今日の臨床サポート

脊髄損傷

著者: 松本聡子 北海道せき損センター

著者: 須田浩太 北海道せき損センター

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2017/02/28

概要・推奨   

  1. 脊髄損傷とは「何らかの外力が脊髄に加わり、脊髄が損傷された状態である。原因の多くは、脊椎の骨折、脱臼などに合併する鈍力による損傷であり、そのほかに射創、刺創による直接損傷のものもある。
  1. 骨傷の明白でないものもあり、頚椎の過進展損傷でよくみられる。病態は「脊髄実質の出血、浮腫を基盤にした挫傷と圧迫病変で、損傷髄節以下に麻痺が出現する。損傷高位により、四肢麻痺を呈する頚髄損傷と、対麻痺を呈する胸髄、腰髄、仙髄、円錐損傷と、髄外の損傷である馬尾損傷に分けられる。」と定義される(日本脊椎脊髄病学会編:脊椎脊髄病用語事典改訂第4版)。
  1. 本人が「手や足が動かせない・しびれる」と訴え、かつ受傷機転(受傷時間・受傷形態)から脊髄にダメージが生じたと推察されるときに脊髄損傷を疑う。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松本聡子 : 特に申告事項無し[2021年]
須田浩太 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 脊髄が損傷され、運動・知覚麻痺や排尿排便障害が生じた状態を指す。完全麻痺と不全麻痺があり、後者の程度はさまざまである。
  1. 頚髄損傷では四肢麻痺、胸腰髄損傷では対麻痺となる。上位(頭側)の損傷ほど麻痺域が広く、特に第4頚髄以上では呼吸麻痺が重症化する。仙髄末端損傷では膀胱直腸障害のみを呈することがある。
  1. 脊椎損傷(脱臼・骨折)に伴うタイプが一般的だが、高度な脊髄圧迫が潜在する症例(脊柱管狭窄症や靱帯骨化症)では脊椎損傷を伴わなくても生じ、非骨傷性脊髄損傷と呼ぶ。
  1. 画像検査で脊椎配列に異常がないようにみえても、脱臼が自然整復された例も存在する。
  1. 原因は、外傷、特に交通事故・転落・転倒が多い。また転移性脊椎腫瘍が進行し脊椎の構造学的破綻を来した場合でも生じ得る。
  1. 日本の高齢化に伴い非骨傷例が増加している[1]
  1. 日本における脊髄損傷の発生頻度は年間5,000人と目されてきたが現状は不明である[1]
問診・診察のポイント  
問診:
  1. 発症時期・状況を確認する。

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文献 

著者: Abhay Varma, Elizabeth G Hill, Joyce Nicholas, Anbesaw Selassie
雑誌名: Spine (Phila Pa 1976). 2010 Apr 1;35(7):778-83. doi: 10.1097/BRS.0b013e3181ba1359.
Abstract/Text STUDY DESIGN.: Retrospective cohort study. OBJECTIVE.: To identify predictors of early mortality following traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA.: Limited information is available on factors associated with early mortality following TSCI. Ability to identify high risk individuals can help to appropriately treat them, and reduce mortality. METHODS.: Early mortality was defined as death occurring during the initial hospital admission. Retrospective analysis of 1995 patients with TSCI, admitted to various hospitals of South Carolina from 1993 to 2003, was performed. There were 251 patients with early mortality. Multivariable logistic regression was used in modeling of early death following TSCI with gender, race, age, Frankel grade, trauma center, level of injury, injury severity score (ISS), traumatic brain injury (TBI), and medical comorbidities as covariates. RESULTS.: Increasing age after 20 years (OR: 1.2, P = <0.0001), male gender (OR: 1.6, P = 0.016), severe (ISS > or =15) systemic injuries (OR: 1.9, P = 0.012), TBI (OR: 3.7, P < 0.0001), 1 or more comorbidities (P < 0.0001), poor neurologic status (P = 0.015), and level 1 trauma center (OR: 1.4, P = 0.026) were significantly associated with early mortality, after adjusting for other covariates. CONCLUSION.: Early mortality following TSCI is influenced by multiple factors. Timely recognition of these factors is crucial for improving survival in the acute care setting. Severe systemic injuries, medical comorbidities, and TBI continue to be the main limiting factors affecting the outcome. These findings also suggest the need to allocate resources for trauma prevention, and promote research towards improving the care of acutely injured patients.

PMID 20228715  Spine (Phila Pa 1976). 2010 Apr 1;35(7):778-83. doi: 10・・・
著者: F L Vale, J Burns, A B Jackson, M N Hadley
雑誌名: J Neurosurg. 1997 Aug;87(2):239-46. doi: 10.3171/jns.1997.87.2.0239.
Abstract/Text The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by using Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations. Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury. Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function. As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function. Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function. The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.

