What is the management for a patient with spinal cord injury and multiple osteoporotic vertebral fractures in the emergency department?

Emergency Department Management of Spinal Cord Injury with Osteoporotic Vertebral Fractures

Immediately immobilize the spine with manual in-line stabilization and a rigid cervical collar to prevent onset or worsening of neurological deficit, as early spinal immobilization is critical to limiting secondary injury. 1, 2

Immediate Spinal Stabilization

• Apply manual in-line stabilization (MILS) immediately upon patient arrival to prevent any movement that could worsen neurological injury 1, 2
• Place a rigid cervical collar for cervical injuries, maintaining head-neck-chest stabilization throughout the evaluation 2, 3
• Position the patient on a rigid backboard with vacuum mattress for transport to imaging or definitive care 2
• Maintain spinal precautions even if the primary injury is thoracic or lumbar, as osteoporotic patients often have multilevel fractures 4, 5

Airway Management (If Cervical Involvement)

If intubation is required, remove only the anterior portion of the cervical collar while maintaining posterior stabilization to improve glottic exposure without compromising spinal protection. 1, 2

• Perform rapid sequence induction with direct laryngoscopy 1, 2
• Use a gum elastic bougie to increase first-attempt success rate 1, 2
• Maintain cervical spine in neutral axis without Sellick maneuver 1
• Critical pitfall: Succinylcholine can only be used safely within the first 48 hours after spinal cord injury; after 48 hours it causes life-threatening hyperkalemia due to denervation hypersensitivity 2, 3

Hemodynamic Resuscitation

Maintain systolic blood pressure >110 mmHg and mean arterial pressure (MAP) ≥70 mmHg to prevent secondary spinal cord injury from hypoperfusion. 2

• Target MAP ≥70 mmHg during the first 7 days, as time spent with MAP <65-70 mmHg inversely correlates with neurological improvement 2
• Initiate vasopressor support early if needed to maintain these targets 2

Neurological Assessment

• Perform complete neurological examination documenting motor and sensory levels using ASIA classification 6
• Look specifically for signs of autonomic dysreflexia in patients with chronic spinal cord injury, as new osteoporotic fractures can trigger this life-threatening complication 7
• Assess for radiculopathy patterns, as osteoporotic vertebral fractures can cause nerve root compression at levels distant from the fracture site 5
• Document any new onset spasticity, which may indicate acute fracture in chronic spinal cord injury patients 7

Imaging Evaluation

Obtain MRI immediately if any neurological symptoms or physical findings suggest spinal cord or nerve root compression, even if plain radiographs show only minor fracture. 5

• Plain radiographs may underestimate the severity of posterior wall involvement and canal compromise 5
• CT scan helps identify posterior wall fractures that may not be apparent on plain films 5
• MRI is essential to evaluate spinal cord compression, edema, and the extent of neurological injury 6, 4, 5
• Look for multilevel fractures, as osteoporotic patients typically have diffuse disease with multiple compression fractures 4

Pain Management

Implement multimodal analgesia immediately, combining non-opioid analgesics, ketamine for antihyperalgesic effect, and opioids as needed. 2, 3

• Avoid relying solely on opioids due to risk of respiratory depression and constipation 2, 3
• Consider early initiation of gabapentinoids if neuropathic pain features are present 2, 3

Respiratory Management (For High Cervical Injuries)

• High cervical injuries (C2-C5) require immediate intubation 3
• Implement respiratory bundle including abdominal contention belt, active physiotherapy with mechanically-assisted insufflation/exsufflation, and aerosol therapy with beta-2 mimetics and anticholinergics 3

Prevention of Acute Complications

Begin pressure ulcer prevention immediately with visual and tactile checks of all at-risk areas, as osteoporotic spinal cord injury patients are at extremely high risk. 2, 3

• Reposition every 2-4 hours even in the emergency department 2, 3
• Implement bladder management with intermittent catheterization as soon as feasible rather than indwelling catheter 2, 3

Surgical Consultation Criteria

Obtain immediate spine surgery consultation for patients with unstable fractures, progressive neurological deficit, severe canal compromise, or intractable pain. 6, 8, 5

• 15-35% of osteoporotic vertebral fractures require surgical intervention 8
• Indications include: unstable fracture pattern, persistent intractable pain despite conservative measures, severely collapsed vertebra causing neurological deficit, progressive kyphosis, or chronic pseudarthrosis 8
• Neurological compromise from osteoporotic fractures, though rare, can be catastrophic and sudden, requiring urgent decompression and stabilization 6, 4
• Surgical approach typically involves decompression via laminectomy or corpectomy, followed by fusion with instrumentation using pedicle screws above and below the fracture level 5

Osteoporosis Management Initiation

• Initiate anti-osteoporotic medication consultation in the emergency department, as treatment improves fracture healing and prevents future fractures 8
• Avoid bisphosphonates initially if surgical intervention is likely, as evidence on fracture healing effects is lacking 8
• Consider teriparatide for patients requiring surgery, as it dramatically improves spinal fusion and fracture healing while lowering mortality risk 8

Disposition

• Admit all patients with neurological deficits for monitoring and definitive management 6, 4
• Patients without neurological compromise but with severe pain or unstable fracture patterns require admission for observation, as neurological symptoms can develop late 5
• Critical pitfall: Most neurological symptoms from osteoporotic fractures develop gradually, but sudden catastrophic deterioration can occur, requiring close monitoring 4