Spinal cord injury

In the UK, the annual incidence of acute spinal cord injury (SCI) is 19 new cases per million population, contributing to an estimated 50,000 people who are currently living with SCI. Trauma is the most common cause of SCI, predominantly from falls and road traffic accidents. Damage to the spinal cord occurs both at the time of injury (primary) and in its aftermath (secondary). Effectively treating and preventing secondary cord injury, and managing complications associated with SCI, can make a significant improvement to patient outcomes. Improving outcomes in this patient population mean more patients with established SCIs are presenting for routine operations. Anaesthetists should be aware of the unique challenges posed by these patients, both in the acute and chronic settings.     

Spinal cord injury

In the UK, the annual incidence of acute spinal cord injury (SCI) is 19 new cases per million population, contributing to an estimated 50,000 people who are currently living with SCI. Trauma is the most common cause of SCI, predominantly from falls and road traffic accidents. Damage to the spinal cord occurs both at the time of injury (primary) and in its aftermath (secondary). Effectively treating and preventing secondary cord injury, and managing complications associated with SCI, can make a significant improvement to patient outcomes. Improving outcomes in this patient population mean more patients with established SCIs are presenting for routine operations. Anaesthetists should be aware of the unique challenges posed by these patients, both in the acute and chronic settings.     

Spinal cord injury following an attempted thoracic epidural

Unsuccessful attempts were made to insert a thoracic epidural in an anaesthetised patient. Signs of spinal cord damage were observed the following day. Magnetic resonance imaging demonstrated a haematoma anterior to the spinal cord. Surgical exploration revealed an intradural haematoma and a needle puncture of the cord. The patient suffered a permanent paraparesis.     

Spinal cord injury

About 10% of blunt polytrauma cases have an underlying overt or occult spinal cord injury. All multiply injured patients should be managed expectantly and aggressively until injury is ruled out and normal physiological parameters are restored. The ability to assess these patients accurately is often limited by an associated head injury or by the absence of sensation below a complete cord injury. A high index of suspicion along with detailed clinical and radiological examination is required to detect any underlying injuries. The possibility of spinal shock should not be considered until hypovolaemia has been excluded. Intensive care management of acute spinal cord injury includes meticulous attention to fluid management, nutrition, thromboprophylaxis, early protective lung ventilation and measures to reduce ventilator-associated pneumonia. These measures have helped provide a steady improvement in long term survival of these patients over the last 20 years. There has been recent controversy about ‘clearing’ the spine in unconscious patients. Accurate clearance requires a painless examination in an alert, orientated patient with no distracting injury. Many ICU patients never fulfil these criteria and a risk benefit calculation has to be made. The consequences of converting a neurologically intact undiagnosed, unstable injury into a complete cord lesion are colossal. However, there is significant morbidity and mortality associated with treating all unconscious blunt trauma patients with universal spinal precautions. Many centres are now ‘clearing’ the c-spine of unconscious patients using a combination of cervical CT scans and plain radiological views.     

Spinal cord injury

The annual incidence of acute spinal cord injury in the UK is 15–40 cases per million. More than half these injuries are the result of road traffic accidents, with falls, industrial accidents, sports or violence making up most of the remainder. Violent injury accounts for only a small percentage of cases in this country. The typical patient is male (male to female ratio is 4:1) and young (peak incidence is at 20–40 years). The initial mechanical trauma leads to injury of the neural elements, this is the primary injury. Blood vessels are damaged, axons disrupted and neural cell membranes broken. The spinal cord swells and is compressed in the spinal canal. Ischaemia occurs when the cord swelling exceeds venous blood pressure. This leads to failure of autoregulation of blood flow. The ischaemia leads to a release of toxins from neural cells triggering a secondary injury. The main goal in the management of spinal cord injuries is to prevent secondary injury.     

