What is the management for a patient with an acute spinal cord injury if surgical intervention is not performed?

Management of Acute Spinal Cord Injury Without Surgical Intervention

For patients with acute spinal cord injury who cannot undergo surgical intervention, comprehensive medical management focusing on maintaining spinal cord perfusion, preventing secondary injury, and early rehabilitation is essential to optimize neurological outcomes and reduce mortality.

Initial Stabilization and Critical Care Management

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg and mean arterial pressure (MAP) up to 70 mmHg during the first week post-injury 1
• Consider continuous arterial blood pressure monitoring with an arterial catheter 1
• This hemodynamic management is critical to limit secondary ischemic injury to the spinal cord

Respiratory Management

• Patients with high cervical cord injuries (C4 or higher) should be intubated immediately 2
• For lower cervical injuries, evaluate intubation needs case-by-case, recognizing that respiratory mechanics are disrupted with any SCI above T11 2
• Implement a respiratory weaning bundle for patients requiring mechanical ventilation:
  • Use abdominal contention belt during spontaneous breathing periods
  • Provide active physiotherapy with mechanically-assisted insufflation/exsufflation devices
  • Administer aerosol therapy combining beta-2 mimetics and anticholinergics 1
• Consider tracheostomy within the first 7 days for upper cervical injuries (C2-C5) to accelerate ventilatory weaning 1

Immobilization and Positioning

• Maintain appropriate spinal immobilization until spine stability is confirmed
• Position patients carefully to prevent pressure ulcers and maintain joint mobility
• For tetraplegic patients, lying down is often better tolerated than sitting due to effects of gravity on abdominal contents and inspiratory capacity 1

Prevention of Secondary Complications

Deep Vein Thrombosis Prophylaxis

• Administer low-molecular-weight heparin for venous thromboembolism prophylaxis 3
• Consider IVC filters in bedbound patients with high risk of thromboembolism 2

Pressure Ulcer Prevention

• Perform visual and tactile checks of all areas at risk at least once daily 4
• Reposition patients every 2-4 hours with pressure zone checks 4
• Use pressure-relieving tools (cushions, foam, pillows) to avoid interosseous contact 4
• Employ high-level prevention supports such as air-loss mattresses or dynamic mattresses 4

Pain Management

• Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids 1
• For neuropathic pain, introduce oral gabapentinoid treatment for more than 6 months, potentially in association with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 1

Early Rehabilitation Interventions

Physical Therapy

• Begin rehabilitation as soon as the spine is stabilized 4
• Maintain joint amplitudes through stretching (at least 20 minutes per zone) to prevent musculotendinous contractions 1, 4
• Use simple posture orthoses (elbow extension, flexion-torsion of metacarpophalangeal joint) to prevent deformities 1, 4
• Implement proper bed and chair positioning to prevent predictable deformities 1, 4
• Strengthen existing musculature through appropriate physical therapy 4

Respiratory Therapy

• Provide intensive respiratory physiotherapy with bronchial drainage and mechanically assisted coughing for patients with respiratory compromise 1
• Consider abdominal contention belt to increase tolerance of spontaneous ventilation 1

Long-term Considerations

• Recognize that neurological recovery is a several-year process with most recovery occurring in the first year 2
• Implement aggressive rehabilitation programs to maximize functional outcomes 2
• Monitor for and manage bowel and bladder disorders, which are common following SCI and significantly reduce quality of life 3

Common Pitfalls and Caveats

1. Failure to maintain adequate spinal cord perfusion: Hypotension (SBP <110 mmHg) is an independent factor for mortality after SCI 1
2. Delayed respiratory management: Respiratory complications are a leading cause of morbidity and mortality
3. Inadequate pressure ulcer prevention: Prevalence can reach 26% without proper prevention 4
4. Overlooking early rehabilitation: Delay in mobilization can lead to preventable neuro-orthopedic complications
5. Undertreatment of neuropathic pain: Can significantly impact quality of life and rehabilitation participation

While early surgical decompression (within 24 hours) has been associated with improved neurological outcomes 1, proper medical management remains essential for all SCI patients, especially those who cannot undergo surgery.