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Traumatic Cervical Cord Injury & its Management

Nov 10 | 3:30 PM

Spinal cord injuries have become an epidemic in the modern society. Despite breakthroughs in our understanding of the pathophysiology and improvements in early detection and treatment, it is still a catastrophic occurrence that leaves many people disabled for the rest of their lives. Join us as Dr. Raja S Vignesh explains the line of management in cases of traumatic cervical cord injury.

[Music] so very good evening uh to everyone present here i hope y'all all had a very nice festive break so i'm dr niveda and on behalf of team netflix i welcome you all to today's session uh we have with us today uh dr raja s vignesh who is a senior consultant and a neurosurgeon and uh moderating him we have a moderating this session we have um we have dr bhumir johan [Music] with 16 years of experience he's one of the well-known um neurologists from amthabad and he has his own uh clinic it's called a mustache neuro clinic um he pursued his um higher studies and super specialization from in neurology uh from uh narayan health city which is in bangalore and he's also contributed to uh numerous international and uh national uh journals and over to you sir please let me know when to start your presentation thank you good evening everybody and at the onset i extend my sincere thanks for having me on this platform um traumatic spinal cord injury it has always been a very common and challenging problem over the years and it has got chronic as well as acute complications if it is not managed well so today we have the one of the best experts to talk on this topic uh may i introduce dr raja swignish he is a consultant senior neurologist a neurosurgeon and he is currently working at the nela institute of medical sciences in terunawali he is a madras medical college graduate with specialization in neurosurgery many of his papers and articles have been published in various journals as well as forums for cases of traumatic subdued hematoma dr vignesh has developed an intra operative prognostic system by himself apart from his all academic achievements dr bigness is also a great humanitarian he performs lot of free surgeries for the less fortunate people and also extends financial aid for deserving students and for his gestures he has received the prestigious tamilnadu governor award in 2013 and the tamil nadu government has also honored him with the best doctor award in 2019 so i welcome dr vignesh on this platform and help us enlighten on this topic of traumatic spinal cord injury [Music] actually this is one of my favorite topics in neurosurgery because as an undergraduate back in 90s so whenever we came across when we were interns or students when we came across cervical spine [Music] so these were the things which uh i was uh exposed to cervical spine with literal divorces today but after doing my neural surgery i had a lot of observations during that period in my 3g period which made me to change the way to approach spine injury and i am very delighted to share my experience so i heard that the audience are many practitioners consultants and lesser number of students so i focused on this study this topic in a way that it will suit both ways so first of all i would like to uh remember my hello matter my ug college general medical college and my pg college biomedical medical college and madras medical college are my neurosurgical schemes were done so i always remember these three things because of these three institutions i am who i am now so now about this presentation this will be an atypical presentation this was actually targeted for a resident in trauma award and more so this will target this audience also so main focus is on a few things that change the outcome in spine trauma which is what is uh really the need to have outlook on the management of cervical spine engine so i use some videos and scans and photos so i obtained proper return concern from all the interested parties for exhibit and academic forums so yes so i will start with the common myths and stigma regarding cervical spine injection these three things are common even among fellow doctors are patients or patient surrenders so whenever we come across circles per injury there is a myth that there is no chance a very less recovery after primary severe deficit for example if the patient gets becomes quadriplegic after the injury as i said yes they think that no there is no chance that this status is going to be dispelled and the second one is whenever we offer the treatment modality as surgery sometimes there will be a little concussion over the card or something like that which needs some decompression a simple surgery but the relatives are fellow doctors you should say if if you operate upon the cervical spine no it is doomed the patient will be walking no no no he may get worsened and he will be bedridden so this is one other thing surgery will worsen the pre-op status and the third most important thing this is the most uh common thing where even among educated public and fellow doctors they think that cervical spine injuries can be managed only by branded big corporate centers so this is the main myth which has to be busted out because i come from a place which is a fire three city and we do surgeries which are being uh done at world class levels we do daycare spine surgery so this one which has to be busted only big corporate centers can deal with cervical spine energy so yes so most commonly traumatic spinal cord injury the most common cause is motor vehicle accident in our place then falls violence sports injuries then you could say that a card injury usually occurs from an indirect injury from the impact of the bones discs or ligaments which compress the card and not direct injury on the card per se so these things they get hit and they injure the car and one other thing which goes hand in hand is cervical spine injury frequently occurs with intelligence so it is a dictum in trauma practice left whenever you have a spine injury rule out heterogeneous whenever you have entity rule or spine injury similarly whenever you have long bone injury or abdominal injury rule out all these things so any trauma patient unless through their voice you take him as some sort of major life-threatening injury like surgery then the last one which is rare in our country [Music] card injury caused by direct trauma from knives or bullets where the card is severed or directly injured so these the the last one is uncommon in our place so this is a basic thing about a spinal cord cross section which everyone in this world will be aware of so we are more in case of spine injury everybody is more concerned about the motor part or part and less so with others like sensory or blood though they are they can also commonly occur so so this is the anatomy of the card which everyone is aware of so any spinal cord injury cervical spine for that matter the most important thing is to transport the patient without worsening his existing injury so that is very much important so pre-hospital resuscitation so this has to occur at the paramedic level at the ground level where they take the patient from uh for transport so our government of double leader has a new initiative called the guy program which i am a part of we have been implementing from 2017 in collaboration with australian government so this model is being uh projected to whole of the country i guess more soon it will be there where we have one station set up for emergency care like in western countries and we have pre-hospital intimation we have one or two ambulances where gps is attached and when the people receive the patient they intimate it through the mobiles and the state of the patient reaches the hospital so that the hospital will be prepared the year will be prepared to receive such a patient if it is a spine injury or a head injury or a myocardial infarction or whatever it is so the hospital will be ready to take such patience so this one coming to the basics of spine injury this philadelphia collar is one which we should never ever forget in our life and this should be the basic standard collar before transporting any spine patient so because i have seen patients who have been transported