What is the management plan for a patient with an axial load injury to the skull presenting with signs of high spinal cord injury and quadriplegia?

Management of Axial Load Skull Injury with High Cord Injury and Quadriplegia

Immediately immobilize the spine with manual in-line stabilization and a rigid cervical collar, secure the airway using rapid sequence intubation with direct laryngoscopy while maintaining cervical spine alignment, and transfer urgently to a specialized spinal cord injury center for definitive management. 1, 2

Immediate Prehospital Stabilization

Spinal Immobilization

• Early spinal immobilization is critical to prevent onset or worsening of neurological deficit in any patient with suspected spinal cord injury 1, 2
• Apply manual in-line stabilization (MILS) immediately, combined with a rigid cervical collar 1
• Remove only the anterior portion of the cervical collar during intubation procedures to limit cervical spine movement while improving glottic exposure 1, 2
• Maintain full spinal precautions including log-roll technique and keeping the patient flat until the spine is fully evaluated by a spine surgeon 3

Airway Management

For high cervical cord injuries (C4 or higher), immediate intubation is mandatory 3

The intubation technique should include:

• Rapid sequence induction with direct laryngoscopy 1, 2
• Use of a gum elastic bougie to increase first-attempt success rate 1, 2
• Retention of cervical spine in neutral axis without Sellick maneuver 1
• Succinylcholine can be safely used as the rapid-acting muscle relaxant within the first 48 hours after spinal cord injury (after 48 hours, denervation hypersensitivity makes it contraindicated) 1

Critical pitfall: Videolaryngoscopy is not recommended as first-line in the prehospital setting based on available evidence, though it may be considered if the operator has significant experience with the device 1

Hemodynamic Management

Blood Pressure Targets

• Maintain mean arterial pressure (MAP) >85-90 mmHg for at least 1 week to ensure adequate spinal cord perfusion and prevent secondary ischemic injury 3, 2
• Vasopressors may be necessary to achieve hemodynamic stability, particularly given the neurogenic shock that commonly accompanies high spinal cord injuries 2, 3
• Avoid fluid overload; use blood products rather than excessive crystalloid or colloid fluids for volume resuscitation 2

Respiratory Management

Immediate Considerations

High cervical injuries (above C5) commonly affect diaphragmatic function and require aggressive respiratory support 2, 3

Mechanical Ventilation Strategy

Implement a comprehensive respiratory bundle that includes: 1

• Abdominal contention belt during periods of spontaneous breathing or raising procedures 1
• Active physiotherapy with mechanically-assisted insufflation/exsufflation device to remove bronchial secretions 1
• Aerosol therapy combining beta-2 mimetics and anticholinergics 1

Tracheostomy Timing

• For upper level spinal cord injury (C2-C5), perform early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times 1, 2
• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures 1
• Early tracheostomy (<7 days) in upper injuries has been associated with better neurological recovery at 1 year 1

Important note: Tetraplegic patients often tolerate lying down better than sitting due to gravitational effects on abdominal contents and inspiratory capacity 1

Diagnostic Evaluation

Imaging

• Computed tomography of the spine is superior to plain films and should be obtained urgently, though occipitocervical dislocation can still be missed 3
• Magnetic resonance imaging should be obtained within 48-72 hours from time of injury to reliably assess spinal neural elements, soft tissues, and ligamentous structures 3

Neurological Assessment

• Grade the patient daily using the American Spinal Injury Association (ASIA) classification 3
• The first prognostic score should be obtained at 72 hours post-injury 3
• Evaluate for other potential causes of quadriplegia including Guillain-Barré syndrome, which requires different management 2

Associated Injuries

There is a high incidence of other bodily injuries with spinal cord injury; maintain a low threshold to assess for visceral, pelvic, and long bone injuries 3

Prevention of Secondary Complications

Pressure Ulcer Prevention

Implement aggressive prevention measures from the acute phase: 2

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

Bladder Management

• Intermittent urinary catheterization is recommended as soon as daily diuresis volume is adequate to reduce urological complications 2
• Self-intermittent urethral catheterization is the gold standard recommended by national and international neuro-urology societies 2
• Remove indwelling catheters as soon as the patient is medically stable to minimize urological risks 2

Thromboembolism Prevention

• IVC filters are recommended in bedbound patients 3
• Low-molecular weight heparins are superior to unfractionated heparin 3

Pain Management

Acute Phase

Implement multimodal analgesia combining: 2

• Non-opioid analgesics 2
• Antihyperalgesic drugs (ketamine) 2
• Opioids 2

Neuropathic Pain (if develops)

• Oral gabapentinoids are recommended for more than 6 months 2
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2

Critical pitfall: Inadequate pain management can lead to chronic pain syndromes that are difficult to treat 2

Surgical Consultation and Timing

A spine surgeon must be consulted immediately to discuss operative versus nonoperative management 3

Indications for surgery include:

• Partial or progressive neurological deficit 3
• Instability of the spine preventing mobilization 3
• Correction of deformity 3
• Prevention of potential neurologic compromise 3

Early Rehabilitation

Early rehabilitation should begin immediately after stabilization to maximize neurological recovery 2, 4

Key components include:

• Physical exercise to enhance central nervous system regeneration through neurotrophic factors 2
• Stretching techniques for at least 20 minutes per zone, completed by simple posture orthosis and proper bed and chair positioning 2
• For incomplete injuries, gravity-assisted ambulation or body weight support with treadmill training 2

The concept of "time is spine" emphasizes the importance of early transfer to specialized centers, early decompressive surgery, and early delivery of treatments to affect long-term outcomes 4

Controversial Therapies

Steroids

Steroids are NOT recommended - professional neurosurgery societies in the United States have given a level 1 statement against their use in all spinal cord injury patients 3

Critical Pitfalls to Avoid

• Delaying immobilization in suspected spinal cord injury cases can lead to worsening neurological outcomes 2
• Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia due to denervation hypersensitivity 1
• Inadequate blood pressure support (MAP <85 mmHg) can worsen secondary ischemic injury 3
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 2
• Failing to implement pressure ulcer prevention strategies leads to significant morbidity 2

Most neurologic recovery occurs in the first year following injury, making aggressive early management and rehabilitation crucial 3