume loading to prevent PE Atropine and even TPI for severe bradycardia
Autonomic dysreflexia (ADR)
Occurs in 85% with SCI > T6 usually 1-3 weeks after injury Uninterrupted sympathetic over discharge in response to stimuli Increase in BP > 250/>150 ( 20mmhg > baseline) Bradycardia , throbbing occipital or bi-frontal headache sweating, pallor, flushing above the lesion Spasticity and muscle rigidity below the lesion Triggering factor occur usually below the level of lesion ( bladder, bowel, uterus, rectal, lower limb)
Autonomic dysreflexia (ADR)
Treatment ( medical emergency)
Remove the trigger Upright position Close monitoring of BP and HR Nefidepine, nitrates, SNP, ganglion blockers Urinary retention & fecal impaction should be relieved Manipulations done under anesthesia Can lead to seizures, MI, ICH if not treated aggressively
Respiratory system
monitored close as most common cause of morbidity and mortality Respiratory rate, O2 saturation, vital capacity recorded CXR obtained; ABG for CO2 levels C 1-3 level injury patient in apneic and intubation instantaneously Intubation criteria
VC < 15 ml/kg ( PaCO2 >50 mmhg) RR > 35 breaths /min Fall in SpO2 (PaO2 < 60mmhg) Negative inspiratory force < 20 cmH2O Pulmonary edema, aspiration
Respiratory system
Most frequent respiratory complications
Atelectasis Pneumonia Pulmonary edema Respiratory failure
Treatment & prevention
Aggressive pulmonary toileting IPPV Intrapulmonary percussion Cough stimulation Postural drainage
Early tracheostomy
Genitourinary system
Acute SCI causes atonic bladder , intermittent catheterization Ach like oxybutin or propantheline added to lower the pressure Complications
UTI Pyelonephritis Nephrolithiasis Renal failure
Chronic bacteruria leads to urosepsis prevented by
Good hydration Chronic low dose antibiotic Intravesical instillation
Surgical options
Gastrointestinal system
GERD , delayed gastric emptying, Increased transit time , severe constipation Abdominal distension & hemorrhoids Ileus ( complete lesions) Treatment
Adequate diet and fluid intake Fibre diet and stool softener Contact irritants and prokinetic agents Ryles tube Hypo Cl- metabolic alkalosis due to gastric suctioning
DVT prophylaxis
Incidence of 60% even with prophylaxis Included as a part of therapeutic regimen from admission Combination is better than either alone
Low dose UF heparin or LMWH if no contraindication Sequential compression devices ( SCD) Gradient elastic stockings
Continued for 3 months and during rehabilitation INR of 2 -3 to be maintained
Temperature & pressure sore control
Loss of thermoregulatory ability below the level of lesion Injury > T6 become poikilothermic (temp of surroundings) Arrhythmias common Delayed awakening during anesthesia Temperature monitoring and warming efforts needed Skin care and treatment of pressure sores is vital Prevention is better Surgical modalities of treatment
Neuro protective strategies
Spine immobilisation Surgical decompression Physiological therapy
Avoid hyperthermia, hypotension, hyperglycemia
Pharmacological therapy
NASCIS- II inj MP 30 mg/kg for 15 min followed by 5.4 mg/kg /hr for 23 hrs Treatment started within 8 hrs of injury had significant improvement NASCIS ±III ; 24 hr regimen for patients < 3 hrs of injury Continued for 48 hrs for patients presenting 3 -8 hrs
Use of high dose steroids remain controversial
Anesthesia for SCI patients
Preoperative evaluation
Multiple medical complications Airway evaluation Neurologic evaluation Counseling about awake intubation and wake up test
Investigations
Complete blood count Renal function LFT Electrolytes ECG ,CXR ABG PFT if needed
Premedication
Minimal sedation Anti-sialogogue Prokinetic for gastric emptying DVT prophylaxis if not contrandicated
Intraoperative monitoring
Invasive arterial BP in shock patients NIBP CVP or PA catheter for monitoring volume status SpO2, ECG, ETCO2, temperature SSEP ICP monitoring if head injury is associated Urinary catheter
Induction agent
Induced after securing the airway in lesion < C6 Nerve block preferred over sedation for awake intubation Sometimes positioned before anesthesia or paralysis Flexometallic armored tube fixed and secured Ketamine is the drug of choice in spinal shock Avoid scoline if injury < 24 hrs ( hyperkalemia)
Positioning
Head and neck in neutral position Adequate padding at pressure points ( eyes, nose, extremities) Avoid excessive neck extension and flexion Avoid sudden change of position Pressure points changed every 15 minutes under anesthesia Abdomen free of compression Prevent peripheral nerve injuries , blindness, pressure necrosis
Positioning
A, Kneeling prone B, Wilson Frame Pad C, Georgia prone; D, Relton - Hall frame E, Seated prone.