with g615 and full power while shifting while they reach here to the hospital the thing is the patient becomes quadriplegic or the patient gets restricted difficulty he gets weakness so this is all because of in incorrect mobilization to the spine so that is most important so a cervical collar lumbar and dorsal braces but nowadays with the advancement even periphery setups have good protection to ship the patient so log roll shifting is is just as we move a long a tree roll from head to foot the patient has to be shifted on a hole like this the patient has to shift it on a hole like this not head separately and put separately so that is log roll movement and the last one is the most important which we have to take in mind so many cases person are die during shifting so these things have to be taken in mind before shifting a patient to the year so basically the levels of injury we have two things a skeletal level and a neurological level so the skeletal level corresponds to the vertebra which is getting injured and the neurological level will correspond to the spinal cord segment which is getting used so as you can see at uh cervical segments the corresponding vector level and the neurological will be the same whereas in upper thoracic segments it will be two levels more that is if the t4 vertebra is fractured we expect a chord level at t6 and lower thoracic algebra around ta to d12 it is you can add two more or three so it is set so the card ends at l1 so at the l1 we have all the uh segments up to s5 level so it is approximately the difference between chord level and skeletal level so whenever we have a injury at c4 usually in cervical spine that will be the cardinal will be around c4 and c5 whereas in the dorsal vertebrae if it is in d10 we have the corresponding card of yellow and l2 likewise so the corrosive skeletal level corresponding to two or three segments lower card level so that we have to take in mind so then this is grossly the mechanism of spinal cord injury during trauma so it could be a flexion injury it could be a hyperextension injury or it could be a compression type and very rarely the fraction rotation complex component which is uncommon but it is most difficult these patients don't survive yeah so this is what is hyperflexion this is typically happening in a motor vehicle accident high speeding vehicle comes to a hall the moment of inertia pulls the head forward and then pushes back so here what happens is the posterior longitudinal ligament gets done the posterior ligament gets torn in case of hyperflexion engine so this is a unstable injury and usually these patients may have complete butt damage so hyper flexion injury the structure that is disrupted is a posterior longitudinal ligament then in case of hyperextension injury this commonly occurs when we slip from a step so this is like a chin hitting the surface a dashboard or a bath these usually cause central cartilage syndrome here the anterior longitudinal ligament gets thought so in case of hyperflexion injury the posterior log equipment gets done and in case of anterior hyperextension the anterior long limit is each [Music] when compression injury this is usually happening these these things don't happen at the cervical level usually very rad to have a compression fracture at the cervical level these things happen at the lumbar and dorsal level fall from height it can happen at cervical level also so the last one is the most unstable one here the typical case is in a case of public transport that is while travelling in the bus we have supporting beam standing adjacent to the seat the neck gets caught between the seat and the rod and the body twists so this is very severe injury the patient will die on this part this will be just like hanging so it is like that so this patients don't survive at all usually so these are the four mechanisms hyperflexion hyper extension and compression and function rotation then in general what happens in pathogenesis of the cardinal so what happens to the neural structure one is mechanical compression then lithium compression can cause transient neuropathy let's say you can disrupt the axonal problem then the other one is god has blood supply compression of blood vessels ischemia the other one is during the whiplash or hyperflexion type the cord can be pulled so the tractional injury the tractional injury typically presents days later because the axon hypothesis or the neuropraxia occurs late so tractional injury there will have a typical history where the patient will say yes i had a fall there i had pain in the neck i was able to go around well but after two or three weeks i have number numbness in my hands and have decreased hand grip so this will be a course of attraction injury which usually presents subacutely and penetrating trauma it is well known the bone chip just transects the cord so mechanism of injury direct compression interruption of blood supply both venus and arterial and transaction and penetrate so so here is where the management of spinal cord injury comes into play one is initial mechanism of injury which we cannot prevent so initial mechanism of injury nobody can proven because the patient falls there so it is like that but the second point is most important which has changed dramatically the course of spinal cord injury which is a secondary injury which occurs due to ischemia hypoxia micro hemorrhage and edema which are all just like any inflammation that can occur in any tissue so the compression results in ischemia venous internal engagement can cause edema in the gut edema causes nervous dysfunction transmission is disrupted hypoxia then again arteries get disrupted god goes for infection and micro hemorrhages in the substance of god which we commonly say is called contusion and edema is one which in which the initial injuries may be a compression type and due to reaction the guard swells up and due to swelling secondary injury so in case of any spine injury the role of a neurosurgeon comes in preventing these or decreasing the effect of the secondary causes of god damage which can be done by surgical intervention so this is the top main part in which the whole topic of improvement in or the scope of improvement for management of cervical spinal energy so this is one thing hemorrhaging edema occur in the gut post injury causing more to god then we could have come across patients wherein a patient with surgical spine injury coming with the power of four by five and in two or three days his power worsens so from a power of four by five the power goes to two by five and if it is a high cervical spine injury a normally breathing patient may become uh dependent on ventilator his respiratory reserve may fall that is due to the card edema which can ascend up and descend down so when it ascends up for example when there is a c45 injury the edema can ascend up to c3c to segment and cast respiratory paralysis so these are effects of secondary engine and as in any neural structure an injury is always accompanied by spinal shock so more so in spinal cord where there is depression of all card and autonomic nervous system function below the injury it can last from few minutes to even few weeks so neurogenic shock is decreased reflexes and loss of sensation below the level of injury water losses placid paralysis below the level sensory loss all modalities are lost below injury it can last from days to months so neurogenic shock the recovery of neurotheric shock also cannot be predicted in some patients a neurogenic shock recovers early in some others it does not so this we all know dermatomes so dermatomy level when compared to skeletal levels so this is a basic idea of dermatomes is needed to assess the level of egypt yeah this is sensory motor assessment we mainly focus on corticospinal tract which is motor and spinothalamic tract pain temperature and dorsal column which is fine touch improved so in case of dramatic card injury all levels will be usually the same except when there is a edema disproportionately edema somewhere you may get different levels but the lowest motor level and the highest sensory level we take into consideration for a problem so reflex assessment yes at the level of injury it is element and after the what is that neurogenic shock