Trauma: Spinal Cord Injury

https://doi.org/10.1016/j.suc.2017.06.008Get rights and content

Section snippets

Key points

  • Hypotension following trauma should be considered secondary to hemorrhage until proven otherwise, even in patients with early suspicion of spinal injury. Neurogenic shock and spinal shock are separate, important entities that must be understood.

  • Hypoxia and hypotension should be aggressively corrected because they lead to secondary spinal cord injury, analogous to traumatic brain injury. Critical care support of multiple organ systems is frequently required early after injury.

  • Early spinal

Assessment of spinal cord injuries

The critical step in early evaluation of patients with possible SCI is recognition of patients at risk and a focused, yet thorough neurologic examination. Too often the steps of physical examination are deferred to the all-knowing computed tomographic (CT) scanner. This delay can slow recognition of SCI and establishment of baseline function and delay consultation of appropriate specialists and the initiation of preventive measures avoiding further secondary injury. The performance of such an

Spinal shock versus neurogenic shock

The terms “spinal shock” and “neurogenic shock” are often both used inappropriately or incorrectly, or are confused for one another in the clinical setting. Neurogenic shock is the hemodynamic consequence of the SCI, classically characterized by hypotension due to vasodilation and increased perfusion of the lower extremities (also known as “warm shock”). In cases of higher SCI (cervical spine), hypotension may often be accompanied by paradoxical bradycardia. This pattern is a relatively unique

Management of acute spinal cord injury

The management of SCI begins with spine precautions (logrolling, cervical collar) and protection from further injury. Spinal immobilization precautions do not mean lying flat and motionless once the initial trauma evaluation has been completed. Reverse Trendelenburg position up to 30° will greatly benefit, and participatory pulmonary toilet should begin if they are not intubated. Ensure adequate pain control to maximize tidal volumes. Have a low threshold for nasogastric decompression because

Management of penetrating spine trauma

Penetrating SCI is most commonly secondary to gunshot wounds and typically results in complete SCI due to direct trauma to the cord and associated blast effect as well as secondary hemorrhage and ischemia.47 In civilian trauma centers, the thoracolumbar spine is the region most frequently injured. The management options for open spine trauma are not much different than those for closed spine trauma, even in patients with open vertebral column fractures. The wound must be managed with irrigation

Airway management

The need for appropriate airway management is of particular importance for patients with cervical SCIs. Most patients with high cervical SCIs will present with quadriplegia and respiratory distress or arrest and clearly require intubation. The difficult patient population is the lower cervical spine injury (C5-C7) and upper thoracic spine (T1-T6), who frequently present with no obvious respiratory distress due to the ability to continue shallow breathing. Be wary of these patients: previous

Spinal cord syndromes

Although simple complete traumatic SCI is relatively straightforward, with a dense and complete neurologic deficit below the level of injury, there are several spinal cord syndromes involving injuries to an isolated segment that have a much more varied and subtle presentation. These syndromes can be easily missed or misdiagnosed if a thorough neurologic examination and appropriate differential diagnosis are not performed. Table 3 reviews the cause, diagnosis, and management for the common

Venous thromboembolism after spinal cord injury

Venous thromboembolism (VTE) events and appropriate prophylaxis are major concerns in the acute and long-term management of SCI patients. A recent large population study of roughly 48,000 SCI patients found an approximately 2.5-fold increased risk of deep venous thrombosis (DVT) and 1.6-fold increased risk of pulmonary embolism compared with controls. The risks were greatest within the first 3 months following injury and with increasing age.61 Additional studies confirm the heightened risk in

Summary

The impact of a SCI in any trauma patient can range from a minor nuisance to devastating paralysis, and unfortunately, the full spectrum of these injuries is frequently seen after trauma. Although much of the damage is done at the time of presentation and irreversible immediately, adherence to comprehensive supportive care aimed at treating the injury and preventing secondary injury may make a significant difference in the patient’s ultimate functional outcome. Every physician should be able to

First page preview

First page preview
Click to open first page preview

References (76)

  • R.W. Teasell et al.

    Spinal cord injury rehabilitation evidence review research team. Venous thromboembolism after spinal cord injury

    Arch Phys Med Rehabil

    (2009)
  • J.S. Harrop et al.

    Guidelines for the management of patients with spinal cord injury: efficacy, safety and timing of anticoagulation prophylaxis

    Spine J

    (2016)
  • National Spinal Cord Injury Statistical Center

    Facts and figures at a glance

    (2016)
  • N.B. Jain et al.

    Traumatic spinal cord injury in the United States, 1993-2012

    JAMA

    (2015)
  • J.S. Herbert et al.

    The effect of polytrauma in persons with traumatic spine injury. A prospective database of spine fractures

    Spine (Phila Pa 1976)

    (2000)
  • E. Silva Santos et al.

    Clinical complications in patients with severe cervical spine trauma: a ten-year prospective study

    Arq Neuropsiquiatr

    (2012)
  • S.C. Kirshblum et al.

    International standards for neurological classification of spinal cord injury (revised 2011)

    J Spinal Cord Med

    (2011)
  • T.C. Ryken et al.

    Radiographic assessment

    Neurosurgery

    (2013)
  • J.F. Holmes et al.

    Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis

    J Trauma

    (2005)
  • J. Bailitz et al.

    CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison

    J Trauma

    (2009)
  • G.J. Hogan et al.

    Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?

    Radiology

    (2005)
  • J.M. Adams et al.

    Spinal clearance in the difficult trauma patient: a role or screening MRI of the spine

    Am Surg

    (2006)
  • M.B. Patel et al.

    Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

    J Trauma Acute Care Surg

    (2015)
  • A. Bozzo et al.

    The role of magnetic resonance imaging in the management of acute spinal cord injury

    J Neurotrauma

    (2011)
  • G.J. Beers et al.

    MR imaging in acute cervical spine trauma

    J Comput Assist Tomogr

    (1988)
  • J.F. Ditunno et al.

    Spinal shock revisited: a four-phase model

    Spinal Cord

    (2004)
  • F. Vale et al.

    Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management

    J Neurosurg

    (1997)
  • R. Stevens et al.

    Critical care and perioperative management in traumatic spinal cord injury

    J Neurosurg Anesthesiol

    (2003)
  • G. Hamryluk et al.

    Mean arterial blood pressure correlates with neurologic recovery after human spinal cord injury

    J Neurotrauma

    (2015)
  • T. Ryken et al.

    The acute cardiopulmonary management of patients with cervical spinal cord injuries

    Neurosurgery

    (2013)
  • M.C. Werndle et al.

    Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study

    Crit Care Med

    (2014)
  • I. Phang et al.

    Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: injured spinal cord pressure evaluation study

    J Neurosurg Spine

    (2016)
  • G.V. Varsos et al.

    Intraspinal pressure and spinal cord perfusion pressure after spinal cord injury: an observational study

    J Neurosurg Spine

    (2015)
  • M.B. Bracken et al.

    Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study

    J Neurosurg

    (1985)
  • M.B. Bracken et al.

    A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study

    N Engl J Med

    (1990)
  • M.H. Bracken et al.

    Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study

    JAMA

    (1997)
  • K. Otani et al.

    Beneficial effect of methylprednisolone sodium succinate in the treatment of acute spinal cord injury

    Sekitsui Sekizui

    (1994)
  • M.R. Prendergast et al.

    Massive steroids do not reduce the zone of injury after penetrating spinal cord injury

    J Trauma

    (1994)
  • Cited by (202)

    View all citing articles on Scopus
    View full text