Spinal emergencies

Delayed or inadequately treated spinal emergencies have a devastating impact on the long-term neurological function of the patient. All clinicians should therefore be aware of the cardinal symptoms and signs of spinal compression, to enable prompt diagnosis and treatment. The aim is to reverse or prevent further neurological deficit. Compression of the spinal cord or nerve roots may be due to disc herniation, trauma, tumours and infection.     

Spinal cord injury caused by direct damage by local anaesthetic infiltration needle

We describe a case of spinal cord injury caused by direct traumafrom a local anaesthetic infiltration needle. During local anaestheticinfiltration before placement of an epidural catheter, the patientsuddenly rolled over onto her back, causing the infiltratingneedle to advance all the way to its hub. She immediately showedsigns of spinal cord injury, confirmed by MRI scan. However,her neurological status gradually improved, and on dischargeshe was able to walk, with a sensory deficit localized to herleft foot. Br J Anaesth 2001; 87: 512–15     

Spinal cord compression by arachnoid cysts

Spinal arachnoid cysts are considered to be rare entities, intradural locations are even less common. We report two cases of patients (two women aged 77- and 21-year-old) who presented spinal cord compression by intradural arachnoid cysts. For the second patient, repeated surgical procedures were necessary to improve the neurological status. After presenting the case reports, we expose the pathophysiological mechanisms and clinical features, and the surgical difficulties of treating this rare cause of spinal cord compression.     

经骶棘肌腰方肌间隙行胸腰段脊柱脊髓损伤侧前方减压术

目的：寻求胸腰段脊柱脊髓损伤侧前方减压的新入路。方法：利用胸腰段的解剖关系设计经骶棘肌腰方肌间隙入路行胸腰段脊柱侧前方减压术。结果：临床应用１２例,手术时间１～１．５ｈ,从皮肤切口到完全显露椎体出血４０～６０ｍｌ。此入路不切断骶棘肌、腰方肌、腰大肌及膈肌,不会伤及胸膜等。随访３～６个月,基本痊愈４例,显著进步３例,进步５例。结论：经骶棘肌腰方肌间隙行胸腰段脊柱侧前前方减压入路简捷,损伤小,出血少。既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸膜损伤等并发症。     

脊髓损伤与胆石病

目的探讨脊髓损伤男性患者胆石病的发病情况以及年龄、体重、脊髓损伤程度、损伤平面和持续时间对结石形成的影响. 方法随访100名脊髓损伤1年以上的男性成年患者,其中ASIA A,B 级者58例, C,D级者42例.年龄为20～65(平均46.5)岁.对照组由100名没有脊髓损伤和胆道疾病史的男性志愿者组成,年龄20～68(平均42.6)岁.两组均行B超检查,了解胆囊和胆道情况.结果两组结石的患病率分别是26.0%和10.0%,差异有显著性(P<0.01).不同的年龄、体重、损伤程度、损伤平面和损伤持续时间其胆石病的发生率近似; 差异均无显著性(P>0.05).结论脊髓损伤是胆石病高发的危险因素;患者的年龄、体重、损伤严重程度、损伤平面和持续时间与结石的形成无明显的关系.     

后路椎管前方减压治疗爆裂性胸腰椎骨折截瘫

目的：探讨严重胸腰椎爆裂骨折合并截瘫,行后正中入路前减压的效果与措施。方法：术前悬吊牵引、局麻,后正中入路。经一侧椎弓根行前减压,６４例中,２７例有椎板骨折,脊椎短节段固定。行椎体、椎板间植骨融合。术后４周带支具起床。结果：随访平均４３个月（２０～７０个月）。畸形矫正：Ｃｏｂｂ氏角平均１２°（术前１７°／术后５°）;术后椎管扩大６２％（术前５％／术后６７％）;不全瘫痪术后提高１级或１级以上７３９％（３４／４６）;平均４５个月脊椎融合。结论：最大限度椎管前方减压是治疗的关键：术前、中、后正确运用脊柱过伸,维持脊柱曲线是重要措施。