recovers you will have hyperreflexia in the segments below the level so these everybody knows why such regular ideas are the root value and score are reflexes we grade from 0 to 4 plus so this is superficial reflex assessment this is nothing but neurological assessment yes abdominal reflexes chromatic reflex vulvar cavern and triapism this occurs in the later phases when the neurogenera shock recovers and in chronic uh injury in the chronic stage we get triapism which is more versatile when patients have to do self catheterization so this is uh the scale where we uh assess the spinal cord injury so here when you go through the scale from a to e e is normal actually a is first in bur in the first scenario you have loss of motor function so whenever there is more car deficit it indicates a severe rejection this is a basic thing a patient complaining of paresthesias or numbness is a better patient in my view rather than one who has a motor deficit so from a to e a is complete transaction of functions and b sensory is preserved whereas motor is lost and in incomplete type you have patchy motor preservation whereas sensory may be well preserved and in d-type water preservation occurs wherein more than 50 of the muscle groups will be functioning with uh power of more than three by five so d c d e the prognosis is good and v and a it is not so good but c d e will be at the presentation can worsen to a and b if we don't intervene early so that is what the secondary injury can do to the car so these are cards and rules which uh you may be aware of central syndrome wherein typically the patient presents with weak upper extremities so he won't be he'll be having a power of around two or three in the upper limbs with no hand grip whereas lower extremities he'll be near normal he may be having a power of four or four plus and he'll be walking well without a good upper limb power and bladder bowel may be mixed so in central cut syndrome is usually affected but sometimes it can be spread so central cuts syndrome then anterior cut syndrome wherein only the anterior structures it commonly occurs during a high perfection injury and motor function loss is common in anti-recoil and bond brown sigma syndrome this this is rare in case of traumatic card injury may be a laceration of the card any section recently i had operated a patient with a power of zero by five the lower there is a parcel cut actually zero we find the lower limit and the opposite side it was nearly four so you can have a hemi cut syndrome wherein a bone piece was transacting half of the guard while the other half was good so this is ground setter syndrome the complete card injury you have a quadriplegia when the upper limb is involved and lower limbs are involved paraplegia when the level is below p1 when the hands are spared and there is paralysis below it so yes how will you diagnose in peripheral set of plain x-rays they have still some role you can see lysthesis or severe fractures etc but nowadays at least in tamilnadu we have mri centers within 30 kilometers in the highway or near the hospital so mri is the modality of choice so where you can get uh detailed about the ligamentous structure some extent and more precisely precisely about the spinal cord where you can have whether it is conclusion or uh or that is just compression of the car so mri is the diagnostic modality of child where mr is not available cds are available cte is next to second worst possible investigation to be done so this is for academic interest for maybe some mbps students who are interested in preparation for are like that shivora this this is this term is now historical because before the advent of mri and ct only we had x-rays so the x-rays will be normal it should be quadriplegic or paraplegic this term was coined spinal cord injury without radiologic abnormality so so this is common in pre-imaging era like mri with mri shivara is historic because even when you have a mild weakness you can find out in mri with the different sequences so mri shivara is historical and management cervical spine injury i would rather classify mainly as a patient with normal breathing and without a normal breathing or who may require a ventilator support so this is what any injury high card injury above c4 and uh below c4 c5 we can have the slower cervical cardio so c4 above c4 respiratory function will be last so that patient may any time going for respiratory failure so anytime you were going for respiratory failure he may require ventilator so for the sake of undergraduates i i mentioned this so people used to say in bedside clinics how will you assess the respiratory effort or the respiratory capacity so there you can have you can have spo2 tidal volume you cannot measure but you can see the pattern of respiration from a regular abdominal thoracic recovery abdominal the rate may be increased shallow breathing with increased respect rate and bedsideness we can have single breath count wherein we can ask the patient to murmur our mumble one two three four are some uh letters without uh interruption of his breathe so single drug count is a good website test and in older days they used to light a candle and ask the patient to blow the candle so that fvc or fev1 can be measured indirectly so now we have good spot monitors respiratory rate it's a bedside test and accessory muscles of breathing and pattern of respiration will give a good account of the respiratory effort or the reserve of the patient so when we when the nurse plots these parameters we can know whether the patient is going in for early respiratory failure so this one is important and when there is uh the patient is on a same mode on a ventilator etco2 measurements if available can say if this respiration is inadequate and we have to switch over to other modes so these are the main thing is respiratory management in cervical spine injury is [Music] very much needed so yes cervical spine circulation patient is in neurologic shock as you know as we know the sympathetic outflow is thoraconosal outflow whereas parasympathetic is craniosacral output so any injury about e6 we have a sympathetic output disrupted so patient will have hypotension bradycardia and it can be mycothermic because of fluctuating uh sympathetic research so what you have to do is to prevent the volume loss we have to resisted fluid and one more thing which we have to keep in mind is not always neurogenic shock will result in this the card injury can result in this we have to rule out other abdominal injuries or thoracic injuries are something like that so these things where abdominal injury are hyperbolic shock is easily treatable so we have to maintain the fluid blood volume with the uh necessary support we can use i know ionotropes also and vasopressors so this is about circulation one thing which i want to emphasize as a neurosurgeon is two things we come across one is a brain injury and another is a cervical spine injury in brain injury when there is icp race we have a constellation of symptoms like a bradycardia and hypertension a variety guardian hypertension is pushing surface whereas in cervic and spine injury where the sympathetic tone is last we have cardio and hypotension so bradycardia hypotension suspect cervical injury or rather a card injury bradycardian hypotension is uh head injury and one more thing a tachycardia and hypotension always rule out hypoallergic shock hyperbolic shock is the simplest thing which does not need a neurosurgeon for treatment hypovolemic shock has to be corrected in the er by a basic mbps so hypovolemic shock is you have tachycardia and you have hypotension but uh when the shock is performed we'll have radicaria also when there is not enough fluid so tachycardia hypotension radical hypertension and bradycardia hypotension so these three things you have to keep in mind corresponding so neurogenic shock yes lack of sympathetic innervation increase in venous capacitance venous cooling hypotension cardiac output decreases tissue permission decreases similarly the stimulus to the heart is decreased of bradycardia then again decreased cardiac so this explains priority cardia and hypotension in case of neurogenic shock so spinal shock as i told earlier classic paralysis loss of all modalities of sensation reflexes