What are the primary goals and treatment plans for managing spinal cord injuries?

Management of Spinal Cord Injury: Primary Goals and Treatment Plans

The primary goals for managing spinal cord injuries include early immobilization to prevent neurological deterioration, optimization of hemodynamic parameters, prevention of secondary complications, management of pain, and early rehabilitation to maximize functional recovery. 1

Initial Management and Stabilization

• Early immobilization of the spine is recommended for any traumatized patient with suspected spinal cord injury to limit the onset or aggravation of neurological deficit 1
• For patients with cervical spinal cord injury, manual in-line stabilization combined with removal of the anterior part of the cervical collar during intubation procedures is suggested to limit mobilization of the cervical spine while promoting glottic exposure 1
• Pre-hospital tracheal intubation should follow a procedure integrating rapid induction with direct laryngoscopy, use of a gum elastic bougie, and retention of the cervical spine in the axis without Sellick maneuver to increase first-attempt success rate 1

Hemodynamic Management

• Maintaining adequate spinal cord perfusion is critical to prevent secondary injury and promote neurological recovery 1
• Target mean arterial pressure (MAP) goals should be maintained to ensure adequate spinal cord perfusion 1
• Fluid resuscitation and vasopressors may be necessary to achieve hemodynamic stability 1

Respiratory Management

• Early identification and management of respiratory complications is essential, particularly in high cervical injuries (above C5) 1
• Tracheostomy may be considered when prolonged airway support is anticipated, particularly when residual vital capacity is significantly decreased 1
• Early tracheostomy (< 7 days) may reduce ICU hospitalization times and the incidence of laryngeal complications due to prolonged intubation 1

Pain Management

• Multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids is recommended during surgical management to prevent prolonged pain 1
• Oral gabapentinoid treatment for more than 6 months is recommended to control neuropathic pain in SCI patients, with the addition of tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 1
• Pregabalin is FDA-approved for management of neuropathic pain associated with spinal cord injury at doses of 150-600 mg/day 2

Prevention of Secondary Complications

Pressure Ulcer Prevention

• From the acute phase, implement the following measures to prevent pressure ulcers 1:
  • Early mobilization once the spine is stabilized
  • Visual and tactile checks of all areas at risk at least once a day
  • Repositioning every 2-4 hours with pressure zone checks
  • Use of tools for discharge (cushions, foam, pillows) to avoid interosseous contact
  • Use of high-level prevention supports (air-loss mattress, dynamic mattress)

Urological Management

• Intermittent urinary catheterization is recommended as soon as the volume of daily diuresis is adequate to reduce urological complications (urinary tract infection, urolithiasis) 1
• Self-intermittent urethral catheterization is recommended by national and international neuro-urology societies 1
• Indwelling catheters should be removed as soon as the patient is medically stable to minimize urological risks 1

Rehabilitation Strategies

• Early rehabilitation should begin immediately after SCI to maximize neurological recovery 1
• Physical exercise plays a major role in enhancing regeneration of the CNS through the elaboration of neurotrophic factors 1
• Stretching techniques should be performed for at least 20 minutes per zone and completed by simple posture orthosis and proper bed and chair positioning 1
• Gravity-assisted ambulation or body weight support with treadmill training can improve walking after SCI, especially in patients with incomplete injuries 1

Pharmacological Interventions

• Pregabalin is indicated for management of neuropathic pain associated with spinal cord injury 2
  • Recommended dose range: 150-600 mg/day
  • Starting dose: 75 mg twice daily (150 mg/day)
  • May increase to 150 mg twice daily (300 mg/day) within 1 week based on efficacy and tolerability 2
  • Patients who don't experience sufficient pain relief after 2-3 weeks at 300 mg/day may be treated with up to 600 mg/day if tolerated 2

Emerging Treatments

• Recent research has focused on neuroprotective and neuroregenerative approaches 3
• Promising experimental treatments include:
  • Combined use of tetrahedral framework nucleic acid with neural stem cells 3
  • Fortasyn Connect supplementation 3
• These treatments have shown potential for attenuating secondary injury processes and promoting functional recovery in pre-clinical studies 3

Common Pitfalls to Avoid

• Delaying immobilization in suspected SCI cases can lead to worsening neurological outcomes 1
• Inadequate pain management can lead to chronic pain syndromes that are difficult to treat 1
• Neglecting early rehabilitation can result in preventable complications and poorer functional outcomes 1
• Failing to implement pressure ulcer prevention strategies can lead to significant morbidity, as the prevalence of pressure ulcers can reach 26% in SCI patients 1