What is the management of spinal cord injury without spinal fracture after axial load injury?

Management of Spinal Cord Injury Without Spinal Fracture After Axial Load Injury

Immediately immobilize the spine of any patient with suspected spinal cord injury to prevent onset or worsening of neurological deficit, even in the absence of fracture, and maintain systolic blood pressure >110 mmHg to reduce mortality. 1, 2

Initial Stabilization and Immobilization

Early spinal immobilization is critical to limit secondary neurological injury in patients with spinal cord injury without radiographic fracture (SCIWORA). 1

Immobilization Protocol:

• Apply rigid cervical collar immediately for suspected cervical injuries with head-neck-chest stabilization. 1, 2
• Use vacuum mattress for transport to maintain spinal alignment during patient movement. 1
• Maintain immobilization until ligamentous injury is definitively excluded, as prolonged immobilization beyond 48-72 hours carries escalating complication risks. 2

Hemodynamic Management:

• Maintain systolic blood pressure >110 mmHg from the initial phase to reduce mortality in spinal cord injury patients. 2
• This target applies regardless of whether fracture is present, as hypotension worsens secondary cord injury. 2

Diagnostic Imaging Algorithm

CT imaging is the initial modality, but MRI is essential for diagnosing ligamentous injury in SCIWORA cases. 3, 2, 4

Imaging Sequence:

1. CT cervical spine without contrast as first-line imaging for acute trauma. 2

2. MRI cervical spine without contrast is mandatory when:

   • CT shows no fracture but neurological deficit is present 2
   • Ligamentous injury is suspected (discoligamentous complex disruption) 3, 2
   • Patient has focal neurological deficits with normal CT 2

3. CT angiography if vascular injury is suspected (90-100% sensitivity). 2

The American College of Radiology specifically recommends MRI as the appropriate next step when ligamentous injury without fracture is suspected on CT. 2

Airway Management Considerations

If intubation is required, use manual in-line stabilization with anterior cervical collar removal during the procedure. 1, 2

Intubation Technique:

• Remove anterior portion of cervical collar during intubation to improve glottic visualization while maintaining manual in-line stabilization. 1, 2
• Use rapid sequence induction with direct laryngoscopy and gum elastic bougie. 1, 2
• Avoid Sellick maneuver as it increases first-attempt failure rates. 1
• Use jaw thrust rather than head tilt-chin lift for simple airway maneuvers. 3

Manual in-line stabilization shows major reduction in complications despite increasing difficult intubation rates. 1

Severity Assessment and Treatment Decision

Use the Subaxial Injury Classification (SLIC) System to determine need for surgical intervention. 3, 5

SLIC Scoring Components:

• Discoligamentous Complex (DLC) disruption: 2 points 5
• Neurological status:
  • Complete cord injury: 2 points 5
  • Incomplete cord injury: 3 points 5

Treatment Algorithm:

• SLIC score ≥5: Surgical intervention indicated 3, 5
• Surgery is indicated for:
  • Neurological deficit attributable to ligamentous injury 3
  • Documented discoligamentous complex disruption with instability 3, 5

The SLIC system demonstrates excellent reliability (ICC 0.49-0.90) for guiding surgical decision-making in cervical spine injuries without fracture. 5

Surgical Timing

Perform early surgical decompression and stabilization within 24 hours when indicated, regardless of injury severity or location. 6

Clinical evidence favors early intervention to optimize neurological outcomes, though the system does not specify exact surgical approach (anterior, posterior, or combined). 5, 6

Critical Pitfalls to Avoid

• Do not rely on CT alone when neurological deficit is present—MRI is mandatory to identify ligamentous injury. 2
• Do not remove cervical immobilization prematurely in patients with neurological deficits, even with normal CT. 2
• Do not allow hypotension below systolic BP 110 mmHg, as this significantly increases mortality. 2
• Avoid prolonged rigid collar immobilization beyond 72 hours without definitive diagnosis, as complications escalate rapidly. 2
• Do not administer high-dose methylprednisolone, as it is associated with significant adverse effects without proven benefit. 6

Intensive Care Monitoring

All patients with spinal cord injury require ICU-level monitoring to detect and manage potential complications, regardless of surgical intervention. 4, 6

The absence of fracture does not reduce the risk of secondary neurological deterioration or systemic complications in SCIWORA patients. 4, 6