and laws of autonomic function so respiration very very important maintain ventilation and when you have doubts regarding the respiratory status it is better to integrate by an anesthesia list with new care of support to the cervical spine not to worsen the injury so that is uh very much important and then we plan to operate or do a major surgery in high cervical card injuries it is better to do an elective tracheostomy before the procedure so i do when the power is zero and i have to operate on c two c three levels so i do this protein tracheostomies are needed because one thing is for we can have for prolonged ventilation and tracheal toileting because aspiration is very very common which can treat the patient so a plan the electric tracheostomy can be done when in case of high cervical cardiac because the morbidity and mortality will totally differ with a patient on tracheostomy versus who is not untreated so where you say how to manage this there are certain things which you have to look in you have to do good chest physiotherapy you can have spirometers you can have craft bypass and abdominal binders and more importantly early mobilization early mobilization if the power is good do really immobilization do good just physiotherapy you can teach the patient attendance so i'll deal with things later the physiotherapy and rehab cornerstone for recovery after our primary intervention so spirometry can be done and early mobilization so cardiovascular complications as i said earlier cardio hypotension so this needs to be addressed because we cannot uh move a patient just like that like any other trauma patient so he may result in severe arthritic condition they become unconscious we have seen patients like that very sensitive so we raise the bed slowly so we can keep the patient in prone if you have operators in lateral position so these things are practical things which will help in preventing this heaviness and a light adrenals yes oil thermia this is another uh dangerous issue when uh we have in ca we have to encounter in cervical spine injuries so we have to keep the patient warm and the last one is in cold places so the skin will not have a normal vascularity due to loss of rasamata tone so the maintenance is very very important so gastrointestinal complications you have abdominal distension we use a nasogastric tube these are all the initial may be in the two or three weeks later all these things will get adjusted to some extent to help the patient so nature adjusts itself to help the patient so ball routine you have you need to give stool softness you need to have supposed to be high fiber diet etc and later we may have to teach digital evacuation etc so ng tube is one of the most important thing so to prevent earlier deaths due to aspiration so nge2 any neurosurgery be it cranial surgery or spinal surgery ng tube saves lots of lives so yes reflexive bladder it is a quite quite complex thing bladder to deal with so commonly we restrict the fluids to around two thousand to five hundred ml we can if it is male we can use quantum particles you can have uh spcs if needed there is injury to others then we can palpate the bladder we give compression and train the person to why so these things can be done and we have to remember about urinary tract infections which are silent more so in diabetics so whenever there is fever amateur or cloudy flower spelling unit change the caterpillar give blood wash center cancer sensitivity and uta silent uta also kills especially immunocompromised variations and diabetes so good intermittent catheterization practice has to be taught because after surgery patients may recover well from uh motor motor deficit and sensory deficit but this bladder and bubble they have to take care so that we have to teach them properly so bladder bubble uh care is very much important in managing a long term patient musculoskeletal yes one of the most important thing patient goes for spasticity contractures so these are long-term complications but even otherwise i have the practice of keeping my bystanders or attendees by the side of the patient and do physiotherapy so one thing is to it will prevent dvt which is one silent killer which can lead to pulmonary embolism so we can when the when there is early physiotherapy and early passive mobilization at least you can prevent the dvt and secondary mortality so that is very much important and contractions can be prevented because once a patient regains power these contractors can can be debilitating so that may require again release surgeries releasing of tendons and contractions may be a big problem so even in the initial stages when there is final shock we have to have splints and uh just like we prevent bed source by having good alphabet and protective things we have to do immobilization mobilization so earlier mobilization lesser contractors and lesser modernity and when we mobilize the skin also gets protection indirectly by the moments so autonomic dysreflexia so this one term which is a good question during undergraduate level wherein when you stimulate anything below the abdomen level mass evacuation of bladder and bubble occurs sweating and sometimes very rarely autonomic dysproplexia can result in a severe sympathetic storm sympathetic storm and can cause myocardial infarction or stroke in my 10 years of experience i have come across two patients one died of mi the patient had a reflex massive evacuation he sweat he had a sweat complaints of chest pain took an ecg it was an mi and patient we lost the patient and we had a hemorrhagic stroke so autonomic dysreflexia can be annoying to the patient but and it can kill in the rarest of there are circumstances also so precipitating factory anything below the umbilicus you stimulate very rarely even in the chest level when you stimulate it can occur so a distended bladder a distended bowel skin tactile stimulation and during periods or even inhale prior person we can get autonomic dystrophy so how to prevent manage try to keep the patient upright and when there is an attack you have to monitor the bp very carefully because hypertensive crisis can result and monitor the neurological status we have we have seen deterioration with gcs probably stroke and try to remove the affected stimuli and give anti-hypertensive medications levital is one which can be used so we have to educate the patient about this sometimes we get nine calls he decides a patient four weeks later at the late night one o'clock patients after sir he becomes unresponsive he becomes he's having palpitations he's sweating so you have to educate the patient regarding autonomic dysreflexia so this is one of the most important things patients suffering from depression because just before the moment of his injury he was as normal as you and me he was walking he was doing his routine life and suddenly after the injury is not able to move his whole world is turned upside down so he he will be knowing he will be anxious to know when he will be able to walk whether or not he will be able to walk it on so these things are really painful and we need good uh care to take a take on the mental uh well-being of the patient so we can have antidepressants good psychological counseling and one main issue regarding psychological counseling is they have to counsel the patient's attendance so because i used to tell the patient yes he's suffering and you are the persons who have to be in good state of mind and you have to be bold you have to encourage the patient you have to take everything because they are the ones who are going to take care of all these activities right from these movements physiotherapy evacuation of bladder bubble blessing turning the patient around frequently so this will put a lot and lot of physical and emotional pattern on the bystanders or attendees so we have to counsel them most and regarding this good psychologically supported patient and strong attenders the patients will have very good outcome i have seen because the three months post-op care if the patients and attendees are very much in a positive note without without getting into negative depression they recover so counselling is very very important and this one yes sexual function erectile dysfunction can occur you can have prioritism and ejaculation