PMID 9254087  J Neurosurg. 1997 Aug;87(2):239-46. doi: 10.3171/jns.19・・・
著者: L Levi, A Wolf, H Belzberg
雑誌名: Neurosurgery. 1993 Dec;33(6):1007-16; discussion 1016-7.
Abstract/Text The cardiovascular response of the patient with acute spinal cord injury (SCI) is known to be altered secondary to the cord injury. Our current protocol of managing the acute phase of patients with SCI includes invasive hemodynamic monitoring (with arterial line and Swan-Ganz catheter) and support with fluids and dopamine and/or dobutamine, titrated to maintain a hemodynamic profile with adequate cardiac output (to be determined by oxygen consumption and delivery) and a mean blood pressure of > 90 mm Hg. We feel that this protocol provides two benefits: 1) maintaining the mean blood pressure improves the morbidity of these patients by deterring ischemia and accompanying secondary insults; 2) aggressive monitoring and hemodynamic intervention help stabilize the hemodynamic status of these patients and make it possible to consider early surgery in selected cases. Our hypothesis is that the pulmonary vascular bed is more sensitive to the sympathectomized effect of acute complete cervical SCI. We analyzed the demographic, neurologic, and hemodynamic data of 50 consecutive patients during their first week postinjury. All had signs of myelopathy; 31 (62%) were considered clinically complete. Of the 50 patients, 9 (18%) died, 20 did not improve functionally, and 21 improved. The mean heart rate (82.1 +/- 13.3), blood pressure (94.4 +/- 9.4), pulmonary artery pressure (22 +/- 5) and wedge (12.7 +/- 3.4), cardiac index (4.5 +/- 0.9), systemic vascular resistance index (SVRI) (1637 +/- 399), pulmonary vascular resistance index (PVRI) (181 +/- 80), and oxygen transport (694 +/- 156) showed good response to the treatment. Because the measurements were obtained during treatment, they differ from the expected "classic sympathectomized" response, but they provide a database for further analysis of hemodynamic manipulation in SCI. An analysis of the hemodynamic parameters did not differentiate between complete and incomplete lesions or between patients with functional improvement. We determined, on the basis of the initial hemodynamic measurements, that no patient with a clinically complete motor deficit (Frankel Grade A+B) improved of the 10 who had measurements compatible with either: 1) PVRI < 100 with SVRI < 1200; or 2) PVRI < 115 with SVRI < 1300 or PVR/SVR ratio of < 0.08 when SVRI was < 1600. These patients could not have other measurements that showed low SVRI < 1350 with PVRI > 139. At odds with this unique group, 13 of 29 patients with the same clinical picture and without the above physiological criteria of severe hemodynamic deficit eventually improved (P < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

PMID 8133985  Neurosurgery. 1993 Dec;33(6):1007-16; discussion 1016-7・・・
著者:
雑誌名: Neurosurgery. 2002 Mar;50(3 Suppl):S58-62.
Abstract/Text STANDARDS: There is insufficient evidence to support treatment standards.
GUIDELINES: There is insufficient evidence to support treatment guidelines.
OPTIONS: Hypotension (systolic blood pressure <90 mmHg) should be avoided if possible or corrected as soon as possible after acute spinal cord injury. Maintenance of mean arterial blood pressure at 85 to 90 mmHg for the first 7 days after acute spinal cord injury to improve spinal cord perfusion is recommended.

PMID 12431288  Neurosurgery. 2002 Mar;50(3 Suppl):S58-62.
著者: K G Lehmann, J G Lane, J M Piepmeier, W P Batsford
雑誌名: J Am Coll Cardiol. 1987 Jul;10(1):46-52.
Abstract/Text The frequency of cardiovascular abnormalities was evaluated in 71 consecutive patients with acute injury to the spinal cord. Persistent bradycardia was universal in all 31 patients with severe cervical cord injury and less common in milder cervical injury (6 of 17) or thoracolumbar injury (3 of 23) (p less than 0.00001). Marked sinus slowing (71 versus 12 versus 4%, respectively, p less than 0.00001), hypotension (68 versus 0 versus 0%, p less than 0.00001), supraventricular arrhythmias (19 versus 6 versus 0%, p = 0.05) and primary cardiac arrest (16 versus 0 versus 0%, p less than 0.05) were significantly more frequent in the severe cervical injury group. The frequency of bradyarrhythmias peaked on day 4 after injury and gradually declined thereafter. All observed abnormalities resolved spontaneously within 2 to 6 weeks. The primary mechanism underlying these observations appears to involve the acute autonomic imbalance created by the disruption of sympathetic pathways located in the cervical cord. Acute severe injury to the cervical spinal cord is regularly accompanied by arrhythmias and hemodynamic abnormalities not found with thoracolumbar cord trauma. These abnormalities are limited to the first 14 days after injury, a period in which life-threatening disturbances must be anticipated.

