Fundamentals of acute care for patients with traumatic spinal cord injury include initial evaluation, cervical collar clearance, diagnostic imaging, spinal injury classification systems, closed reduction of fracture-dislocation injuries, corticosteroid therapy, hemodynamic management, timing of decompressive surgery, spinal cord perfusion pressure monitoring, lumbar intrathecal cerebrospinal fluid drainage, and venous thromboembolism prophylaxis. In this review, modern management paradigms are highlighted in the context of published clinical practice guidelines from the American Association of Neurologic Surgeons/Congress of Neurologic Surgeons, AO Spine-Praxis, the American College of Surgeons Trauma Quality Programs, and the National Association of Emergency Medical Services Physicians.
Key points
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Rigid spinal motion restriction aims to prevent unstable spinal column injuries from inducing spinal cord injury (SCI) in the presence of excess spinal movement. However, the efficacy of this practice is largely unproven. Judicious use during transportation and expedient discontinuation of rigid motion restriction devices should be pursued to facilitate clinical assessment and reduce associated complications (pain, pressure wounds, respiratory compromise, unnecessary radiological testing, and agitation).
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Systemic mean arterial blood pressure (MAP) targets do not account for patient-specific differences in the local microenvironment of an injured spinal cord. Acutely elevating MAP may increase spinal cord blood flow in some regions, reducing it in others (ie, blood pressure-induced local steal). Vasopressor use in patients with impaired local spinal cord autoregulation and pathologic patterns of spinal cord blood flow may worsen secondary injury and neurologic function.
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Spinal cord perfusion pressure (SCPP) is the difference between MAP and intrathecal pressure (ITP) in a manner analogous to the relationship among cerebral perfusion pressure, MAP, and intracranial pressure. SCPP may be safely optimized by reducing ITP using a catheter to drain cerebrospinal fluid (CSF) from the lumbar subarachnoid cistern, allowing concurrent dose reduction of cardiotoxic vasopressors.
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“Early” decompressive spinal surgery within 24 hours of SCI is associated with improved American Spinal Injury Association Impairment Scale grade and sensorimotor scores at 6-month and 12-month follow-up.
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Anticoagulant thromboprophylaxis should be started within 72 hours (or as early as medically feasible) of SCI to reduce the risk of venous thromboembolism. Mechanical prophylaxis with sequential or pneumatic compression devices can be considered for use immediately post-injury, particularly in those with elevated hemorrhage risk precluding chemoprophylaxis.
| AANS | American Association of Neurologic Surgeons |
| ACS-TQP | American College of Surgeons Trauma Quality Programs |
| ASIA | American Spinal Injury Association |
| AIS | American Spinal Injury Association Impairment Scale |
| BCVI | blunt cerebrovascular injury |
| CNS | Congress of Neurological Surgeons |
| CSF | cerebrospinal fluid |
| eTVAI | extracranial traumatic vertebral artery injury |
| ISNCSCI | International Standards for Neurologic Classification of Spinal Cord Injury |
| ICP | intracranial pressure |
| ISP | intraspinal pressure |
| ITP | intrathecal pressure |
| LMWH | low molecular weight heparin |
| MAP | mean arterial blood pressure |
| MP | methylprednisolone |
| NAEMSP-ACSCT | National Association of Emergency Medical Services Physicians and the American College of Surgeons Committee on Trauma |
| NASCIS | National Spinal Cord Injury Study |
| NEXUS | National Emergency X-Radiography Utilization Study |
| RR | risk ratio |
| SCI | spinal cord injury |
| SCPP | spinal cord perfusion pressure |
| SLICS | Subaxial Injury Classification System |
| TBI | traumatic brain injury |
| TLICS | Thoracolumbar Injury Classification System |
| VTE | venous thromboembolism |
Introduction
Modern medical management of acute traumatic spinal cord injury (SCI) aims to mitigate biochemical and pathologic secondary injury processes. The use of injury-specific classification systems may facilitate a systematic approach to diagnosis and treatment-related decision making. While management controversies persist, recent publication of consensus guidelines and novel treatment strategies have driven advances in evidence-based care and improved clinical outcomes.
