What is the plan of care for a patient with a spinal cord injury?

Plan of Care for Spinal Cord Injury

Immediate Prehospital Management

Early spinal immobilization must be initiated immediately in any patient with suspected spinal cord injury to prevent onset or worsening of neurological deficit. 1

Spinal Stabilization Protocol

• Apply rigid cervical collar with manual in-line stabilization (MILS) for head-neck-chest stabilization 1, 2
• Transport patient on rigid backboard with vacuum mattress 1, 2
• Maintain cervical spine in neutral axis throughout transport 1, 2
• Avoid any unnecessary movement of the spinal column during prehospital transport 3, 4

Hemodynamic Resuscitation

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1, 2
• Target mean arterial pressure (MAP) ≥70 mmHg during the first 7 days post-injury to limit neurological deterioration 1, 2
• Continuous arterial line monitoring is recommended as MAP frequently falls below target 25% of the time 1
• Avoid all episodes of hypotension (SBP <90 mmHg) through day 5-7 1

Airway Management in Cervical Injuries

• Remove only the anterior portion of the cervical collar during intubation while maintaining posterior stabilization 1, 2
• Perform rapid sequence induction with direct laryngoscopy 1, 2
• Use gum elastic bougie to increase first-attempt intubation success 1, 2
• Maintain cervical spine in neutral axis without Sellick maneuver 1, 2
• Critical pitfall: Succinylcholine can only be used within the first 48 hours after injury; after 48 hours it causes life-threatening hyperkalemia due to denervation hypersensitivity 2

Hospital Admission and Triage

Transport to Specialized Centers

• Direct admission to Level 1 trauma centers reduces morbidity and mortality 1
• Level 1 centers provide earlier surgical procedures, reduced ICU length of stay, and improved neurological outcomes 1

ICU Admission Criteria

• All patients with high cervical spinal cord injury (C2-C5) 3
• Any patient with hemodynamic instability 3
• Patients with other life-threatening injuries requiring intensive monitoring 3

Diagnostic Evaluation

Imaging Protocol

• Perform emergency MRI to determine presence of persistent spinal cord compression 5
• MRI guides decision for immediate operative decompression and stabilization 5
• Address life-threatening injuries (hemorrhage, intracranial hemorrhage, acute vascular compromise) before spinal surgery 3

Surgical Management

Timing of Decompression

• Perform early surgical decompression and spine stabilization within 24 hours of injury regardless of severity or location 6
• Immediate spinal cord decompression based on MRI findings significantly improves neurological outcome 5
• 50% of patients undergoing immediate decompression improved from their admitting Frankel grade, compared to only 24% with delayed treatment 5
• 12% of immediate decompression patients improved from complete motor quadriplegia to independent ambulation 5

Surgical Approach

• Achieve spinal cord decompression through immediate spinal column alignment and skeletal traction when possible 5
• Perform operative decompression if MRI documents persistent spinal cord compression despite traction 5
• Stabilize spine with appropriate instrumentation (pedicle screws, rods, plates) based on injury level 7

Respiratory Management

High Cervical Injuries (C2-C5)

• Perform early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times 2
• Immediate intubation is mandatory for high cervical cord injuries 2
• Use aggressive measures including CoughAssist and Intermittent Positive Pressure Breaths (IPPB) to maintain lung recruitment and mobilize secretions 3
• Consider diaphragmatic pacer placement in select patients 3

Pharmacologic Therapy

Methylprednisolone

• High-dose methylprednisolone is strongly discouraged due to significant systemic adverse effects without proven benefit 6
• No evidence-based neuroprotective treatments are currently available 2, 6

Pain Management

• Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute phase 2
• For neuropathic pain: prescribe oral gabapentinoids for more than 6 months 2

Prevention of Secondary Complications

Pressure Ulcer Prevention

• Begin early mobilization as soon as spine is stabilized 1, 2
• Perform visual and tactile checks of all at-risk areas at least once daily 1, 2
• Reposition patient every 2-4 hours with pressure zone checks 1, 2
• Use discharge tools (cushions, foam, pillows) to avoid interosseous contact at knees 1
• Utilize high-level prevention supports (air-loss mattress, dynamic mattress) 1, 2
• Critical pitfall: Pressure ulcer prevalence reaches 26%, with sacrum (39%), heels (13%), ischium (8%), and occiput (6%) being main locations 1

Urological Management

• Implement intermittent urinary catheterization as soon as daily diuresis volume is adequate to reduce urinary tract infections and urolithiasis 1, 2
• Remove indwelling catheter as soon as patient is medically stable 1
• Self-intermittent urethral catheterization is the gold standard method 1, 2
• Use micturition calendar to adapt frequency and schedule of catheterization 1

Early Rehabilitation

Immediate Mobilization

• Begin rehabilitation immediately after spinal stabilization to maximize neurological recovery 2
• Implement physical exercise to enhance central nervous system regeneration through neurotrophic factors 2
• Perform stretching techniques for at least 20 minutes per zone 2
• Utilize bed and chair positioning to correct and prevent predictable deformities 1

Multidisciplinary Team Approach

• Coordinate care with respiratory therapists, nutritional experts, physical therapists, and occupational therapists 3
• Ensure equivalent of 2.5 full-time physiotherapists per 15 patients in rehabilitation centers 1

Critical Pitfalls to Avoid

• Delaying spinal immobilization leads to worsening neurological outcomes 2
• Using succinylcholine after 48 hours post-injury causes life-threatening hyperkalemia 2
• Inadequate blood pressure support below target thresholds increases secondary injury 2
• Prolonged rigid cervical collar immobilization beyond 48-72 hours causes significant complications 8
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 2
• Administering high-dose methylprednisolone causes significant adverse effects without proven benefit 6