PMID 3597994  J Am Coll Cardiol. 1987 Jul;10(1):46-52.
著者: B P Gardner, J W Watt, K R Krishnan
雑誌名: Paraplegia. 1986 Aug;24(4):208-20. doi: 10.1038/sc.1986.30.
Abstract/Text The case histories of the 44 ventilated spinal cord damaged patients who have been treated at the Mersey Regional Spinal Injuries Centre prior to 1985 were reviewed. Complications of ventilation were commoner in patients whose ventilation was initiated prior to transfer to the specialised centre. Inappropriate early management before or during transfer to the spinal injuries centre led to the need for ventilation in several cases. Spinal cord damaged patients should be transferred to a specialised comprehensive centre as soon as possible after injury so that the requirement for ventilation can be minimised, the incidence of cardiac and respiratory arrest reduced, optimal methods of ventilation and weaning employed and global emotional and educational support provided from the outset for the patient and his family.

PMID 3531981  Paraplegia. 1986 Aug;24(4):208-20. doi: 10.1038/sc.1986・・・
著者: Yasuo Ito, Yoshihisa Sugimoto, Masao Tomioka, Nobuo Kai, Masato Tanaka
雑誌名: Spine (Phila Pa 1976). 2009 Sep 15;34(20):2121-4. doi: 10.1097/BRS.0b013e3181b613c7.
Abstract/Text STUDY DESIGN: Consecutive cohort study.
OBJECTIVE: To reconsider effects of the Second National Acute Spinal Cord Injury Study.
SUMMARY OF BACKGROUND DATA: High dose methylprednisolone sodium succinate (MPSS) for the patients with acute spinal cord injury has been considered standard treatment in the several countries. However, many authors have criticized the effect of MPSS because of lack of evidence about neurologic improvement and the high incidence of complications.
METHODS: During 2-year, all patients with cervical cord injury were treated with MPSS within 8 hours of their injuries based on the Second National Acute Spinal Cord Injury Study protocol (MPSS group). During the next 2-year, all patients were treated without MPSS (non-MPSS group). There were 38 patients in the MPSS group and 41 in the non-MPSS. Early spinal decompression and stabilization was performed as soon after injury in both the groups.
RESULTS: According to The American Spinal Injury Association (ASIA) motor score, there was an average improvement by 3 months postinjury of 12.4 points in the MPSS group and 13.8 points in the non-MPSS group. In patients with complete motor loss, average ASIA motor score improved 9.0 points in the MPSS group and 12.6 points in the non-MPSS group. For patients with incomplete motor loss, average ASIA motor score improvement was 14.1 and 15.5 points in the MPSS and non-MPSS groups, respectively.In the MPSS group, 19 patients developed pneumonia, 13 developed urinary tract infections, and 5 developed wound infections. Incidence of pneumonia was significantly increased with the use of MPSS medication.
CONCLUSION: We found no evidence supporting the opinion that high-dose MPSS administration facilitates neurologic improvement in patients with spinal cord injury. We believe MPSS should be used under limited circumstances because of the high incidence of pulmonary complication.

PMID 19713878  Spine (Phila Pa 1976). 2009 Sep 15;34(20):2121-4. doi: ・・・
著者: M B Bracken, M J Shepard, W F Collins, T R Holford, D S Baskin, H M Eisenberg, E Flamm, L Leo-Summers, J C Maroon, L F Marshall
雑誌名: J Neurosurg. 1992 Jan;76(1):23-31. doi: 10.3171/jns.1992.76.1.0023.
Abstract/Text The 1-year follow-up data of a multicenter randomized controlled trial of methylprednisolone (30 mg/kg bolus and 5.4 mg/kg/hr for 23 hours) or naloxone (5.4 mg/kg bolus and 4.0 mg/kg/hr for 23 hours) treatment for acute spinal cord injury are reported and compared with placebo results. In patients treated with methylprednisolone within 8 hours of injury, increased recovery of neurological function was seen at 6 weeks and at 6 months and continued to be observed 1 year after injury. For motor function, this difference was statistically significant (p = 0.030), and was found in patients with total sensory and motor loss in the emergency room (p = 0.019) and in those with some preservation of motor and sensory function (p = 0.024). Naloxone-treated patients did not show significantly greater recovery. Patients treated after 8 hours of injury recovered less motor function if receiving methylprednisolone (p = 0.08) or naloxone (p = 0.10) as compared with those given placebo. Complication and mortality rates were similar in either group of treated patients as compared with the placebo group. The authors conclude that treatment with the study dose of methylprednisolone is indicated for acute spinal cord trauma, but only if it can be started within 8 hours of injury.

