Neck and Spinal Cord Injury

1. Neck and Spinal Cord Injury Alpesh A. Patel MD FACS Associate Professor Chief, Orthopaedic Spine Surgery Co-Director, Northwestern Spine Center Director, Fellowship in Spinal Surgery Department of Orthopaedic Surgery Northwestern University Feinberg School of Medicine

2. Disclosures • Consulting • Amedica, Biomet, DePuy, GE Healthcare, Stryker Spine, Zimmer • Product Design/Royalties • Amedica, Ulrich Medical • Stock options/Ownership (<1%) • Amedica, Trinity, Nocimed, Cytonics • Board • Cervical Spine Research Society, Lumbar Spine Research Society, Indo-American Spine Alliance • Editorial Board • Contemporary Spine Surgery, Surgical Neurology International

3. NMH Spinal Cord Injury Center • RIC – Midwest Regional Spinal Cord Injury Center • One of 14 national sites • NIH

5. Traumatic Spinal Cord Injury • Cervical spine most common • 12,000 new cases per year in U.S • Dramatic Injuries • Young, Fearless Population

6. SCI Grouped Etiology Percentage

7. Age at Injury and Gender Males: 23,442 (80.7%) Females: 5,610 (19.3%)

8. 203080 million people 20% of US population

9. Mortality • Long-term • 23-66% @ 1 year Fasset JN Spine 2007 Harris JBJS 2010

10. Falls and SCI • Fall Risk • Propioceptive dysfunction • Neuropathy • Medications • Medical co-morbidities • Pre-existing canal stenosis • Spondylotic disease • Asymptomatic • 25-90% > 60 years old Boden JBJS 1990 Teresi Radiology 1987

11. Economic Costs • >170 days of hospitalization - 1st 2 yrs • Direct costs – 12-14 billion US $ per yr • Indirect costs • Lost wages • Caregivers • Lost productivity

12. The Acutely Injured The Chronically Injured What are the challenges facing spinal cord recovery?

13. “One having a crushed vertebrae in his neck; he is unconscious of his two arms (and) his two legs, (and) he is speechless. - Translation of the Edwin Smith papyrus, 3000 B.C. Historical Perspective • Traction • Bedrest • Benign neglect an ailment not to be treated.”

14. Pathophysiology of Spinal Cord Injury • Primary mediators: • Direct injury to spinal cord tissue • Hemorrhage • Ischemia

15. Acute Pathophysiologic Processes + PRIMARY DAMAGE Intact Cord PRIMARY INJURY SECONDARY DAMAGE Acute Spinal Cord Injury Mechanical Forces SECONDARY DAMAGE

16. Goals of Treatment Neurological Preservation Spinal Stabilization Neurological Regeneration

17. Evaluation • Standardized • Spinal Immobilization • Exam • Neurological exam • Concomitant injuries

18. Current Interventions • Surgical decompression • Optimizing spinal cord circulation • Steroids

19. Later Now Timing of Surgery Neurologic Recovery When do we operate?

20. Past – Timing of Surgery • No urgency in treatment • “Early treatment” 3-5 days • Early treatment = risk ! • Neurological decline • Cardiopulmonary • Polytrauma • Marshall 1985, Vaccaro 1997, Mirza 1999, McKinley 2004…

21. Benefits of Early Surgery • Neurological protection • Early stabilization • Quicker and safer mobilization • Decreased morbidity • ICU stay • Pulmonary complications • GI complications Schlegel, J. Orth. Trauma, 1996

22. Primate Kobrine et al 1978, 1979 Feline Brodkey et al 1972 Croft et al 1972 Canine Bohlman et al 1979 Delamarter et al 1995 Carlson et al1997, 2003 Rats Guha et al 1987 Zhang et al 1993 Dimar et al 1999 Animal Data

23. Human Models We operated right away and by the next morning she was moving her legs!

24. The plural of anecdote is not evidence

25. Multicenter, Non-randomized • 2002 to 2009 • Acute Cervical SCI – 313 patients • 182 Early (<24 hours): mean 14.2 hr • 131 Late (>24 hours): mean 48.3 hr

26. STASCIS • SAFETY : Equivalent • RECOVERY (p<0.05) 1 Grade Improvement 2 Grade Improvement * * *

27. ? Later Now SCI Evidence

28. Current Interventions • Surgical decompression • Optimizing spinal cord perfusion • Steroids • Hypothermia

29. Spinal Cord Circulation • Decline in Blood Flow After Trauma • Autoregulation disrupted by trauma • Systemic hypotension • Post-Traumatic Ischemia and Infarction • Microcirculatory changes • Blood flow drops to < 20 cc/100g/min within 2 hrs • Vascular congestion & vasogenic edema • Neurogenic shock Tator CH. Review of experimental spinal cord injury with emphasis on the local and systemic circulatory effects. Neurochirurgie 1991; 37:291-301. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg 1991; 75:15-26.

30. Spinal Cord Perfusion • PRESERVE cord perfusion • PRESERVE neuro function • AVOID • Hypotension • Anemia • No strong published guidelines

31. Spinal Cord Perfusion • Mean arterial pressure >80 • Optimize Volume (CVP) • Pressure support • Hematocrit >30 • Duration • 3-7 days • ICU care

32. Steroids – Wonder Drug?

33. NASCIS II and III High Dose Methylprednisolone IV bolus: 30 mg/kg Continuous infusion: 5.4 mg/kg/hr If steroids given: Duration 0-3 hrs post injury 24 hrs 3-8 hrs post injury 48 hrs Bracken, et al. JAMA 1997 Bracken, et al. N Engl J Med 1990

34. NASCIS Limitations • Methodology • Post hoc analysis • Arbitrary time cut-offs • Transparency • Private data • Objectivity • Drug sponsored studies • COMPLICATIONS

35. High Dose Steroids • AVOID steroids in: • Neurologically intact • Nerve root injuries • Patients > 3-8 hours from injury • Gun shot wounds • Penetrating trauma • Elderly • Multiply injured • Dose >24 hours

36. Why do we use steroids? • Therapeutic Benefit – 17% • Litigation – 70 % Hurlbert et al 2002 and 2009

37. Neuroprotectives and Regenerative Strategies

38. Future Studies • Drug interventions • TWO at Northwestern • Multi-center trials • IV treatments in patients with Cervical/Thoracic Acute Spinal Cord Injury

39. Future Studies • Early detection • Advance MRI studies: find patients at risk BEFORE they are injured

40. Right Now: • Early Diagnosis and Comprehensive Treatment

41. Thank You