Fluid management
Preoperative deficit and intra-operative loss replaced Cardiopulmonary status of high cervical lesion High propensity for pulmonary edema with < T6 Avoid glucose containing solutions( RBS <150mg%) Crystalloid VS colloid debatable
Temperature management
Warm blankets and warm enviroment Humidification of gases Warm fluids Avoid hyperthermia
Postoperative care
Extubation
Cautious in deciding in high cervical and thoracic injuries Patients with preoperative pulmonary impairment Metabolic derangement and persistent muscle weakness Excessive facial or pharyngeal edema in prolong surgery Cuff leak test to confirm reduction of edema Ability to generate cough Minimal secretion and stable cardiac function Absence of pulmonary infection
Postoperative care
Analgesia
Intermittent iv or im opioid Continuous infusion of low dose opioids PCA ; epidural and intravenous with opioid PCEA with opioid +LA or only LA Intercostal nerve block Paravertibral blocks Wound infiltration Non-opioid analgesics
Dr. R. Muthu Kumar
Definition
SCI (spinal cord injury ) defined as disruption of the normal spinal cord anatomy with neurological deficit may be traumatic or non - traumatic
Epidemiology
More common in males (80%) average age 31.4 years 10000 cases reported per year 2.25 to 2.28 lakh people in US are living with paralysis Most commonly injured regions Cervical 4 to 6 (51%) and thorocolumbar T12 to L1(34%)
Fourth leading cause of death next to IHD, cancer and CVA Annual cost in for caring these patients was 7.73 billion $
Etiology
Motor vehicle accidents (40-56%) Falls (20-25%) Recreational and sports (10-15%) Violence eg -gun shot wounds (10-15%) Other causes ( work related) [10-15%]
Frequency of SCI according to level of injury
Level of injury
Cervical spine C 4-6 Thoracic spine Thorocolumbar T 12 to L2 lumbosacral Sacral Multiple levels Associated head injury (mild) severe
Frequency in %
50-55 10-15 15 -20 10 < 10 20 40 -50 2-3
Pathophysiology
Primary SCI
Caused by mechanical forces Direct neuronal disruption, petechial hemorrhages, hematomyelia, vasospasm and ischemia
Histologically extravasations of proteins into central grey horn Cord edema leading to necrosis and scar formation
Pathophysiology
Secondary SCI
Complex cascade of events (biochemical, enzymatic and micro vascular)
Release of cytokinins and AA generates inflammatory cascade Leading to free radical formation, cellular edema and cellular apoptosis
Loss of vascular auto regulation Compounded by hypoxia, hypotension, and local cord edema causing destruction of axons
Anatomical correlates
Flexion injuries causes anterior column and vertebral injury Hyperextension mostly whiplash and posterior column Vertical compression burst # and ligamentous rupture Rotational facetal and peduncle # Combined Stable or unstable potential for further injury and failure to heal
Mechanistic classification of cervical spinal injuries
Allen and colleagues
Clinical presentation of SCI
Clinical syndromes
Key clinical features
Arm weakness in disproportion to legs Sparing vibratory and position senses Loss of fine vibration and positional senses Ipsilateral motor & touch and , contra lateral pain and temperature loss Flaccid areflexic parperesis or paraplegia
Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown -sequard syndrome Cauda equina syndrome
Conus medularis syndrome Deep tendon reflexes preserved. Areflexic bladder, bowel, legs Complete cord transection Complete loss of autonomic, sensory, and motor functions below
General measures in acute SCI patients
airway breathing circulation immobilization transportation
Careful oxygenation with attention to spine mobility Nasotracheal intubation and avoidance of neck extension Volume and vasopressors as needed Hard collars with block , sand bags and strapping Immediate transport to SCI centers < 4 hrs ASIA score
Clinical examination Radiological examination
X rays (5 views) CT and MRI
Immobilization and transportation
Moved by log roll technique Soft collars- 96% flexion, 73% extension & full lateral rotation Rigid collars ± (Philadelphia collar) 2 pieces- 30% flexion & extension and 45% lateral rotation
Easy to remove during intubation, easy to fix without lifting the head Sandbags and tapes -flexion & lateral rotation 5% , extension 35% Tong and Halo permits 4% flexion, 1% rotation and no extension So intubation is only fibroptic
Immobilization
A, Soft cervical collar B, Philadelphia-type reinforced cervical collar
C, halo brace.