Acute care decision making is complex and multifaceted. The importance of multidisciplinary intensive care management is underscored by a high incidence of concomitant polytrauma (eg, traumatic brain injury [TBI] and major cardiothoracic or visceral injury). Clinicians are increasingly challenged by multi-comorbid, older patients, warranting an assessment of frailty and age-related conditions known to impact spinal stability (eg, ankylosing disorders and osteoporosis).
Here, we review fundamentals of acute care for patients with SCI in the context of recently published clinical practice guidelines from AO Spine-Praxis, the American College of Surgeons Trauma Quality Programs (ACS-TQP), and the National Association of Emergency Medical Services Physicians and the American College of Surgeons Committee on Trauma (NAEMSP-ACSCT).
Epidemiology and economic burden
The annual global incidence of acute SCI is approximately 23 cases per million. In the United States, the estimated annual incidence is 54 cases per million. While the incidence rate has remained relatively stable for decades, the global prevalence is rising. , The latter appears partly driven by an increase in low energy falls among older adults against the backdrop of a growing population and an aging demographic. , This is also reflected by an increased age at time of injury (43 vs 29 years) over the past 5 decades. SCI remains more common among males (80%). , Vehicular trauma, falls, sporting activity, and firearm-related injuries are common mechanisms.
The average duration of acute care hospitalization has declined from 30 to 19 days over the past 50 years. Despite this, national SCI-related hospitalization costs exceed 1.7 billion dollars annually, without accounting for additional costs related to rehabilitation, long-term care, lost employment, rehospitalization, chronic pain, and reduction in baseline activity level. Average direct expenses (healthcare costs and living expenses) per patient in the first-year post-injury range from $460,224 American Spinal Injury Association (ASIA) Impairment Scale (AIS) D to $1,410,163 USD (American Spinal Injury Association (ASIA) Impairment Scale (AIS) ABC [AIS ABC], high tetraplegia).
Spinal motion restriction
Long backboards are commonly used for spinal motion restriction (spinal immobilization) of the entire spine following blunt trauma. While they aim to prevent unstable spinal column injuries from inducing neurologic injuries in the presence of excess spinal movement, the efficacy of this practice is largely unproven. Judicious use during transportation and expedient discontinuation of rigid motion restriction devices should be pursued in order to facilitate assessment and reduce associated complications (eg, pain, pressure wounds, respiratory compromise, unnecessary radiological testing, and agitation). Other motion restricting modalities include vacuum splints, scoop stretchers, and ambulance cots. Maintaining in-line stabilization, maximizing trained personnel available, and minimizing the frequency of transfers may reduce the risk of displacement of an unstable spinal injury. A position statement from NAEMSP-ACSCT highlights indications for the appropriate use of spinal motion restriction ( Table 1 ).
| Motion Restriction of the Entire Spine with a Long Backboard | Spinal Precautions with Rigid Cervical Collar Application and Securing the Patient to an EMS Stretcher (No Long Backboard) |
|---|---|
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Initial evaluation
All blunt trauma patients should be evaluated according to principles of Advanced Trauma Life Support, regardless of suspicion for SCI. Mechanism of injury (eg, ground level fall in older patients), conditions placing patients at elevated risk of spinal injury (eg, TBI, osteoporosis or ankylosing disorders, and seat-belt shaped abdominal contusion), and history of prior spinal surgeries should be documented. Early signs of SCI may include bradycardia, tachypnea, diaphragmatic breathing, asymmetric limb movement or sensory deficit, loss of muscle tone, bowel or bladder dysfunction, or priapism (male patients). Careful sacral and rectal examination should assess for the retention of sacral sensation at S4-5 levels, 72 hours to 1 week following injury (strongest predictor of favorable neurologic outcome). Intact sacral pinprick portends favorable recovery of bladder function. , Patients with suspected SCI should be expeditiously transported to a site capable of delivering definitive surgical spine care.
