What are the guidelines for mobilization with a brace in spinal cord injury patients not undergoing surgery?

Guidelines for Mobilization with Brace in Spinal Cord Injury Patients Not Undergoing Surgery

Both braced and unbraced mobilization are equally effective options for neurologically intact patients with thoracolumbar burst fractures, with the decision to use external bracing being at the discretion of the treating physician. 1

Evidence-Based Recommendations for Mobilization

The 2019 Congress of Neurological Surgeons systematic review provides a Grade B recommendation regarding the management of thoracolumbar burst fractures in neurologically intact patients:

• External bracing and no brace approaches equally improve pain and disability outcomes 1
• No difference in final clinical and radiographic outcomes between patients treated with or without external bracing 1
• The decision to use an external brace should be made by the treating physician, as bracing is not associated with increased adverse events compared to no brace 1

Mobilization Considerations for Spinal Cord Injury Patients

For patients with spinal cord injury not undergoing surgery, several important considerations should guide mobilization decisions:

• Early mobilization should be initiated as soon as the patient is medically stable to reduce perioperative morbidity and length of hospital stay 2
• Spinal stability assessment is crucial before mobilization, as further vertebral collapse can occur in unstable spines 3
• Maintenance of adequate perfusion is essential during mobilization, with a recommended mean arterial pressure >85-90 mm Hg for at least 1 week post-injury 4

Bracing Considerations

When deciding whether to use bracing for mobilization:

• The evidence suggests equivalent clinical outcomes for external bracing versus no brace in neurologically intact patients with thoracolumbar burst fractures 1
• No randomized controlled trials have specifically evaluated bracing in patients with metastatic spinal cord compression, highlighting a gap in evidence for this specific population 3
• Spinal immobilization (including bracing) may potentially contribute to airway compromise, which is a major concern in trauma patients 5

Mobilization Protocol

For safe mobilization of spinal cord injury patients not undergoing surgery:

1. Ensure medical stability before initiating mobilization 2
2. Maintain spinal precautions (log-roll, flat positioning, cervical spine protection) until the spinal column has been fully evaluated by a spine surgeon 4
3. Obtain appropriate imaging (CT scan and MRI) to assess bony and ligamentous injury before mobilization 6
4. Monitor for respiratory compromise during mobilization, particularly in patients with cord lesions above T11 4
5. Implement measures to prevent pressure ulcers during both immobilization and mobilization phases 4

Common Pitfalls and Caveats

• Failure to adequately assess spinal stability before mobilization can lead to further neurological damage
• Prolonged immobilization increases risk of complications including pneumonia, deep venous thrombosis, pressure ulcers, and urinary tract infections 2
• Lack of high-quality evidence specifically addressing mobilization with bracing in non-surgical spinal cord injury patients means clinical judgment remains important
• Respiratory function must be closely monitored during mobilization, especially in patients with high cervical injuries 4

While the available evidence provides guidance primarily for thoracolumbar burst fractures in neurologically intact patients, the principles of careful assessment of stability, early mobilization when safe, and individualized decisions regarding bracing can be applied to the broader population of spinal cord injury patients not undergoing surgery.