failure so we have modern things like uh electro ejaculation without regulation etc so these things will come into play and the patient regains all other functions so uh a bed-ridden patient initially he like to walk first he wants to sense he wants to have his bladder and bone control and the last thing they want is the sexuality but still for completion sake yes it is very much important young couple who need children these these factors come into play and we have lot a lot of modern techniques to assist them similarly with females uh patients with injury and pregnancy you can sometimes have abortion you can have difficult labor so these things cannot and uh sexually active individuals you can have dysphoria etc and uh lots of other stuff so labor can be a difficult one yes oh this is where i i want to focus on my topic so surgical management timing of surgery so the timing of surgery is very very important final outcome morbidity mortality and recovery are better when interventing prevention of secondary injury is the key so surgical intervention delay so this is what i have been seeing in my setup at least in in our state the time delay the patient gets injured say at 1 o'clock he comes to the hospital by two one hour delay and then to get all the investigations things done and for the procedure today it may take from eight hours to ten hours to even days so actual problem is the delay and delay in intervention in our setup at least to my knowledge most financial injuries are not increasing time and for this reason precisely all the studies and things which uh tell about the outcome i don't think the first part of the earlier intervention is taken into account usually so this delay is one thing which can cause worse prognosis in spine injury why the delay yes delay in diagnosis transport imaging specialists other associated life-threatening injuries facilities some rural setup may have may not have a neurosurgeon or a spine surgeon or a cm or instruments to operate so he has to be transferred transported to antennas or one day later so there are certain issues for the delay so what is the app type of surgery so as soon as you have clinical data deliverance you convince the patient and go for surgery if it is surgically treatable so within others so these two things sometimes happens with certain uh setup where the anaesthetist or the emergency physicians they say you have to wait for the bp to stabilize bb is not according to me bp is not going to stabilize at all because it is an autonomic dysfunction and there is cervical spine injury so you rule out other causes of correction of bp varieties and hypoallergic shock and go for surgery so don't wait for rigor and sometimes in case of high cervical cortina c2 c3 or c1 c2 there won't be respiration and people say yes there is no respiration so no point during operating that is not the case you have to fix the fracture fix the fracture and allow the neurological tissues to recover if you are not going to fix the fracture the compression is going to injure cause more damage and secondary factors will take over so fix the fracture first and decompress whatever it is so use space for the car to expand so that is a basic thing so this is a practical classification where a high cervical cardia above c4 the mortality is uh usually 95 percent and c 1 c to subluxation of c 2 are universally fatal so the highlighted things are early intervention changes lives any injury below c5 because they need the most aggressive management where their patient bedridden may walk later so this is the difference they may recover from complete quadriplegic to self-ambulation many times aggressive management is not done because uh two things one is the patient and attenders not really the patients the attenders may not be convinced they may ask for as usual guarantee warranty the operating doctor so you are telling it is a dismal prognosis yes cfa injury is quadriplegic really recover will he walk we cannot guarantee that the basis is if you operate on 100 patients maybe 10 to 20 percent percent of the patients may be able to walk and take care of themselves but that 20 is a very good success rate when these patients will not recover if you are not stabilizing the spine so instead of 100 percent mortality or morbidity a 20 to 30 percent recovery is such a huge success so it it becomes little difficult to convince the patients on that and this so indication for surgery any stable injury with evidence of card compression with or without card signal change the card signal change is one factor nowadays which we neurosurgeons are worried about more so medical legal more so medical legally because when when there is hyper intensity in the god due to signal change we say that prognosis is dismantled because car damage is severe as found by mri so neurosurgeons may be worrying that operating on this and cost of the surgery rehab rehabilitation etc the patient may see that we were not expressed were told properly so these things are their records it will change and unstable fractures have to be attended soon subluxation has to be attended so this is one which i had emphasized here is one point where the neurosurgeons differ there are two schools of neurosurgeons where one like me we will operate even when there is card signal change the other persons they don't operate when there is consequence so why i operate is cards will change as we all know it could be due to either due to condition or edema which the mri recent mri cannot predict even for 24 hours initial 24 hours and mri taken will not cannot differentiate between a card signal change signal whether it is due to a conditional so what we say is if it is due to contusion yes the process is going to be dispelled and we will be knowing only after two or three days taking an mr if it is due to card demand it is going to recover so why not operate it yearly and wait for it whether it is conclusion or edema explain that to the patient and not understand so if decompressed earlier secondary itself can be reduced in cardiac demand prognosis is better and it can be better even in card pollution so we are a group we will say yes operate fix the fractures as early as possible with a word of caution to the patients absolutely yes if it is called conclusion it is difficult to the prognosis so pr group we will operate early and in my personal experience operating really rewards good results so surgery yes this is more of technical so it is an anterior approach you can do a anterior if it is a disc structure descriptory with bone graft or cage if it is a severe vertebral compression fracture you can do a carpal tuning in c2 fractures you can do a watertight screw or when there is severe injuries you may be you will need a posterior approach simple laminectomies to a lateral mass and vertical screws or in case of that rare rotational injuries unstable lock facets you will do a 360 degree approach where you do approach anteriorly and also posterior yes this is one thing which is very important for practicing clinicians and students always remember this happens everywhere usually a patient comes with a spine injury he'll be complaining to us that yes he is not able to move his limbs totally and his bladder is full he has been catheterized and when you ask about upper lip super easily we used to ask yes are you able to move the limbs yes he will say yes i am able to move my upper lips but any a time there will be subtle upper limb weakness which will be missed if we don't check specifically for apparently weakness and a profound lower limit we have seen occasions when cervical spine injuries have been missed but for a simple clinical test of upper limb power which has been missed i find the mri of the docile spine i find the mri of lumbar spine because the power in the hips will be zero the patient will be moving these upper limbs when we examine the upper limb power will be four or four minus or rather three with no hand grip but the patient is very much concerned that he'll be telling you i am not able to move my lower limbs and he himself will think that yes this upper limb is able to move maybe it will recover soon so his thought will be like that he will be highlighting the thing where the power is zero and we should not