Spinal Yaralanmalarda Acil Müdahale ve Spinal Şok
Özet
Travmatik omurilik yaralanmaları, yüksek mortalite ve morbidite oranları nedeniyle ciddi bir halk sağlığı sorunudur; Türkiye'de insidansı milyon başına yıllık 12,7 olarak saptanmış olup en sık 20-40 yaş arası erkeklerde, trafik kazaları ve yüksekten düşme sonucu görülür. Tedavi olay yerinde boyunluk ve travma tahtasıyla stabilizasyon sağlanarak başlar. İlk müdahalede havayolu, solunum ve dolaşım değerlendirilmeli, nörolojik durum takibi için küresel olarak kabul görmüş ASIA formu eksiksiz doldurulmalıdır. Vasküler sempatik tonus kaybıyla karakterize nörojenik şok ile hasar seviyesinin altında gevşek paraliziye yol açan spinal şok tablosu birbirinden ayırt edilmeli; ortalama arteriyel basınç 80-90 mmHg arasında tutulmalıdır. Spinal yaralanmanın dışlanmasında NEXUS kriterleri kullanılırken, cerrahi kararında subaksiyel servikal yaralanmalar için SLICS, torakolomber yaralanmalar için ise TLICS skorlama sistemlerinden yararlanılır. Bilgisayarlı tomografi acil görüntülemede öncelikliyken, paravertebral dokular için MRG kullanılır. Güncel kılavuzlarda enfeksiyon riski ve yetersiz kanıt nedeniyle steroid kullanımı artık önerilmemektedir. Reflekslerin geri dönmesiyle, özellikle ilk beliren bulbokavernöz refleks ile spinal şokun bitişi ve yaralanmanın komplet veya inkomplet ayrımı netleşerek prognoz öngörülebilir hale gelir.
Traumatic spinal cord injuries represent a severe public health issue due to high mortality and morbidity rates; their annual incidence in Turkey was determined as 12.7 per million, occurring most frequently in males aged 20-40 primarily resulting from traffic accidents and falls from height. Treatment initiates at the scene with stabilization using a cervical collar and a trauma board. In the initial approach, airway, respiration, and circulation must be evaluated, and the globally accepted ASIA form should be thoroughly completed for neurological monitoring. Neurogenic shock, characterized by the loss of vascular sympathetic tone, must be differentiated from spinal shock, which causes flaccid paralysis below the injury level; mean arterial pressure should be maintained between 80-90 mmHg. While NEXUS criteria are utilized to exclude spinal injury, SLICS and TLICS scoring systems are leveraged for surgical decision-making in subaxial cervical and thoracolumbar injuries, respectively. Computed tomography is prioritized in emergency imaging, whereas MRI is used for paravertebral tissues. Recent guidelines no longer recommend steroid administration due to adverse effects like infection risks and insufficient evidence of benefit. With the return of reflexes, particularly the bulbocavernosus reflex which returns first, the termination of spinal shock and the differentiation between complete and incomplete injury become distinct, rendering the prognosis predictable.
Referanslar
Wyndaele M, Wyndaele JJ. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord. 2006;44(9): 523–529. doi:10.1038/sj.sc.3101893.
Karacan İ, Koyuncu H, Pekel Ö, et al. Traumatic spinal cord injuries in Turkey: A nation-wide epidemiological study. Spinal Cord. 2000;38(11): 697- 701. doi: 10.1038/sj.sc.3101064.
Ning GZ, Wu Q, Li YL, et al. Epidemiology of traumatic spinal cord injury in Asia: a systematic review. The Journal of Spinal Cord Medicine. 2012;35(4): 229-239. doi: 10.1179/2045772312Y.0000000021.
Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury (revised 2011). The Journal of Spinal Cord Medicine. 2011;34(6): 535-546. doi: 10.1179/204577211X13207446293695.
Hadley MN, Walters BC, Aarabi B, et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery 2013;72(Suppl 2): 40-53. doi: 10.1227/NEU.0b013e318276edda.
Ploumis A, Yadlapalli N, Fehlings MG, et al. A systematic review of the evidence supporting a role for vasopressor support in acute SCI. Spinal Cord. 2010;48(5): 356–362. doi: 10.1038/sc.2009.150.
Ryken TC, Hurlbert RJ, Hadley MN, et al. The acute cardiopulmonary management of patients with cervical spinal cord injuries. Neurosurgery. 2013;72(suppl 2): 84-92. doi: 10.1227/NEU.0b013e318276ee16.
Stiell IG, Clement CL, McKnihgt RD, et al. The Canadian Cspine rule verses the NEXUS low-risk criteria in patients with trauma. New England Journal of Medicine. 2003;349(26): 2510-2518. doi: 10.1056/NEJMoa031375.
Ditunno JF, Little JW, Tessler A, et al. Spinal shock revisited: a four-phase model. Spinal Cord. 2004;42(7): 383-395. doi: 10.1038/sj.sc.3101603.
American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised edition. Atlanta, GA: American Spinal Injury Association; 2013.
Antevil JL, Sise MJ, Sack DI, et al. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? The Journal of Trauma. 2006;61(2): 382-387. doi: 10.1097/01.ta.0000226154.38852.e6.
Wilson JR, Cadotte DW, Fehlings MG. Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. Journal of Neurosurgery Spine. 2012;17(1 Suppl): 11-26. doi: 10.3171/2012.4.AOSPINE1245.
Fehlings MG, Wilson JR, Cho N. Methylprednisolone for the treatment of acute spinal cord injury: counterpoint. Neurosurgery. 2014;61 Suppl 1:36-42. doi: 10.1227/NEU.0000000000000412.
Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013;72(suppl 2): 93–105.
Patel AA, Dailey A, Brodke DS, Daubs M, Anderson PA, et al. Spinal Trauma Study Group. Subaxial cervical spine trauma classification system and case examples. Neurosurg Focus 2008; 25: E8.
Joaquim AF, Daubs MD, Lawrence BD, Brodke DS, Cendes F, Tedeschi H, Patel AA. Retrospective evaluation of the validity of the Thoracolumbar Injury Classification System in 458 consecutively treated patients. Spine J 2013; 13(12): 1760-1765.
Gündüz B, Erhan B. Updates in ASIA Evaluation: Lower Extremity Motor Evaluation [Omurilik Yaralanması Nörolojik Sınıflaması için Uluslararası Standartlar Değerlendirme Formunun Güncellenmesi]. Turk J Phys Med Rehab 2015;61(1):19–24. Crossref
