Acute treatment of traumatic spinal cord injuries

Essentials

  • Whenever there is a high-energy accident or head injury, the possibility of spinal cord injury should be considered.
  • In low-energy injuries, as well, the possibility of spinal cord injury should be kept in mind particularly if the patient shows pain in the spinal area, muscle weakness or paraesthesia.
  • More than half of all traumatic spinal cord injuries are due to falling from standing or from a height. Other common causes are traffic (particularly car and bicycle) accidents and sports injuries.
  • Acute treatment of patients with traumatic spinal cord injury should be carried out in a hospital with adequate expertise (tertiary level hospital).

Initial treatment

  • An unconscious patient with a high-energy injury must be handled as a patient with spinal cord injury (Prehospital emergency care).
  • The whole spine should be supported by either a vacuum mattress and cervical collar or a spinal board, cervical collar and head supports.
  • If the patient is unconscious, the airway patency, oxygenation and ventilation must be ensured (Airway management in an emergency).
    • In a patient with cervical spine injury, the airway must be secured without manipulating the spine or compromising its support.
    • Of the various methods of securing the airway, choose the one you are most confident with.
  • In the case of high-level spinal cord injury, hypotension may be due to bleeding from any associated injury but also to functional sympathectomy due to injury to the autonomic nervous system, which should be treated with vasopressors (such as noradrenaline). The target mean arterial pressure is > 85 mmHg.
  • A risk of bradyarrhythmia associated with injury to the sympathetic nervous system should be taken into consideration.
  • During transportation, the following should be considered:
    • need for urinary catheterisation
    • prevention of pressure sores.
  • Patients should be taken directly to a tertiary level hospital if this is appropriate and medically justified.

Diagnostic work-up

  • Spinal computerized tomography (CT) is one of the initial investigations in patients suspected of having a spinal cord injury.
  • In all patients with spinal cord injury, the possibility of brain injury should be assessed at the acute stage. Cranial CT should also be performed at the initial stage if brain injury is suspected.
  • The spinal cord should be assessed by magnetic resonance imaging (MRI), which can provide findings such as spinal cord swelling or bleeding in the acute phase. Additionally, MRI will provide information on soft tissues outside the spinal cord, such as ligaments and intervertebral discs.
  • The level and extent of spinal cord injury can be defined clinically using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI, https://asia-spinalinjury.org/international-standards-neurological-classif...). The classification is based on examining muscle strength and sensory functions. It can only be used for conscious and cooperative patients.
  • In the acute phase, recovery from spinal cord injury can be roughly predicted based on ISNCSCI and MRI.
  • In patients with cervical spine injury, angiography may reveal traumatic vertebral artery dissection; the risk of such dissection is increased particularly in patients with subluxation or fracture of the upper cervical spine involving the transverse foramen.

Treatment in the acute phase

  • In the acute phase, treatment aims at maintaining vital functions, preventing the progression of neurological damage and prevention of complications.
  • The choice of the place for further treatment (e.g. intensive care unit, surgical ward) after initial treatment depends on the level and extent of injury and on the patient’s clinical condition.
  • The aim of any spinal surgery is to restore the form of the vertebral canal, to release any compression of the spinal cord and to stabilize the spine to prevent further spinal cord injury and to facilitate early mobilization. Immediate surgery has been found to reduce complications and to shorten the period of hospital treatment.
  • Adequate ventilation should be ensured to avoid hypoxaemia and hypercapnia.
  • Hypotension should be avoided to ensure sufficient circulation in the spinal cord.
    • In the case of high spinal cord injury, a mean arterial pressure (MAP) of > 85 mmHg should be ensured for the first week after injury using vasopressor support, as necessary.
  • Prevention of complications and associated injuries should be started immediately after initial treatment.
    • Initial treatment of venous thromboembolism and pulmonary embolism with low molecular weight heparin should be begun as soon as this is considered safe considering the risk of bleeding (Prevention of venous thromboembolism). Use of various types of venous pumps is recommended in cases where pharmacological thromboprophylaxis is contraindicated.
    • Use of a high risk zero-pressure mattress and frequent changes of position are very important to prevent pressure sores (Prevention and treatment of pressure ulcers).
    • At the acute stage of treating early-stage spinal cord injuries, the possibility of the following associated problems, in particular, should be kept in mind:
      • breathing problems
      • hypotension
      • autonomic dysreflexia
      • bradycardia
      • swallowing problems, risk of aspiration
      • condition of the skin, risk of pressure sores
      • bladder dysfunction
      • bowel dysfunction
      • neuropathic pain
      • spasticity
      • mood, need for crisis therapy
      • possibility of brain injury.

References

1. Bagnall AM, Jones L, Richardson G, Duffy S, Riemsma R. Effectiveness and cost-effectiveness of acute hospital-based spinal cord injuries services: systematic review. Health Technol Assess 2003;7(19):iii, 1-92.  [PMID:13678550]

2. Kirshblum SC, Burns SP, Biering-Sorensen F et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 2011;34(6):535-46.  [PMID:22330108]


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