Diagnosis and documentation
Clinical documentation of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) level and severity of SCI should be performed using the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI) tool. Accurate AIS assignment necessitates resolution of spinal shock, defined as the absence of segmental reflexes with complete loss (or suppression) of motor and sensory function below the anatomic level of injury following SCI. Resolution of spinal shock is indicated by early return of the delayed plantar and bulbocavernosus reflexes. Progressive recovery of the Babinski, ankle jerk, cremasteric, and knee jerk reflexes does not necessarily follow a caudal to rostral pattern. Clinical assessment should distinguish between complete and incomplete (sacral sparing) injuries, noting the presence of any spinal cord syndromes (eg, central cord syndrome). ACS-TQP Best Practice Guidelines recommend exercising caution in determining extent of neurologic injury in the presence of a depressed level of consciousness, burns, long bone fractures, or suspected brachial plexus injury.
Cervical collar clearance and diagnostic imaging
Rigid cervical collar application is another widely adopted spinal motion restriction technique. Similar to long backboard use, the risk of neurologic injury from an unstable cervical spine fracture or ligamentous injury should be carefully weighed against the risks associated with collar use. This is the case particularly when SCI is suspected, given an elevated risk profile that includes pressure ulcers, airway management challenges, aspiration pneumonia, deep vein thrombosis, and increased intracranial pressure (ICP).
Criterion-based tools may facilitate decision-making regarding the need for spinal imaging in awake and stable trauma patients. Examples include the Canadian C-spine Rule and National Emergency X-Radiography Utilization Study Group (NEXUS) rules ( Table 2 ). , Sensitivity of the Canadian C-spine rule approximates 100%, and it is associated with lower imaging rates compared with NEXUS. This well-validated decision rule may be used to rule out cervical spine injury and obviate the need for further imaging. If SCI is suspected, modern multidetector CT should be obtained. The sensitivity and specificity of plain radiography are insufficient as a screening test in the setting of blunt trauma. The negative predictive value of modern CT approximates 100%.
| High Risk | Action |
|---|---|
| Age ≥65 y, extremity paresthesia, dangerous mechanism b | Yes : Obtain cervical imaging No : Proceed to “Low Risk” |
| Low Risk | Action |
| Simple rear end motor vehicle collision, c ambulatory any time at scene, no neck pain at scene or during midline cervical palpation | Yes : “Proceed to Active Rotation of the Neck” No : Obtain cervical imaging |
| Active Rotation of the Neck | Action |
| Voluntary active rotation 45° to left and right regardless of pain | Yes : No cervical imaging (clear cervical collar) No : Obtain cervical imaging |
b Fall ≥ 3 ft, 0.9 m, or 5 stairs; axial load injury; high speed motor vehicle collision, rollover, ejection; bicycle or motorized recreational vehicle collision.
c Hit by bus or large truck, rollover, vehicle speed greater than 100 km/h.
Cervical collar clearance can be performed without further diagnostic imaging in alert, asymptomatic blunt trauma patients who meet established criteria and for whom SCI is not suspected ( Table 3 ). ACS-TQP Best Practices Guidelines in Imaging recommend exercising caution and more liberally imaging older patients. Cervical spine clearance algorithms (eg, NEXUS) have a lower sensitivity in older patients compared with general adult blunt trauma patients. Asymptomatic older patients with cervical spine fractures may require intervention at a rate comparable to those that are symptomatic.
| Awake and Asymptomatic | Awake and Symptomatic |
|---|---|
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| Obtunded (Unevaluable) | Elderly |
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Prolonged cervical collar use is often inappropriately utilized in obtunded patients with negative multidetector computed tomography (CT) cervical imaging. Panczykowski and colleagues analyzed 17 studies including 14,327 obtunded blunt trauma patients and reported a negative likelihood ratio for unstable cervical injury after a multidetector CT scan negative for acute injury (<0.001). In patients who are obtunded (unevaluable) or alert and asymptomatic without persistent neurologic symptoms, a negative CT alone is sufficient for collar clearance (see Table 3 ). However, MRI may be considered in the setting of persistent neurologic deficit or suspected SCI. AO Spine-Praxis 2017 guidelines regarding MRI acquisition following acute SCI for clinical decision making and outcome prediction are summarized in Table 4 .
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