title: Management of acute traumatic spinal cord injury.
abstract: Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.
authors: Department of Neurosurgery, Yale University-Yale New Haven Health System, Tompkins Memorial Pavilion, 789 Howard Avenue, 4th Floor, New Haven, CT, 06519, USA, ryan.grant@yale.edu.
authors: Ryan A
authors: RA
authors: Grant
authors: Jennifer L
authors: JL
authors: Quon
authors: Khalid M
authors: KM
authors: Abbed
references: Anesth Analg. 2010 Jul;111(1):46-58
references: 20522706
references: J Neurosurg Spine. 2014 May;20(5):550-61
references: 24628130
references: Neurosurgery. 1994 Aug;35(2):240-8; discussion 248-9
references: 7969831
references: J Neurotrauma. 2010 Aug;27(8):1357-68
references: 20504158
references: J Trauma. 2008 Dec;65(6):1328-32
references: 19077622
references: Eur J Cardiothorac Surg. 2004 May;25(5):708-15
references: 15082271
references: J Neurosurg Spine. 2009 Mar;10(3):181-93
references: 19320576
references: Injury. 2002 Sep;33(7):579-82
references: 12208060
references: Arch Phys Med Rehabil. 1998 Nov;79(11):1456-66
references: 9821910
references: Spine (Phila Pa 1976). 1997 Dec 15;22(24 Suppl):25S-31S
references: 9431641
references: World Neurosurg. 2014 May-Jun;81(5-6):825-9
references: 23295632
references: Arch Phys Med Rehabil. 1994 Mar;75(3):270-5
references: 8129577
references: Neurosurgery. 2010 Apr;66(4):670-7
references: 20190669
references: Neurosurgery. 2013 Mar;72 Suppl 2:234-43
references: 23417194
references: Spinal Cord. 2000 Dec;38(12):741-7
references: 11175374
references: J Spinal Cord Med. 1996 Oct;19(4):206-14
references: 9237787
references: PLoS One. 2012;7(2):e32037
references: 22384132
references: Thorax. 1986 Dec;41(12):940-5
references: 2954256
references: Spine (Phila Pa 1976). 2001 Dec 15;26(24 Suppl):S27-30
references: 11805605
references: Am J Surg. 1995 Dec;170(6):676-9; discussion 679-80
references: 7492025
references: J Trauma. 2008 Jan;64(1):179-89
references: 18188119
references: Neurosurg Focus. 2000 Mar 15;8(3):E8
references: 16676931
references: Spinal Cord. 2014 Jan;52(1):58-60
references: 24145687
references: Paraplegia. 1986 Aug;24(4):208-20
references: 3531981
references: Neurosurgery. 2013 Mar;72 Suppl 2:54-72
references: 23417179
references: Spine (Phila Pa 1976). 1999 Oct 15;24(20):2154-61
references: 10543015
references: Spine (Phila Pa 1976). 1994 Oct 15;19(20):2281-7
references: 7846572
references: J Neurotrauma. 2011 Aug;28(8):1445-77
references: 20030559
references: Spine (Phila Pa 1976). 2001 Dec 15;26(24 Suppl):S2-12
references: 11805601
references: Neurosurgery. 2014 Aug;61 Suppl 1:36-42
references: 25032529
references: Arch Phys Med Rehabil. 2004 Nov;85(11):1740-8
references: 15520968
references: Am Rev Respir Dis. 1987 Feb;135(2):367-71
references: 3813198
references: J Neurosurg. 1991 Jul;75(1):15-26
references: 2045903
references: J Spinal Cord Med. 1995 Jul;18(3):175-82
references: 7552422
references: Neurosurgery. 2013 Mar;72 Suppl 2:84-92
references: 23417181
references: J Neurotrauma. 2009 Mar;26(3):455-67
references: 19292697
references: Arch Phys Med Rehabil. 2009 Apr;90(4):682-95
references: 19345787
references: Spine (Phila Pa 1976). 2014 May 20;39(12):971-7
references: 24583739
references: Neurosurgery. 2013 Mar;72 Suppl 2:40-53
references: 23417178
references: Global Spine J. 2011 Dec;1(1):1-8
references: 24353930
references: J Am Acad Orthop Surg. 2006 Feb;14(2):78-89
references: 16467183
references: J Spinal Cord Med. 2006;29(3):183-90
references: 16859222
references: J Trauma. 2005 Dec;59(6):1400-7; discussion 1407-9
references: 16394913
references: JAMA. 1980 Feb 8;243(6):528-31
references: 7351783
references: Spine (Phila Pa 1976). 1982 Jan-Feb;7(1):1-27
references: 7071658
references: Spine (Phila Pa 1976). 1993 Jun 15;18(8):971-6
references: 8367784