PMID 1727165  J Neurosurg. 1992 Jan;76(1):23-31. doi: 10.3171/jns.199・・・
著者: M B Bracken, M J Shepard, W F Collins, T R Holford, W Young, D S Baskin, H M Eisenberg, E Flamm, L Leo-Summers, J Maroon
雑誌名: N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056/NEJM199005173222001.
Abstract/Text Studies in animals indicate that methylprednisolone and naloxone are both potentially beneficial in acute spinal-cord injury, but whether any treatment is clinically effective remains uncertain. We evaluated the efficacy and safety of methylprednisolone and naloxone in a multicenter randomized, double-blind, placebo-controlled trial in patients with acute spinal-cord injury, 95 percent of whom were treated within 14 hours of injury. Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23 hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram, followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos were given to 171 patients by bolus and infusion. Motor and sensory functions were assessed by systematic neurological examination on admission and six weeks and six months after injury. After six months the patients who were treated with methylprednisolone within eight hours of their injury had significant improvement as compared with those given placebo in motor function (neurologic change scores of 16.0 and 11.2, respectively; P = 0.03) and sensation to pinprick (change scores of 11.4 and 6.6; P = 0.02) and touch (change scores, 8.9 and 4.3; P = 0.03). Benefit from methylprednisolone was seen in patients whose injuries were initially evaluated as neurologically complete, as well as in those believed to have incomplete lesions. The patients treated with naloxone, or with methylprednisolone more than eight hours after their injury, did not differ in their neurologic outcomes from those given placebo. Mortality and major morbidity were similar in all three groups. We conclude that in patients with acute spinal-cord injury, treatment with methylprednisolone in the dose used in this study improves neurologic recovery when the medication is given in the first eight hours. We also conclude that treatment with naloxone in the dose used in this study does not improve neurologic recovery after acute spinal-cord injury.

PMID 2278545  N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056・・・
著者: Michael G Fehlings, Doron Rabin, William Sears, David W Cadotte, Bizhan Aarabi
雑誌名: Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S166-73. doi: 10.1097/BRS.0b013e3181f386f6.
Abstract/Text STUDY DESIGN: Systematic review of the literature and prospective survey study.
OBJECTIVE: To characterize expert opinion regarding the timing of surgery for decompression of the injured spinal cord and critically summarize the evidence for early surgical intervention for acute spinal cord injury (SCI).
SUMMARY OF BACKGROUND DATA: The optimal timing of decompressive surgery for acute SCI is controversial, resulting in considerable variability in clinical practice. Moreover, the current opinion of spine surgeons regarding the optimal timing of surgery after SCI is unknown.
METHODS: We undertook a systematic review of the applied preclinical and clinical published data regarding the timing of decompression following SCI. A 20-question survey was sent to orthopedic and neurosurgical spine surgeons across the world. Response frequencies were compiled for respondent demographics and preference for timing of surgical decompression in 6 distinct clinical scenarios. χ2 statistics were used to compare response frequencies based on specialty and fellowship training.
RESULTS: A total of 971 spine surgeons responded to the survey. In almost every clinical scenario, with the exception of central cord syndrome, the majority of respondents (≥ 80%) preferred to decompress the spinal cord within 24 hours. A complete cervical SCI would preferably be decompressed within 6 hours by 46.2% of respondents, but 72.9% would operate within 6 hours for an incomplete SCI in an otherwise identical clinical scenario.
CONCLUSION: The majority of spine surgeons prefer to decompress the acutely injured spinal cord within 24 hours. The majority of spine surgeons prefer to decompress the cervical spine for patients with complete or incomplete cervical SCI within 24 hours. Early decompression (within 24 hours) should be considered as part of the therapeutic management of any patient with SCI, particularly those with cervical SCI. Very early decompression (within 12 hours) should be considered for a patient with an incomplete cervical SCI (with the possible exception of central cord syndrome).

PMID 20881458  Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S166-73.・・・
著者: Michael G Fehlings, Alexander Vaccaro, Jefferson R Wilson, Anoushka Singh, David W Cadotte, James S Harrop, Bizhan Aarabi, Christopher Shaffrey, Marcel Dvorak, Charles Fisher, Paul Arnold, Eric M Massicotte, Stephen Lewis, Raja Rampersaud
雑誌名: PLoS One. 2012;7(2):e32037. doi: 10.1371/journal.pone.0032037. Epub 2012 Feb 23.
Abstract/Text BACKGROUND: There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.
METHODS: We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.
FINDINGS: A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).
CONCLUSION: Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.

PMID 22384132  PLoS One. 2012;7(2):e32037. doi: 10.1371/journal.pone.0・・・

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