What is the treatment for spinal cord contusion?

Treatment of Spinal Cord Contusion

Spinal cord contusion requires immediate hemodynamic stabilization with mean arterial pressure maintained at ≥70 mmHg for 7 days, early spinal stabilization, aggressive respiratory management, and comprehensive prevention of secondary complications—methylprednisolone is NOT recommended due to lack of benefit and increased infectious complications. 1

Immediate Acute Phase Management (First 24-48 Hours)

Hemodynamic Stabilization

• Maintain mean arterial pressure (MAP) ≥70 mmHg continuously for the first 7 days to optimize spinal cord perfusion and limit neurological deterioration 2, 3
• Use arterial catheter for continuous MAP monitoring as target levels can be difficult to maintain 2
• Avoid hypotension (systolic BP <110 mmHg) as it is associated with increased mortality 2

Spinal Immobilization and Imaging

• Immediate spinal immobilization with cervical collars and backboards to prevent further injury during transport 3, 4
• Obtain CT scan to assess bony injury and MRI to evaluate spinal cord compression and ligamentous injury 4
• Transfer promptly to a specialized spinal cord injury center as delays may result in patients arriving outside the therapeutic window for effective interventions 1

Respiratory Management

• For upper cervical injuries (C2-C5): perform early tracheostomy within 7 days to improve respiratory outcomes and neurological recovery 5, 2
• For lower cervical injuries (C6-C7): perform tracheostomy only after failed extubation attempts 5
• Implement respiratory bundle including:
  • Abdominal contention belt during spontaneous breathing 5, 2
  • Active physiotherapy with mechanically-assisted insufflation/exsufflation devices for secretion removal 5, 2
  • Aerosol therapy combining beta-2 mimetics and anticholinergics 5, 2

Surgical Considerations

Timing and Indications

• Consider early surgical decompression within 24 hours when indicated, as this has been associated with superior neurological recovery 1, 6
• Optimal surgical window appears to be 4-14 days after injury based on outcomes data 6
• Surgery should address spinal stabilization, decompression, and in select cases, neurosurgical intervention including separation of arachnoid adhesions and debridement of necrotic tissue 6

Important Caveat on Methylprednisolone

• Do NOT routinely administer methylprednisolone despite historical practice 1
• Multiple studies have failed to show consistent neurological benefit, with the NASCIS trials containing scientific irregularities 1
• Methylprednisolone is associated with higher rates of infectious complications (pulmonary and urinary) without beneficial effects on motor function 1
• The Congress of Neurological Surgeons provides Grade Insufficient recommendation, emphasizing the unfavorable complication profile 1

Prevention of Secondary Complications

Pressure Ulcer Prevention (Initiate Immediately)

• Early mobilization as soon as spine is stabilized 5, 2
• Visual and tactile checks of all at-risk areas at least once daily 5
• Repositioning every 2-4 hours with pressure zone checks 5
• Use pressure-relief tools (cushions, foam, pillows) to avoid interosseous contact 5
• High-level prevention supports (air-loss mattress, dynamic mattress) 5

Urological Management

• Implement intermittent urinary catheterization as soon as daily diuresis volume is adequate to reduce urinary tract infections and urolithiasis 5
• Remove indwelling catheter as soon as patient is medically stable 5
• Use micturition calendar to adapt frequency and schedule of catheterization 5

Venous Thromboembolism Prophylaxis

• Initiate thromboprophylaxis early, as VTE incidence in acute spinal cord injury can reach 4-100% without prophylaxis 5
• Highest VTE incidence occurs with thoracic segment injuries 5
• Continue prophylaxis for approximately 3 months post-injury 5
• Combination pharmacologic and mechanical prophylaxis may offer additional benefit beyond single modality 5

Pain Management

Acute Pain Control

• Implement multimodal analgesia during surgical management combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain 5

Neuropathic Pain (Subacute/Chronic Phase)

• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain 5
• Combine with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 5

Rehabilitation and Positioning

Early Mobilization Strategy

• Begin stretching techniques for at least 20 minutes per zone to maintain joint amplitudes 5
• Use simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening) 5, 2
• Proper bed and chair positioning to correct and prevent predictable deformities 5, 2
• In tetraplegic patients, lying down is often better tolerated than sitting due to gravity effects on abdominal contents and inspiratory capacity 5

Critical Pitfalls to Avoid

• Do not delay transfer to specialized centers waiting for "stability"—early intervention is time-dependent 1
• Do not use methylprednisolone routinely despite its historical use—risks outweigh benefits 1
• Do not allow hypotension or hypoxia as these worsen secondary injury 3, 7
• Do not delay respiratory support in high cervical injuries—early tracheostomy improves outcomes 5, 2
• Do not use prolonged indwelling urinary catheters when intermittent catheterization is feasible 5