What is the treatment for a spinal injury?

Treatment of Spinal Injury

Spinal cord injury treatment requires immediate hemodynamic optimization with mean arterial pressure ≥70 mmHg for 7 days, early surgical decompression within 24 hours when indicated, and comprehensive rehabilitation beginning from day one—while methylprednisolone should NOT be used due to its unfavorable risk profile. 1, 2, 3, 4

Acute Phase Management (First 24-72 Hours)

Hemodynamic Stabilization

• Maintain mean arterial pressure (MAP) ≥70 mmHg continuously for the first 7 days using vasopressors if needed, as hypotension is associated with increased mortality and secondary spinal cord injury 2
• Use arterial catheter for continuous MAP monitoring since target levels are difficult to maintain 2
• Avoid systolic blood pressure <110 mmHg at all costs 2
• Optimize cardiorespiratory parameters immediately to prevent secondary injury 1

Surgical Intervention

• Perform early surgical decompression within 24 hours for all incomplete spinal cord injuries to improve neurological outcomes and reduce morbidity and mortality 1, 4
• Only 20-50% of patients currently arrive within this critical 24-hour window, so immediate transfer to specialized spinal cord injury centers is essential 1
• Surgical approaches include dorsal laminectomy, hemilaminectomy (preferred when practical as it causes less instability), or ventral cervical slot depending on injury location 5
• Stabilization techniques vary by location: ventral approach with cross-pinning for atlantoaxial subluxation, dorsal fixation or combined plate techniques for thoracolumbar injuries 5

Pharmacotherapy: What NOT to Use

• Do NOT administer methylprednisolone despite its historical use—the Congress of Neurological Surgeons provides a Grade Insufficient recommendation emphasizing its unfavorable complication profile 2, 4
• The FDA warns that high-dose systemic corticosteroids should not be used for traumatic brain injury, and similar concerns apply to spinal cord injury 3
• Methylprednisolone is associated with significant systemic adverse effects including increased infection risk, gastrointestinal bleeding, and metabolic complications 4

Respiratory Management

For High Cervical Injuries (C2-C5)

• Perform early tracheostomy within 7 days to improve respiratory outcomes and neurological recovery 2
• Timing: after 7 days if anterior cervical surgical approach was used; earlier possible with posterior approach 6
• Position patient semi-recumbent or recumbent rather than sitting when possible, as this is better tolerated due to gravity effects on abdominal contents 6
• Consider abdominal contention belt to increase tolerance of spontaneous ventilation, particularly in sitting position 6
• Implement respiratory bundle including active physiotherapy and aerosol therapy 2

For All Cervical Injuries

• Anticipate potential need for tracheostomy if vital capacity is reduced by >50% 6

Prevention of Secondary Complications

Pressure Ulcer Prevention

• Begin early mobilization as soon as spine is stabilized 6, 2
• Perform visual and tactile checks of all at-risk areas at least once daily 6
• Reposition every 2-4 hours with pressure zone checks 6
• Use high-level prevention supports and discharge tools to avoid interosseous contact 6
• Prevalence can reach 26% with sacrum, heels, and ischium most affected if prevention measures are neglected 6

Bladder Management

• Remove indwelling catheter as soon as patient is medically stable to minimize urological risks 6
• Initiate intermittent urinary catheterization once daily diuresis volume is adequate—this is the reference method that reduces urinary tract infections, urolithiasis, and increases continence probability 6, 2
• Use micturition calendar to adapt frequency and schedule of catheterization 6
• Do NOT treat asymptomatic bacteriuria with antibiotics, as this creates antimicrobial resistance 6

Thromboprophylaxis

• Initiate thromboprophylaxis early, as venous thromboembolism incidence in acute spinal cord injury can reach 4-100% without prophylaxis 2

Pain Management

Multimodal Approach

• Introduce multimodal analgesia during surgical management, combining non-opioid analgesics, antihyperalgesic drugs, and opioids to prevent prolonged pain 6, 2

Neuropathic Pain

• Initiate oral gabapentinoid treatment for more than 6 months 6, 2
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 6

Rehabilitation Protocol

Immediate Initiation

• Begin rehabilitation immediately upon medical stability in the ICU, even before transfer to a dedicated rehabilitation unit 6
• Modern management emphasizes strict attention to rehabilitation during all phases of care from the first days of injury 7, 1

Musculoskeletal Management

• Perform stretching exercises for at least 20 minutes per anatomical zone to maintain joint amplitudes and prevent contractures 6, 2
• Apply simple posture orthoses including elbow extension, flexion-torsion of metacarpophalangeal joints, and opening of thumb-index commissure 6
• Position patient correctly in bed and chair to prevent predictable deformities 6
• Focus on strengthening existing musculature from the earliest phase 6

Staffing Requirements

• Ensure rehabilitation centers have the equivalent of 2.5 full-time physiotherapists per 15 patients 6

Specialized Center Management

• Transfer to specialized acute spinal cord injury unit reduces morbidity and mortality 1
• Do NOT delay transfer waiting for "stability"—early intervention is time-dependent 2
• Comprehensive care must address autonomic dysreflexia, respiratory function, thromboembolism, pressure ulcers, bowel function, and depression 7, 1

Critical Pitfalls to Avoid

• Never use methylprednisolone—risks outweigh any potential benefits 2, 3, 4
• Do not delay surgical decompression beyond 24 hours when indicated 1, 4
• Do not prolong use of indwelling urinary catheters when intermittent catheterization is feasible 6, 2
• Do not delay removal of indwelling catheters, as prolonged use increases urological complications 6
• Do not treat asymptomatic bacteriuria or rely on pyuria, urine odor, or cloudiness alone to diagnose UTI in catheterized patients 6
• Do not delay respiratory support in high cervical injuries—early tracheostomy improves outcomes 2
• Do not neglect pressure ulcer prevention measures from day one 6
• Do not delay rehabilitation until transfer to a dedicated rehabilitation unit—begin in the ICU as soon as medically stable 6