Acute traumatic spinal cord injury

INTRODUCTION

Spinal cord injury has become epidemic in modern society. Despite advances made in the understanding of the pathogenesis and improvements in early recognition and treatment, it remains a devastating event, often producing severe and permanent disability. With a peak incidence in young adults, traumatic spinal cord injury (TSCI) remains a costly problem for society; direct medical expenses accrued over the lifetime of one patient range from 500,000 to 2 million US dollars.

Traumatic spinal cord injury (TSCI) is a problem that largely affects young male adults as a consequence of motor vehicle accidents, falls, or violence.

●Most TSCI occurs with injury to the vertebral column, producing mechanical compression or distortion of the spinal cord with secondary injuries resulting from ischemic, inflammatory, and other mechanisms.

●Most TSCI is associated with injury to brain, limbs, and/or viscera, which can obscure its presentation.

●The neurologic injury produced by TSCI is classified according to the spinal cord level and the severity of neurologic deficits (table 2). Half of TSCIs involve the cervical spinal cord and produce quadriparesis or quadriplegia.

●The initial evaluation and management of patients with TSCI in the field and emergency department focuses on the ABCDs (airway, breathing, circulation, and disability), evaluating the extent of traumatic injuries, and immobilizing the potentially injured spinal column.

●Patients with suspected TSCI because of neck pain or neurologic deficits and all trauma victims with impaired alertness or potentially distracting systemic injuries require continued immobilization until imaging studies exclude an unstable spine injury.

●All patients with potential TSCI should receive complete spinal imaging with plain radiographs or helical computed tomography (CT) scan.

●Patients with abnormal screening imaging studies or in whom TSCI remains strongly suspect despite normal screening imaging studies should have follow-up CT scanning with fine cuts through the region of interest.

●Magnetic resonance imaging (MRI) can be useful to further define the extent of TSCI and should be performed on stable patients with TSCI as well as on patients suspected to have TSCI (because of neck pain or neurologic deficits) despite a normal CT scan.

●Patients with TSCI require urgent neurosurgical consultation to manage efforts at decompression and stabilization.

●There is limited evidence that glucocorticoid therapy improves neurologic outcomes in patients with acute TSCI, and such therapy is not endorsed by major society guidelines.

●Because the neurologic benefits are uncertain, we recommend not using glucocorticoid therapy in cases when there are clear risks associated with such therapy, such as penetrating injury, multisystem trauma, moderate to severe traumatic brain injury (TBI), and other comorbid conditions associated with risk of complications from glucocorticoid therapy (Grade 1B).

●In other patients who present within eight hours of isolated, nonpenetrating TSCI, administration of intravenous (IV) methylprednisolone can be considered with knowledge of potential risks and uncertain benefits. The standard dose in this setting is 30 mg/kg IV bolus, followed by an infusion of 5.4 mg/kg per hour for 23 hours. 

●Patients with acute TSCI require admission to an intensive care unit for monitoring and treatment of potential acute, life-threatening complications, including cardiovascular instability and respiratory failure. Patients with TSCI should receive prophylaxis to protect against deep venous thrombosis (DVT) and pulmonary embolism (Grade 1B).