Comprehensive neurological examination
Should be quick and efficient Assess consciousness and orientation Motor system assessment (grade 0-5) & Deep tendon reflexes Cerebellar function & cranial nerves examination in head injury Sensory system- light touch, pin prick, temperature, proprioception and vibration
Perirectal sensation , bulbo cavernous or anal cutaneous reflex {sacral sparing} favorable prognosis
Comprehensive neurological examination
Classification
Explanation
No motor or sensory function preserved in sacral segments Only sensory function is preserved below the neurological level including sacral segments Motor function preserved below the lesion & 50% and more of muscles have > grade 3 strength Motor function preserved below the lesion & less than 50% of muscles have > grade 3 strength Motor and sensory normal
Complete ASIA (A) Incomplete ASIA (B) incomplete ASIA (C) Incomplete ASIA (D)
Normal ASIA (E)
Radiological evaluation
Five views of cervical spine X ray ( visualized till C7)
Lateral - misses about 15 to 20% of CS # oblique Antero posterior Open mouth odontoid views Flexion & extension 93% sensitivity
Radiological evaluation
15 -20 % have to be evaluated with CT and MRI to rule out whiplash and ligamentous injury
SCIWORET- without radiological evidence SCIWBA- without bony injury (children) Widening of paravertibral space indicates unstable spine and airway problems
Radiological evaluation
1-anterior vertebral border 2-posterior margins 3-jn between lamina and spinous processes 4-Tips of spinous process 2 & 3 ± borders of spinal canal Lardotic alignment on 4 anatomical lines
Airway management
Urgency of airway intervention Associated facial, neck and soft tissue injuries Basilar skull fractures Awake or unconscious patient Skill of the operator
Airway management
Intubation worsens C ±spine injuries polytrauma are considered to have C spine injury unless proved Jaw thrust causes 5mm widening of disc space (aprahamain et al) Single handed Cricoid pressure causes 9 mm posterior displacement (Gabbot A .D et al )
No evidence to prove the efficiency of posterior support I-LMA and LMA causes posterior displacement @ C2-3
Wood P.R et al
Airway management
MILS reduces neck movement during intubation Axial traction causes subluxation and distortion Laryngoscopy (curved/straight) 3-4 mm widening @ C5-6 Maximal extension @ C1-2 & occipito-attlantal joint Bullard and glide-scope reduces movement @C2-5 <50% Blind nasal intubation -2 to 5mm subluxation @ C5-6
Hastings R.H et al
Blind nasal intubation
Advantages Minimal head movement Disadvantages Trauma to nasal passage and infections Can be done in spontaneously Longer time breathing Contraindicated in basal skull # and facial injury Needs expertise
Awake fibroptic
Advantages Least neck movement Patient need not be anesthetized and breathing spontaneous Disadvantages Need expertise only in non emergency Airway free of blood and aspirate only in non emergent situations Patient should be cooperative
Summary of airway control
There is no evidence that any particular airway management technique is either safe or dangerous in a patient with an unstable cervical Several retrospective studies have failed to demonstrate a higher incidence of neurologic injury in patients with cervical instability after trauma associated with intubation
The method for definitive airway control should be based primarily on the operator¶s skill and experience rather than on the fear of inflicting cervical cord damage
Cotrell and Young
Medical management of SCI
Cardiovascular system
Intense SNS activity immediately after injury Can cause MI, pulmonary edema, raised ICP Spinal shock ± 4 phases Hypo reflexive / flaccid paralysis / loss of DTR- 24 hrs Denervation super sensitivity ± return of initial reflexes Initial hyper reflexia after a week ± axonal growth Final hyper reflexia after a month of phase 3 ± soma growth
1. 2. 3. 4.
Cardiovascular system
Spinal shock ( neurogenic shock)- phase 1
Loss of SNS more with lesions above T6 Hypotension, vasodilatation, ventricular dysfunction and dysrhythmias Unopposed vagal tone with loss of T2 ±T5 fibers Reflex bradycardia and asystole during airway manipulation Relative tachycardia indicates hypovolumia
Treatment
Isotonic fluids and vasopressors to maintain cord perfusion PA catheter / CVP guided volume loading to prevent PE Atropine and even TPI for severe bradycardia
Autonomic dysreflexia (ADR)
Occurs in 85% with SCI > T6 usually 1-3 weeks after injury Uninterrupted sympathetic over discharge in response to stimuli Increase in BP > 250/>150 ( 20mmhg > baseline) Bradycardia , throbbing occipital or bi-frontal headache sweating, pallor, flushing above the lesion Spasticity and muscle rigidity below the lesion Triggering factor occur usually below the level of lesion ( bladder, bowel, uterus, rectal, lower limb)
Autonomic dysreflexia (ADR)
Treatment ( medical emergency)
