How does management differ for non-spinal cord injuries versus spinal cord injuries?

Management Differences Between Spinal Cord Injuries and Non-Spinal Cord Injuries

The key difference in management between spinal cord injuries (SCI) and non-spinal cord injuries is that SCI requires specialized protocols for respiratory support, hemodynamic management, and long-term rehabilitation due to neurological deficits, while non-SCI management focuses primarily on the specific injured structures without these neurological considerations.

Airway Management

Spinal Cord Injury:

• Intubation approach:

  • Emergency: Rapid-sequence induction with videolaryngoscopy is recommended 1
  • Non-emergency: Fiberoptic intubation with spontaneous ventilation if difficult mask ventilation anticipated 1
  • Videolaryngoscopy reduces cervical spine movements compared to direct laryngoscopy 2
  • Remove anterior part of rigid cervical collar during intubation to minimize cervical spine movement 1

• Special considerations:

  • High cervical cord injury (C4 or higher) requires immediate intubation 3
  • Succinylcholine can be used within first 48 hours post-injury but is contraindicated after this period due to risk of hyperkalemia 2
  • Early tracheostomy (within 7 days) recommended for upper level SCI (C2-C5) 2
  • For lower cervical SCI (C6-C7), tracheostomy only after extubation failures 2

Non-Spinal Cord Injury:

• Standard airway management protocols without special spine precautions
• No restrictions on muscle relaxant use
• Tracheostomy decisions based on standard ICU criteria

Hemodynamic Management

Spinal Cord Injury:

• Blood pressure targets:

  • Maintain systolic BP >110 mmHg before injury assessment 2
  • Maintain mean arterial pressure (MAP) up to 70 mmHg during first week post-injury 2
  • Some guidelines recommend MAP >85 mmHg for first 5-7 days to improve neurological outcomes 3

• Rationale: Preventing secondary cord ischemia by maintaining adequate spinal cord perfusion pressure

Non-Spinal Cord Injury:

• Standard hemodynamic targets based on trauma protocols
• No specific MAP targets for neurological protection

Respiratory Management

Spinal Cord Injury:

• Ventilatory weaning protocol:

  • Abdominal contention belt during spontaneous breathing 2
  • Active physiotherapy with mechanically-assisted insufflation/exsufflation device 2
  • Aerosol therapy combining beta-2 mimetics and anticholinergics 2
  • Lying position often better tolerated than sitting in tetraplegic patients 2

• Risk factors for ventilatory weaning failure:

  • Upper level SCI (above C5) 2
  • Complete SCI (ASIA Impairment Scale A) 2

Non-Spinal Cord Injury:

• Standard ventilatory weaning protocols
• No special considerations for positioning or respiratory muscle support

Pain Management

Spinal Cord Injury:

• Acute phase:

  • Multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine) and opioids 2

• Chronic neuropathic pain:

  • Oral gabapentinoids for >6 months 2
  • Add tricyclic antidepressants or serotonin reuptake inhibitors if monotherapy ineffective 2

Non-Spinal Cord Injury:

• Standard pain management protocols
• Less focus on neuropathic pain treatments

Rehabilitation

Spinal Cord Injury:

• Early ICU rehabilitation:

  • Maintain joint amplitudes and prevent contractures 2
  • Stretching for at least 20 minutes per zone 2
  • Simple posture orthosis and proper positioning 2
  • Daily ASIA classification assessment, with first prognostic score at 72h post-injury 3

• Long-term considerations:

  • Most recovery occurs in first 9-12 months, with plateau by 12-18 months 4
  • Complete SCI: 10-20% convert to incomplete during first year 4
  • Incomplete SCI: 20-75% recover some walking capacity by 1 year 4

Non-Spinal Cord Injury:

• Rehabilitation focused on specific injured structures
• Typically shorter rehabilitation periods
• Better functional recovery prognosis

Bladder Management

Spinal Cord Injury:

• Intermittent urinary catheterization is the reference method 2
• Associated with reduced risk of urinary tract infection and urolithiasis 2
• Remove indwelling catheter as soon as patient is medically stable 2
• Implement micturition calendar to adapt frequency of catheterization 2

Non-Spinal Cord Injury:

• Standard bladder management without neurogenic considerations
• Earlier return to normal voiding patterns

Complications Prevention

Spinal Cord Injury:

• Pressure ulcer prevention:

  • Early mobilization once spine is stabilized 2
  • Visual and tactile checks of risk areas daily 2
  • Repositioning every 2-4 hours 2

• Thromboembolism prevention:

  • IVC filters recommended for bedbound patients 3
  • Low-molecular weight heparins preferred over unfractionated heparin 3

Non-Spinal Cord Injury:

• Standard DVT prophylaxis protocols
• Lower risk of pressure ulcers due to preserved sensation and mobility

Imaging and Assessment

Spinal Cord Injury:

• CT scan superior to plain films for fracture detection 3
• MRI indicated to assess neural elements, soft tissues, and ligaments 3
• MRI should be obtained within 48-72h from injury 3
• Daily ASIA classification assessment 3

Non-Spinal Cord Injury:

• Imaging focused on specific injured structures
• No need for neurological classification scales

Surgical Considerations

Spinal Cord Injury:

• Emergency decompression within 24 hours of neurological deficit onset 1
• Ultra-early surgery (within 8 hours) may improve outcomes 1
• Surgical approach (anterior vs posterior) depends on pathology location, number of levels, and sagittal alignment 1

Non-Spinal Cord Injury:

• Surgical decisions based on structural stability rather than neurological considerations
• Less time-sensitive surgical interventions