be carried away so that is why we have a proper we should have a proper clinical examination so i my rule is any patient complaining of paraparasitis blood disturbance after your fall or injury or rather any patient with weakness or parasitism lower limb rule or cervical spine that is the dictum very simple clinical examination of power of upper limb can know that the injury is higher remember this upper lip weakness which this i have seen practically yearly i will see three or four patients who have lost their life because an mri of the circumstance not being taken in time and the intervention was delayed i have seen i have seen and i will see upper limb weakness which will be relieved one revealed only an examination and by the time patient becomes distinct because the card edema it ascends up a c4 c56 injury we have missed the upper limb weakness called edema versus c3 he needs victory to support he dies so this is a real case scenario the card edema worsens and he'll be recurring ventilate and by the time he's put on ventilator you will have the previous mri of a lumbar central spine and arsenal style with you and no amount of circle spine which cannot be done after the patient is put on eventually so always examine power and sensation in all four limbs and get an mri suitably as my teacher used to say checking pulse you have to check pulse in all four limbs you will always you will be lucky enough to not to miss a quietation of iota always check pulsing all four upper lip similarly any trauma patient never ever forget to ask for power or examine power in all four limbs upper limbs and sensation also this simple clinical test will save life and morbidity lessen the market so management summary is as i said i have been emphasizing it is always good and realization and careful shifting hemodynamic management just limp physiotherapy dvt prophylaxis is very much needed in advanced state you can have a special dvd prevention apparatus you can connect to them or dvd stockings and pressure source care is very much important because many patients with unintended pressure source will die of secondary infection and management of nutrition is very much important and early tracheostomy if you anticipate long ventilatory support and finally to my place earlier surgery earlier so remember dbt dvt any chronic ventricular patient even after for uh 24 hours or 40 trust is prone for dvt pulmonary embolism and pressure so in chronic patients which has to be attended more so in diabetes so i wanted to stress upon recent advances so we are lucky that the system our sciences advance in such a way that we can use brain spine interface so these are implants which can be done in spine the spinal cord where we can bypass the injured segment to stimulate the lower segments so one thing being a neurosurgeon is that i always admire and wonder about the brain you think we think that neurons are yes just like end organs what is the end arteries neuronal injury is catastrophic but our neuronal circuit is made up of billions of neurons and lots and lots of neurons can come into the rescue of non-specialized neurons also [Music] this is the thing which i have to emphasize here you will have an electronic device a simple circuit which will connect the card above the injury to the card below the injury the brain of the individual will map this electronic artificial connection to the lower lip so this is this is the what is that the insane capacity of the brain to reconnect itself through an artificial system to the injured part so you you can surf youtube videos where in recently yes the success rate is maybe around 10 to 15 to 20 in the completely severed cards but still earlier uh so earlier intervention good uh leads to better prognosis so this is one advancement which is going to change and in future in another 5 or 10 years this will improve a lot so this is a spinal implant so similarly we have got spinal implants for thoracic and cervical levels so where you have non-invasive electrical spinal cord stimulation where the generator will be placed outside the patient can operate and you have a targeted epidural spinal cord stimulation also where you can implant it inside for lower limb this is for mainly for paraplegic so these are recent advances which i am mentioning and yes stem cell therapy is also there is it okay now yes stem cells therapy is also there but these two things where these are actually modern day marvels so when the technology advances more you'll be able to have even good microchips but uh the thing is these are very much costlier and one implant surgery may cast around 30 to 40 lakhs so for affordable patients yes these are promising tools so we can replace that yes and this is another one diaphragmatic pacemaker so here yeah rarely you have phrenic nerve injury with good power in all leans so only just like a cardiac pacemaker you put the pacemaker into electrodes in the diaphragm is a simple procedure you can do it uh just like in the opd you do anesthesia you open the abdomen you place the pacemaker inside and the battery will be outside so it is like a cardiac pacemaker so this can help in isolated functional injuries these are very rare but even these are costly it can cost about three to five lakhs so diaphragmatic placement so this one slide because we have to see videos at last so this is one thing previously when the when there is severe uh skeletal injury we were recurring carpectomies we had isolated cages with implant fixation so this cast uh certain difficulties current the fixing of the implant uh has to be meticulously done but when you tighten the screws you cannot distract the implant also so the alignment may change and we may injure the card more so this was a very tricky issue this was also the reason for worsening of pre-op statuses so now with the advancement of technology we have a dance ultra system that in you can remove the vertebra you can put the ultra case system if it keeps in place you can distract it the advantage of distraction in situ distraction is the distraction will happen only along the anatomical planes you need not pull you need not push you just tighten the screws the extractor will work and this will happen only along the anatomical alignment planes and then you can see with the advent of this gas ultra system posterior uh segment what is the fixation levels have come down posterior fixation 360 degree fixations have come down so this is one advancement dance algorithm using it for past four years so we do this in periphery so somebody was asking about uh role of steroids yes so it is it is proven or unproven again two schools of thought is some say it is of no use some say yes it is abuse so this is for yes it is a fuse means you use lethal pretty zone within three hours this dosage 30 milligram per kg in the first hour followed by the remainders to be run continuous infusion for 23 hours if it is three to eight of us the loading dose is same but the inclusion rate has to be carried out for 40 hours and as for textbooks recent advances journals and even my practical experience after eight hours there is no role for any uh methamphetamine it does not help and using that as a metaphor also uh has similar effects and i don't use lexamathosa if it is after 40 does so role of steroids is controversial but as for our academic purposes yes so this is one thing for undergraduate level you can have lethal friendly salon within three hours you infuse it within 24 hours if it is after three to four eight hours textbooks you infuse for 47 hours if it is after eight hours there is no role but still some people say yes steroids are beneficial and they give for five days so our reports don't support that so this is the role of steroids so i i thought of bringing it last so yes again i am emphasizing techno messages you you got more slides because videos will be coming up early recognition of spine trauma is mandatory shifting and transport repeatedly i am telling we should not kill the patient and make him quadriplegic by our movements so it should be very very meticulous and we neurosurgeons yes early aggressive surgical management has better results in spine trauma pressure for care is very very vital more so in diabetes physiotherapy has a pivotal role