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The Acute Management of Traumatic Spinal Cord Injury and Polytrauma
Summary of Key Points
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Avoiding hypotension after spinal cord injury (SCI) is a key pillar of modern SCI management.
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The concept of a complete SCI is outdated: no intervention (including surgery) should be delayed in the acute setting as a result of the clinical examination indicating a complete injury. A true complete injury is not possible to determine acutely after SCI, and thus should not be a criterion in surgical decision making.
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Surgical intervention for the purposes of spinal stabilization and/or decompression after SCI should be performed as soon as possible after injury. Currently, there is very good evidence that surgery within 24 hours (compared with later than 24 hours) is beneficial after any SCI. Surgery within an ultra-early time window (<4–12 hours) may also be more beneficial than surgery within 24 hours; however, this is an area of ongoing research.
Cervical traumatic spinal cord injury (tSCI) is a heterogeneous disease resulting from an insult to the spinal canal causing neural damage and/or spinal instability. , The morbidity and mortality of tSCI is usually proportional to the amount of neurological damage sustained. Thus, the acute management of spinal cord injury (SCI) is built around avoiding secondary injury to preserve neurological function.
In this chapter we first summarize the current best practices in the treatment of acute SCI. In particular, we focus on the time period from initial injury to the decision for surgical treatment. Although the management of acute SCI extends beyond this time range, the goal of this chapter is to facilitate rapid triaging of SCI and to clarify the decision of when to operate. Throughout, we focus on areas of controversy and current research for tSCI management, including (1) the timing of surgery after tSCI, (2) the applicability of scoring systems for surgical decision making, and (3) the development of diagnostic examinations.
We also describe the challenges of triaging patients with tSCI in the setting of polytrauma. Polytrauma complicates almost every phase of SCI management, from diagnosis and triage to postoperative care. Most importantly, polytrauma creates competing management strategies between the spine and the rest of the body, and requires that the treating spine surgeon work closely with the critical care and trauma surgical team to optimize management in these complex cases.
Overview of Acute Management of Spinal Cord Injury
The management of acute tSCI has evolved on several fronts over the past 20 to 30 years. However, one landmark publication was the “Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries.” This multiissue volume detailed all aspects of tSCI care and carefully documented the level of evidence associated with each recommendation. , As a result, the field had a complete, exhaustive source of expert consensus regarding SCI management. Here, we focus on how these guidelines have created a standard of care regarding the triage and surgical management of tSCI, and provide updated trends concerning ongoing controversies regarding these topics.
Prehospital Care
The first opportunity to intervene in the clinical course of SCI is in the field, immediately after the injury. At this point, the patient has to be both mechanically and medically stabilized, and the emergency treating services need to decide how to transport the patient to a trauma center and which trauma center to transport them to. Currently, the accepted guidelines for prehospital management are based on spinal immobilization. In particular, the best practice is to place all patients with a concerning mechanism of injury or possible neurological injury in a rigid cervical collar (with supportive lateral cervical bocks) and strap them into a hard backboard. These guidelines stem from data showing that worsening of spinal injuries is possible in the absence of maximal rigid fixation. ,
However, the spine surgeon should be aware of the risks of rigid fixation. Placing patients on a hard backboard increases the risk of pressure ulcers, especially in the setting of SCI. Several recent studies have noted that the increased use of hard backboards has resulted in pressure ulcers and increased subsequent infections in SCI patients. In addition, once a patient is in a hard backboard, the patient has a higher rate of receiving computed tomography (CT) scans, and the radiation exposure in a backboard is increased. In cases where the patient is found down with no obvious signs of trauma but has a prolonged course of altered mental status, the cervical collar and “log roll” precautions can persist for days or even weeks. The spine surgeon should not only be aware of the reasons for rigid fixation, but should also be prepared to accept the responsibility for removing such fixation once it is no longer indicated.
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