From the Guidelines
The patient should undergo immediate surgical decompression within 24 hours of injury, ideally sooner if neurological deficits are progressing, despite being neurovascularly intact, as the presence of an unstable extension-distraction injury, traumatic retrolisthesis, and suspected focal disruption of the ligamentum flavum may lead to further deterioration. Given the complexity of the patient's spinal injuries, including the unstable extension-distraction injury at T11-L1 level, traumatic 6 mm retrolisthesis of L1 over T12 vertebral body, and suspected focal disruption of the ligamentum flavum at T11-T12 level, surgical intervention is crucial to prevent further injury and potential neurological decline 1. The patient's MRI findings, such as the equivocal thin ventral epidural hematoma at T11-12 and moderate to severe spinal canal stenosis at T11-T12 level, also support the need for surgical decompression to relieve pressure on the spinal cord and prevent secondary injury 1. Some key considerations in the management of this patient include:
- Immobilization to prevent further injury and transfer to a trauma center with neurosurgical capabilities
- High-dose methylprednisolone may be considered, although its use remains controversial
- Maintenance of blood pressure with a mean arterial pressure of 85-90 mmHg for the first 7 days using IV fluids and vasopressors like norepinephrine or phenylephrine if needed
- MRI is the preferred imaging modality to visualize the hematoma and spinal cord
- Surgical intervention typically involves laminectomy to evacuate the hematoma and decompress the spinal cord
- Post-operatively, patients require ICU monitoring, DVT prophylaxis with low-molecular-weight heparin, and early rehabilitation consultation. It is essential to prioritize the patient's safety and consider the risks associated with performing the MRI procedure, such as the risk of maintaining the patient in a supine position for about 30 minutes, particularly in patients with traumatic brain injury 1. However, the expected benefits of MRI may be greater than these undesirable effects, and it is crucial to weigh these risks against the potential benefits of surgical decompression in preventing further neurological decline 1.
From the Research
Management of Acute Spinal Cord Injury and Potential Epidural Hematoma
The patient's MRI findings indicate an unstable extension-distraction injury at the T11-L2 level, traumatic retrolisthesis, and suspected focal disruption of the ligamentum flavum. Given the complexity of the injury, management should focus on stabilizing the spine and preventing further neurological deterioration.
- The use of methylprednisolone, a neuroprotective medication, is controversial, as studies have shown mixed results regarding its efficacy in improving neurological outcomes 2.
- In patients with ankylosing spinal disorders, CT scans may not be sufficient to identify all spinal injuries, and MRI may be necessary to detect additional injuries, such as disco-ligamentous hyperextension injuries or intracanal pathology 3.
- Prolonged bed rest and immobilization can lead to musculoskeletal and cardiovascular complications, including loss of muscle strength and endurance, contractures, and venous thromboembolism 4, 5.
- The route of administration of methylprednisolone (oral vs. intravenous) may not significantly impact its efficacy in reducing gadolinium-enhancing lesions in patients with multiple sclerosis 6.
Considerations for Treatment
Given the patient's neurovascular intactness, management should focus on:
- Stabilizing the spine to prevent further injury
- Monitoring for signs of neurological deterioration
- Considering the use of MRI to detect additional injuries or intracanal pathology
- Implementing early mobilization and rehabilitation strategies to prevent complications associated with prolonged bed rest and immobilization
- Weighing the potential benefits and risks of methylprednisolone treatment, considering the patient's specific injury and medical history.