immediately and as well as long-term outcome so most important again i am telling you don't miss a cervical cord injury in a patient complaining of paraparasites and blood disturbance and once again for the sake of consultants any patient complaining with lower back ache and lower limb symptoms always check for cervical spine you will have you will be having lower lower limiting for infectious weakness and when you examine the upper limb you you'll be having weakness and a cervical spine has to be addressed first so remember any patient complaining of lower limb neurological symptoms be it in trauma or your general practice always examine the upper limb rule out cervical cord so this is one most important thing so here again uh these things i have put in mainly because i have done all these things in peripheral setups okay not uh premier institute examples okay so this was one two three four five six five six dislocation where it happened appeared that this was a very severe injury this was operated in the government setup five years back i had to put a primitive gauge previously and a regular titanium plate and a screw so can you have this video you won't you won't believe so this patient is walking so one thing i want to emphasis to the audience is please don't compare the movements fineness or uh what is that these movements are bladder ball recovery to a normal patient you cannot compare so i say this is a very successful surgery because he's able to ambulate himself he doesn't have a very good power in his hands or his fingers or something but still this is better off being bedridden so we tend to compare always as always when we are at a position we used to see those people who are above us and we think oh we need this but in this person's point of view you'll see smiles in him is able to walk somewhere so this is what is more important always remember this so if you give some manipulation some ambulation that is far better than being hydrated so that is why so i had operated out of 10 cases which i have operated only one patient would have been walking like this but had i not operated him this patient also would be better so that is the main thing which i want to convey yeah this is again this was a c56 subluxation with card condition you can see can you see the white signal change in the card this is two three four five two three four five six so at the level of six seven you can see a white thing in the card the gray thing is the spinal cord the gray thing the things which are antenna and posterior csf and the white thing inside the substance of the card is a c what is that the signal change which i was talking about a t2 signal change which is i was talking about here again yes two schools of thought this patient are breathing difficulty so whether to operate or not so that is a concern so i chose to operate so now this was the thing i i need to run these two videos so this was a 14th post update but in post update you don't have even power in your shoulders and what is that left side right side barely he is able to lift three lower limbs you can see is barely able to move two or three just like that and you can see his trunk support is also not good but next video you want billy this is how he's he's he's self-ambulant he's self-ambulant the very same patient this is operated in the government of government hospital so this is what so this is what early intervention this is what is eddy intervention so i would say that i had i gone to the other side where i don't operate a t2 signal change card contusion this person would have died so i had i i was able to prove the secondary complications yeah this is one girl who had arthritis i i guess it was uh and closing spawned like this all her uh vertigo was uh there was a degenerative changes in the spine she had a fall and she had quadriplegics so this we did the age-old technique of a bone graft you could see here because uh neurologist and neurosurgeon will appreciate this the cervical spine is straightened here in the pre-op mr the circle spine is straight there is loss of cervical lordosis it is just like a straight spine you could see two ruptured this which i have been compressing the card with water paralysis uh here if you can see carefully i have operated and kept it drained here you can see the c5 c6 and 67 interface you can see bone grafts you can see bone grafts so only with bone grafts no tightening gauge no titanium plate because that was not available at the ground hospital then so we have to use this and here after the surgery you could see the lordosis is restored you can see the spine is again having a good curvature the pre up mra there was no curvature you can see and can you show this video so here again she could walk near normal she's a little bit hesitant because the power is not that good and she has a sense that she made fun this one this one recently around eight months ago we had operated so this is one unbelievable thing where people think about miracles okay and the god effect people say god is there i am not a believer but sometimes these things will uh even i used to think yes something is there so this is an auto driver who had who had driven his newly married children okay his daughter is married in his auto he's taking them and unfortunately the otter capsized and this fella was hanging out okay with just a segment just sticking there and this fellow fortunately had good power pre-op also nobody if i show this x-ray to anyone nobody will believe that this fellow was in such a state that he could walk okay so he had a very good power around more than four plus i guess so he had very good power and this was just sticking there and he could reach me in time and the thing is this this is one thing that is demanding for a new recipe he is a poor patient he had come for a private visit ideally speaking this needs 360 degree rotation but the point that keeps in lingering in my mind is is a well-preserved patient who can walk without any so-called weakness but when i had to manipulate this uh both the facets have just been shattered and i have to manipulate reduce it intra i could cut off his card so this is one thing that worried me i didn't go for there was no time to go over an mri you cannot ship team x-ray was available and this is one latest cage where there is self-tapping cage and there is a self-tapping cage which i had used which solves the problem of 360 degree uh fixation and unimaginably this you could see he's raising his arms he'll be raising his foot also so you can play that video he's well preserved and after uh six weeks of immobilization he had removed his collar also his post obsidian is also good so you won't believe the success as a neurosurgeon for me comes see his distal hand movements see slim movements what more you can have nothing more than that so this is just a miraculous put on philadelphia color for 68 weeks so uh had something gone wrong in drop you'd be dead on the tip so it was a c2 c3 subluxation okay we can go to the slides he was an electric ventilation you could see that also because we were he had some breathing difficulty with good power there so that is a thing which i used to say you can have mixed variety of patients patients with zero by power and normal breathing patient with good power without difficult what is it a good respiratory effect so you can have all sorts of things this is another one so this is also another miraculous patient c one c to fracture subluxation you could see here again white hyperintense signal in the cut the densest fracture the atlanta axial ligament has ruptured and it is compressing the car so this i had to do it this was a upper double patient so i did a c1c2 posterior screws and the alignment is near normal so this patient is a miraculous patient the thing is he had a pre-operative power of 0 or 1 okay shoulder power was there otherwise it was nearly zero and the remaining videos are for to emphasize the importance of physiotherapy and rehabilitation physiotherapy and rehabilitation he was mentally disappointed for around uh maybe or three or four weeks then we could be in him for ventilation he didn't need a rectangular because he was not affordable and he told better to change the tube and have it so that was another constraint