Remove the trigger Upright position Close monitoring of BP and HR Nefidepine, nitrates, SNP, ganglion blockers Urinary retention & fecal impaction should be relieved Manipulations done under anesthesia Can lead to seizures, MI, ICH if not treated aggressively
Respiratory system
monitored close as most common cause of morbidity and mortality Respiratory rate, O2 saturation, vital capacity recorded CXR obtained; ABG for CO2 levels C 1-3 level injury patient in apneic and intubation instantaneously Intubation criteria
VC < 15 ml/kg ( PaCO2 >50 mmhg) RR > 35 breaths /min Fall in SpO2 (PaO2 < 60mmhg) Negative inspiratory force < 20 cmH2O Pulmonary edema, aspiration
Respiratory system
Most frequent respiratory complications
Atelectasis Pneumonia Pulmonary edema Respiratory failure
Treatment & prevention
Aggressive pulmonary toileting IPPV Intrapulmonary percussion Cough stimulation Postural drainage
Early tracheostomy
Genitourinary system
Acute SCI causes atonic bladder , intermittent catheterization Ach like oxybutin or propantheline added to lower the pressure Complications
UTI Pyelonephritis Nephrolithiasis Renal failure
Chronic bacteruria leads to urosepsis prevented by
Good hydration Chronic low dose antibiotic Intravesical instillation
Surgical options
Gastrointestinal system
GERD , delayed gastric emptying, Increased transit time , severe constipation Abdominal distension & hemorrhoids Ileus ( complete lesions) Treatment
Adequate diet and fluid intake Fibre diet and stool softener Contact irritants and prokinetic agents Ryles tube Hypo Cl- metabolic alkalosis due to gastric suctioning
DVT prophylaxis
Incidence of 60% even with prophylaxis Included as a part of therapeutic regimen from admission Combination is better than either alone
Low dose UF heparin or LMWH if no contraindication Sequential compression devices ( SCD) Gradient elastic stockings
Continued for 3 months and during rehabilitation INR of 2 -3 to be maintained
Temperature & pressure sore control
Loss of thermoregulatory ability below the level of lesion Injury > T6 become poikilothermic (temp of surroundings) Arrhythmias common Delayed awakening during anesthesia Temperature monitoring and warming efforts needed Skin care and treatment of pressure sores is vital Prevention is better Surgical modalities of treatment
Neuro protective strategies
Spine immobilisation Surgical decompression Physiological therapy
Avoid hyperthermia, hypotension, hyperglycemia
Pharmacological therapy
NASCIS- II inj MP 30 mg/kg for 15 min followed by 5.4 mg/kg /hr for 23 hrs Treatment started within 8 hrs of injury had significant improvement NASCIS ±III ; 24 hr regimen for patients < 3 hrs of injury Continued for 48 hrs for patients presenting 3 -8 hrs
Use of high dose steroids remain controversial
Anesthesia for SCI patients
Preoperative evaluation
Multiple medical complications Airway evaluation Neurologic evaluation Counseling about awake intubation and wake up test
Investigations
Complete blood count Renal function LFT Electrolytes ECG ,CXR ABG PFT if needed
Premedication
Minimal sedation Anti-sialogogue Prokinetic for gastric emptying DVT prophylaxis if not contrandicated
Intraoperative monitoring
Invasive arterial BP in shock patients NIBP CVP or PA catheter for monitoring volume status SpO2, ECG, ETCO2, temperature SSEP ICP monitoring if head injury is associated Urinary catheter
Induction agent
Induced after securing the airway in lesion < C6 Nerve block preferred over sedation for awake intubation Sometimes positioned before anesthesia or paralysis Flexometallic armored tube fixed and secured Ketamine is the drug of choice in spinal shock Avoid scoline if injury < 24 hrs ( hyperkalemia)
Positioning
Head and neck in neutral position Adequate padding at pressure points ( eyes, nose, extremities) Avoid excessive neck extension and flexion Avoid sudden change of position Pressure points changed every 15 minutes under anesthesia Abdomen free of compression Prevent peripheral nerve injuries , blindness, pressure necrosis
Positioning
A, Kneeling prone B, Wilson Frame Pad C, Georgia prone; D, Relton - Hall frame E, Seated prone.
Fluid management
Preoperative deficit and intra-operative loss replaced Cardiopulmonary status of high cervical lesion High propensity for pulmonary edema with < T6 Avoid glucose containing solutions( RBS <150mg%) Crystalloid VS colloid debatable
Temperature management
Warm blankets and warm enviroment Humidification of gases Warm fluids Avoid hyperthermia
Postoperative care
Extubation
Cautious in deciding in high cervical and thoracic injuries Patients with preoperative pulmonary impairment Metabolic derangement and persistent muscle weakness Excessive facial or pharyngeal edema in prolong surgery Cuff leak test to confirm reduction of edema Ability to generate cough Minimal secretion and stable cardiac function Absence of pulmonary infection
Postoperative care
Analgesia
Intermittent iv or im opioid Continuous infusion of low dose opioids PCA ; epidural and intravenous with opioid PCEA with opioid +LA or only LA Intercostal nerve block Paravertibral blocks Wound infiltration Non-opioid analgesics
