What is the treatment for spinal cord hemi injuries?

Treatment of Spinal Cord Hemi Injuries

The comprehensive treatment of spinal cord hemi injuries requires a multimodal approach including early stabilization, maintenance of adequate blood pressure, prevention of complications, management of pain and spasticity, and early rehabilitation to optimize functional outcomes and quality of life.

Acute Management Phase

Initial Stabilization

• Immobilize the spine early to limit onset or aggravation of neurological deficit 1
• For cervical injuries:
  • Use manual in-line stabilization during intubation procedures
  • Remove anterior part of cervical collar during intubation to improve glottic exposure 1
  • Consider rapid sequence intubation with direct laryngoscopy and gum elastic bougie 1

Blood Pressure Management

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1
• Target mean arterial pressure (MAP) up to 70 mmHg during the first week to limit risk of worsening neurological deficit 1
• Consider continuous arterial blood pressure monitoring via arterial catheter 1

Respiratory Management

• Early assessment of respiratory function, particularly for injuries above C5 1
• Consider tracheostomy after 7 days if prolonged airway support is needed (earlier if posterior surgical approach was used) 1
• Monitor for respiratory complications, particularly in high cervical injuries where vital capacity may be reduced by >50% 1

Pain Management

Acute Pain

• Implement multimodal analgesia combining:
  • Non-opioid analgesics
  • Antihyperalgesic drugs (ketamine)
  • Opioids during surgical management 1

Neuropathic Pain

• Introduce oral gabapentinoid treatment for at least 6 months to control neuropathic pain 1
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is ineffective 1
• Monitor for side effects and adjust dosing as needed

Spasticity Management

Pharmacological Management

• Tizanidine: Shown to significantly reduce muscle tone (Ashworth score) with peak effect 1-2 hours after administration 2

  • Start with low doses (2-4 mg) and titrate up to maximum tolerated dose or 36 mg daily
  • Monitor for hypotension, particularly at higher doses 2
  • Note: Women on oral contraceptives may have 50% lower clearance of tizanidine 2

• Baclofen: Effective for flexor spasms, clonus, and muscular rigidity 3

  • Particularly useful for patients with residual function that can be restored
  • Start with low doses (5 mg TID) and gradually increase

Physical Interventions

• Stretching techniques: Should be performed for at least 20 minutes per zone 1
• Simple posture orthosis (elbow extension, flexion-torsion of metacarpophalangeal joint, opening of thumb-index commissure) 1
• Proper bed and chair positioning to correct and prevent predictable deformities 1

Prevention of Complications

Pressure Ulcer Prevention

• Early mobilization once spine is stabilized
• Visual and tactile checks of all risk areas at least once daily
• Repositioning every 2-4 hours with pressure zone checks
• Use of cushions, foam, pillows to avoid interosseous contact
• High-level prevention supports (air-loss mattress, dynamic mattress) 1

Urinary Management

• Implement intermittent urinary catheterization as soon as daily diuresis volume is adequate 1
• Remove indwelling catheter as soon as patient is medically stable 1
• Use micturition calendar to adapt frequency and schedule of intermittent catheterization 1
• This approach reduces risk of urinary tract infection, urolithiasis, and improves continence 1

Rehabilitation Phase

Early Rehabilitation

• Begin rehabilitation as soon as the patient is medically stable
• Focus on:
  • Maintaining joint amplitudes
  • Preventing and treating spasticity
  • Strengthening existing musculature 1
  • Preventing neuro-orthopedic limb complications

Advanced Rehabilitation

• Consider activity-based therapy during rehabilitation phase
• Options include:
  • Functional electrical stimulation
  • Robotic exoskeleton training
  • Suspended walking systems 1, 4

Special Considerations

Autonomic Dysreflexia

• Life-threatening complication in injuries above T6 level 5
• Recognize symptoms: sudden hypertension, bradycardia, headache, flushing above injury level
• Immediate treatment: upright positioning, removal of noxious stimuli, antihypertensives if needed

Central Pain

• Develops in many SCI patients and can be refractory to treatment 6
• Requires aggressive multimodal approach combining medications and non-pharmacological strategies
• Consider early referral to pain specialist if pain is difficult to control

Emerging Therapies

• Several neuroprotective and neuroregenerative strategies are in development:
  • Riluzole
  • Cethrin
  • Stem cell transplantation
  • Advanced functional electrical stimulation 4, 7
• These may be considered for eligible patients through clinical trials

Pitfalls and Caveats

• Avoid hypotension (SBP <110 mmHg) as it is associated with increased mortality 1
• Recognize that women taking oral contraceptives may require lower doses of tizanidine 2
• Higher doses of tizanidine (16 mg) produce larger effects but with more adverse events including hypotension 2
• Baclofen is not indicated for skeletal muscle spasm from rheumatic disorders 3
• Functional electrical stimulation orthoses have not shown efficacy for grip capacity recovery in acute phase 1