which we had but we could manage for two or three weeks and i fixed it can you can you play the slide is your therapy has made wonders here you can change [Music] yeah see he cannot grasp his hands his hands are tied you could see that his hands are tight he is stooping that is he has no trunk muscle power and he is being supported by his what is that his limbs are supported and his waist is also supported by two things the students are holding his hands and moving so next video please this was around uh three or four weeks post up i guess then we admitted in the rehab center now you could see see they are holding his hands he can't even hold his hands no hand grip [Music] now this is at four months he was able to move his lower lips and he is able to sit and roll by five months his uh his son is supportive like that and now he's able to stand for a few seconds and he is able to say tata so you can see the smile in his face and now this is 10 months is having good functional hand recovery you could see that so this is what i always operate i operate operate i tell the patients maybe here again 10 cases you operate only this fellow would have been lucky enough to have this so but that ten percent is thousand percent for me see he's able to hold his tumbler everything so 10 months we may not know how much he is going to improve so this is the only reason i had put on this presentation only for this video circle spine injuries were not like during my whole days or undergraduate days no you treat them you operate them you give them a chance yes so rehabilitation is a pillar of recovery proper physiotherapy does wonders this is why again i would say i admire about the brain rain has lots of plasticity if you take head injury i have seen cases where i have excised the whole left temporal lobe i have exercised the whole left temporal lobe two years later patient can talk and right okay so left temporal lobe and frontal lobe i have excised but patient after two years of training he can draw a talk he can read so opposites it takes over our are the near by adjacent side takes over so the the thing that brain once injured or god considered cannot recover is a myth so that has to be bursted rain has lots and lots of plasticity and the other important thing is motivation of family members and patients psychological support and yes financial assistance is needed so yes i think that sums up and uh yes thank you thank you again excellent excellent class from dr vignesh i think everything starting from basics to clinical knowledge to his surgical skills and his experience also has been incorporated and very very enlightened to have the basic knowledge it was i was nostalgic of my residence to be very frank and and the last videos were very excellent very glad to see recovery and i agree with your point that operating on 10 patient is worth even to have a single patient having recovery like this so it is it is a very very good approach and i am also somebody who advocates aggressive practice and i think you also have the same way of managing patients and i am really i mean thankful that you are having this sort of practice and a very good register from your site uh very uh i think most of the questions which have been asked have been covered uh i just asked one or two questions which have come up during the talk uh one of them was what is the proper actual method of placing the philadelphia column uh i'm sure it will be very difficult to demonstrate it on video like this uh so maybe any youtube tutorial or some guide or textbook yeah it's available it's available you can google it and it is readily available a little application if you type in google we have it exactly right so i agree with that it is very difficult to mention it in this sort of platform right uh second thing was uh it is one of my own questions as well uh like how um you know useful are stem cells in the long run maybe not in acute injury but once we have operated once we uh uh the patient is on the rehab course uh is there any role of a stem cell therapy in long term uh yes sir these things uh uh limited studies are available worldwide but uh study from burma can denmark and germany they say it is actually beneficial it's actually beneficial because the re-circuiting happens well with the stem cells they say so it is good but we need more evidence-based cases which compare giving stem cells the similar type of injury and the fallout of patients but yes stem cells as in other all other diseases work here so and studies positive approaches yeah and i'm sure those patients must have been handled well in their acute cases whenever they had their ex exactly working right yes so that's it and uh another thing would be yes uh do we have any markers or any method of procrusticating especially regulating bladder and bubble recovery because sometimes that is one thing which is very embarrassing and difficult to handle for patients and their family so anything else on that definitely sir definitely the thing is when the motor motor component is affected the recovery of bladder and bubble is delayed so this is one uh good criteria when water there is weakness and associated bladder power the prognosis for ground goal is also poor when the motor is at uh power is good the recovery of blood flow is better so sensory is first blood flow next more or less so when motor is preserved our motor is relatively good recovery of bladder polish and uh one thing i used to advise you want to point to we have to train the bladder just like other muscles people usually put on continuous bladder catheterization that should not be done you have intermittent concentration from day one give the signals give the afferent always to the cart or to the brain and the earth will start functioning so this is one of my personal experience which i do even for head injuries i will have intermittent catheterization from day one even if i have to measure the urinal six servers once i release so that the bladder distance and more more more so to simulate the normal physiologically so release the bladder every six hours that helps and that has better prognosis even in case of neurologic neuro neurogenic blood stream so that is one which i do every six hours intermittent catheterization right and one final question i think uh uh somebody is asked that regarding hanging so there are instances where hanging patients partial hanging or maybe complete but they do survive and they are brought to hospital in emergency so anything different do we do in a hanging patient apart from those no not much if it is subluxation yes we do operate hanging partial hanging survivors usually will have uh all these hypoxic features so that is more like uh with regarding to brain partial hanging patients having spinal cord injuries even if otherwise that will be a due to card traction or something it usually recovers if it is subluxation and he is good we operate is a general thing just like any other comp all right all right perfect i think that sums up everything and very very enlightened uh with your lecture sir uh i think we can finish uh dr nina okay i think uh i think we can close the session then uh thank you so much sir for coming up on uh netflix for this amazing talk and uh we really had uh it was a very informative talk and the fact that cervical cord injuries is not the end for someone's life we can keep on having a better quality of life for such patients that was really informative uh and dr bhumer thank you so much for coming in and moderating uh this session for us we look forward to having both of you all on our platform uh in the future thank you so much

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Dr. Bala Tamil & 1187 others

SPEAKERS

dr. Raja S Vignesh

Dr. Raja S Vignesh

Senior Consultant, Neuro-Surgeon, Nellai Institute of Medical Sciences (NIMS)

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dr. Bhumir Chauhan

Dr. Bhumir Chauhan

Consultant Neurologist

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dr. Raja S Vignesh

Dr. Raja S Vignesh

Senior Consultant, Neuro-Surgeon, Nellai Inst...

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dr. Bhumir Chauhan

Dr. Bhumir Chauhan

Consultant Neurologist

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