What is the management for SSNI (Spinal or Spinal Nerve Injury)?

Management of Spinal or Spinal Nerve Injury (SSNI)

Early surgical decompression within 24 hours of neurological deficit onset is the cornerstone of management for spinal cord injury to improve long-term neurological recovery. 1

Initial Management

Immobilization and Transport

• Use appropriate spinal immobilization during transport to prevent secondary injury
• For cervical injuries: Apply rigid cervical collar with head-neck-chest stabilization 1
• For life-threatening emergencies: Quick extraction may be necessary with manual stabilization 1
• Transfer patients directly to specialized Level 1 trauma centers with capabilities for managing spinal cord injuries 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1
• During the first week post-injury, maintain mean arterial pressure (MAP) at 70 mmHg to limit risk of worsening neurological deficit 1
• Hypotension (SBP <110 mmHg) at hospital admission is an independent factor for mortality 1

Diagnostic Imaging

• MRI is essential for detecting medullary compression, contusion, ligament lesions, herniated discs, and epidural hematomas 1
• CT scan should be performed first to evaluate bony injury, but may miss up to 13% of epidural hematomas that are only visible on MRI 1

Surgical Management

Timing of Surgery

• Emergency surgical decompression should be performed within 24 hours of neurological deficit onset 1
• Ultra-early surgery (<8 hours) may further reduce respiratory complications and improve neurological recovery in specialized centers 1
• Delayed surgery (>24 hours) is associated with poorer neurological outcomes 1

Surgical Approach

• The choice between anterior or posterior surgical approach depends on:
  • Location of pathology
  • Number of levels involved
  • Sagittal alignment 2

Airway Management in SSNI Patients

Intubation Techniques

• In emergency conditions: Rapid-sequence induction with videolaryngoscopy is recommended 2
• In non-emergency conditions with cooperative patients: Fiberoptic intubation with spontaneous ventilation if difficult mask ventilation is anticipated 2
• Remove anterior part of rigid cervical collar during intubation attempts to minimize cervical spine movement 2
• Use a stylet or bougie as an adjunct during intubation 1

Tracheostomy Considerations

• Consider early tracheostomy (<7 days) in patients with high cervical injuries (above C5) and complete spinal cord injury (ASIA A) 1
• Early tracheostomy may reduce ICU hospitalization times and laryngeal complications 1
• If anterior cervical approach was used for surgery, wait at least 7 days before performing tracheostomy 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 more than 6 months 1
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 1

Respiratory Management

Ventilation Support

• Early extubation followed by intensive respiratory physiotherapy with bronchial drainage and mechanically assisted coughing may avoid tracheostomy in some patients 1
• Abdominal contention belt may increase tolerance of spontaneous ventilation, particularly in sitting position 1
• Supine position is often better tolerated than sitting due to effects of gravity on abdominal contents and inspiratory capacity 1

Rehabilitation

Early Interventions

• Begin rehabilitation interventions as soon as possible in the ICU 1
• Implement stretching techniques to maintain joint amplitudes (at least 20 minutes per zone) 1
• Use simple posture orthosis (elbow extension, flexion-torsion of metacarpophalangeal joint) 1
• Proper bed and chair positioning to correct and prevent predictable deformities 1

Bladder Management

• Intermittent urinary catheterization is the reference method for urine drainage in SCI patients 1
• This approach reduces long-term risk of urinary tract infection and urolithiasis 1

Common Pitfalls and Caveats

• Avoid hypotension (SBP <110 mmHg) at all costs as it significantly worsens outcomes 1
• Cervical collars may have adverse effects including increased intracranial pressure, pressure sores with prolonged use, and airway problems 2
• Penetrating or missile injuries (knife or gunshot wounds) have poor potential for neurological recovery and require different management approaches 1
• The risk of secondary spinal cord injury during airway management is approximately 0.34% 2
• Delayed transfer to specialized centers may result in patients arriving outside the critical therapeutic time window for optimal intervention 1