Der spinale neurologische Notfall - Uniklinik Balgrist · Der spinale neurologische Notfall Prof....
Transcript of Der spinale neurologische Notfall - Uniklinik Balgrist · Der spinale neurologische Notfall Prof....
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Der spinale neurologische Notfall
Prof. Dr. A. Curt, FRCPC
Spinal cord emergency
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Spinal cord emergencies
• traumatic
• non - traumatic
– primary (myelitis, syringomyelia, intramedullary tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital
– (meningo-myelocele, diastematomyelia, tethered cord..)
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Spinal cord disorders:„the neurological examination is key!“
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Spinal cord emergencies
• traumatic
• non - traumatic
– primary (myelitis, syringomyelia, intramedullary tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital
– (meningo-myelocele, diastematomyelia, tethered cord..)
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Sport injuries
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Traffic accidents
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Emergency management
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Rettungs-Bergungskette medizinische Akutversorgung
ASIA Protokolin-/komplett
funktionelle AusfälleLäsionshöhe
neurologischesDefizit
klin. Untersuchungen
RöntgenCTMRI
Wirbelsäulen-verletzung
Bildgebung
RückenmarkConus/Cauda
periphere Nerven
neurogeneLäsionen
Neurologie
PolytraumaIntensivmedizin
Akute Komplikationen
ZusatzverletzungenBegleiterkrankungen
labortechn. Untersuchungen
Anamneseklinische Untersuchung
zeitlicher Verlauf
traumatischeQuerschnittlähmung
Diagnostische Abklärung einer akuten traumatischen Querschnittslähmung, Leitlinien DGN 2010
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� Time is spine(early treatment)
� Decompression surgery
� Stabilization
� Cardiovascular management (ICU guidelines)
� Controlled mobilization
� MethylprednisoloneNo evidence!
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Spinal cord emergencies
• traumatic
• non - traumatic
– primary (myelitis, syringomyelia, intramedullary tumors..)
– secondary (spinal metastases, intraspinal hemorrhageand abscess, spinal canal stenosis..)
• congenital
– (meningo-myelocele, diastematomyelia, tethered cord..)
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Red flags
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Anamnese
Zeitlicher Verlauf
Untersuchungsbefund
Bildgebung (MRT, CT, Myelographie)
Rückenmark-Kompression?
Tumor intra-/extramedullär
Spondylitis,-diszitis, Abszeß
WS-degenerative Ursachen
Blutung intra-/extramedullär
Liquor: Pleozytose; IgG-Index, OKB
MRT: KM-Anreicherung
JA
NEIN
JA
Myelitis transversa
Infektiöse/parainf.
Myelitis
Multiple SkleroseADEM
Neuromyelitis optica SystemischeAutoimmunerkrankung
Spinale Ischämie
AVM
Superfizielle Siderose
Strahlenmyelopathie
Metabolisch/toxisch
psychogen
NEIN
Ggf. Staging-Diagnostik (CT,
MRT, Szintigraphie, PET)
Direkter
Erregernachweis,
spez. AK, PCR
cMRT, VEP, AP-4,AK Antikörper Serologie
Organbeteiligung
(Bildgebung, Biopsie)
CSF, cMRT,
evozierte
Potentiale
MRT (DWI, FLAIR, SWI),
selektive spinale
Angiographie
Serum: Cobalamin,
Folsäure, Vit B12 u 6,
Methylmalonsäure,
Kupfer, Coeruloplasmin
Diagnostische Abklärung nicht-traumatischen Querschnittlähmung
DGN Guidelines 2010
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Degenerative spinal canal stenosisSpinal canal encroachments and instability
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Red flags
Distribution of pain:
• bilateral pain
• clumsy hands/feet
• altered temp sen.
• girdle/belt like
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Segmental Sensory Assessment
Large Diameter(tactile)
Small Diameter (temperature, pain)
Contact Heat Evoked Potentials CHEPS
Somato-sensory Evoked Potentials SSEPS
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Segmental Sensory Assessment
Contact Heat Evoked Potentials CHEPS
Somato-sensory Evoked Potentials SSEPS
Large Diameter(tactile)
Small Diameter (temperature, pain)
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Kramer J, et al.. D-SSEP and EPT for the assessment of posterior cord function in SCI. J Neurotrauma 2008
Segmental Sensory Assessment
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Snake – eyemyelopathy
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Snake – eyemyelopathy
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C6
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police officer, ♂ 51 yrsthermal hypaesthesia
Ulnar SSEP
Tibial SSEP
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Red flags
Walking signs:
• unsteadiness
• fatigue
• weakness(limb or bilateral)
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Calcified disc herniation T10/11Back pain, left leg painBladder - bowel normalUnlimited walkingMale 53 years
Calcified disc herniation T7/8Lower back painDysesthesia left legLower limb reflexes increasedFemale 36 years
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dCHEP dSSEPSpinalis AnteriorSyndrome
Patient with complete paralysis due to spinalis anterior syndrome with loss of thermal and pain sensation below T7 but preserved light touch where accordingly dSSEP remained normal but dCHEP were abolished below the level of lesion.
C7
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Intraspinal – epidural haemorrhage
Post Op
Acute, non traumatic epidural haemorrhage
male, 31 years,physiotherapist, paraplegia T3 AIS B,became paralyzed within 60 min
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Intraspinal – epidural haemorrhage
Although patient received decompression surgery within 6 hours after onset of symptoms he suffers from established (chronic) paraplegia (AIS-B)
T3
T3
Spinal cord damage as a sequel of spinal cord compression due to
epidural haemorrhage
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Intraspinal – epidural haemorrhage
Post ORPre OR
Sub-acute onsetMale 63 yrs, marcumar therapyAIS-C, able to stand and walk indoors
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Red flags
Bladder signs:
• frequency
• voiding
• incontinence
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Arterio-venous malformation of spinal cord
Lower limb fatigue and bladder urgency!
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Meningeoma of thoracic cord
Lower limb pain and bladder urgency!
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Spinal metastases
constant & increasing
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Take home message: Red flags
Walking signs:
• unsteadiness
• fatigue
• weakness(limb or bilateral)
Bladder signs:
• frequency
• voiding
• incontinenceLecture can be found on:www.balgrist/Zentrum für Paraplegie
Distribution of pain:
• bilateral pain
• clumsy hands/feet
• altered temp sen.
• girdle/belt like
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…the spinal cord works not wireless yet, but we have ways toassess it….
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Supplement
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The examination
of motor function
is key!!
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Thank you for your attention!