What is the management and treatment for a patient with a closed cervical cord injury?

Management of Closed Cervical Cord Injury

Perform emergency surgical decompression within 24 hours (ideally within 8 hours if safely feasible) to improve long-term neurological recovery and reduce respiratory complications. 1

Immediate Stabilization and Immobilization

Apply a rigid cervical collar with head-neck-chest stabilization immediately upon suspicion of cervical cord injury, combined with manual in-line stabilization (MILS) to prevent onset or worsening of neurological deficit. 2 A combination of rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting cervical spine motion. 3 However, remove patients from the hard backboard surface as soon as possible (ideally after initial imaging) to avoid tissue ischemia, as most complications from prolonged immobilization appear and rapidly escalate after 48-72 hours. 4, 2

Maintain systolic blood pressure >110 mmHg continuously before and during injury assessment to reduce mortality. 4, 5, 2 Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration. 5 Place an arterial line for continuous accurate blood pressure monitoring. 5, 2

Transport directly to a Level 1 trauma center within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention. 5, 2

Diagnostic Imaging Protocol

Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected acute cervical spine trauma. 4, 5 For patients with suspected ligamentous injury without fracture on CT, MRI of the cervical spine without IV contrast is the appropriate next imaging modality. 4 Perform CT angiography if vascular injury is suspected (sensitivity 90-100%, specificity 98.6-100%). 4, 5

Surgical Timing

Early surgery (within 24 hours) is associated with improved neurological recovery as measured by ASIA score improvement (RR of recovery = 8.9,95% CI [1.12-70.64], P = 0.01) and reduced pulmonary complications. 1 This benefit applies to both complete (ASIA A) and incomplete (ASIA B-D) injuries, as well as cervical and thoracic injuries. 1

Ultra-early surgery (<8 hours) may further reduce complications and increase neurological recovery in stable patients at well-organized trauma centers, particularly for reducing respiratory complications. 1 French Level 1 trauma centers frequently achieve this timeframe safely. 1

Airway Management (If Required)

Use rapid sequence induction with videolaryngoscopy in emergency conditions to reduce intubation failure risk (RR 0.53,95% CI 0.35-0.80). 1 The Airtraq videolaryngoscope specifically reduces intubation failure from 28.6% to 3.4% (RR 0.14,95% CI 0.06-0.33, NNT 5.0). 1

Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure. 4, 5, 2 Do not use Sellick maneuver as it increases cervical spine movement. 5, 2

In non-emergency conditions with cooperative patients, perform fiberoptic intubation with spontaneous ventilation, especially if difficult mask ventilation or mouth opening <2.5 cm is anticipated, as this minimizes cervical spine mobilization. 1

Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid hyperkalemia risk from denervation. 1, 2

Respiratory Management and Ventilator Weaning

Implement a comprehensive respiratory bundle for cervical spinal cord injury patients combining: 1, 2

• Abdominal contention belt during spontaneous breathing periods or raising procedures (tetraplegic patients tolerate lying down better than sitting due to gravity effects on abdominal contents and inspiratory capacity). 1, 2
• Active physiotherapy with mechanically-assisted insufflation/exsufflator device (Cough-Assist type) for bronchial secretion removal. 1, 2
• Aerosol therapy combining beta-2 mimetics and anticholinergics. 1, 2

**Perform early tracheostomy (<7 days) for upper cervical injuries (C2-C5)**, as these patients have >50% reduction in vital capacity and high risk of ventilator weaning failure. 1, 2 For lower cervical injuries (C6-C7), perform tracheostomy only after one or more extubation failures. 1

Temperature Management

Prevent hypothermia aggressively with target core temperature 36-37°C, as each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 2 Remove all wet clothing immediately, increase ambient temperature, apply forced air warming devices as first-line, and administer only warm intravenous fluids. 2

Pain Management

Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 2 Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain. 2 Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient. 2

Early Rehabilitation

Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities. 5, 2 Perform stretching for at least 20 minutes per zone. 2 Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening). 2 Use proper bed and chair positioning to correct and prevent predictable deformities. 2

Critical Pitfalls to Avoid

• Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates. 5
• Do not allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk. 5
• Avoid prolonged rigid collar immobilization beyond 48-72 hours without definitive treatment, as complications rapidly escalate. 4
• Do not delay surgical decompression beyond 24 hours when indicated, as this worsens neurological outcomes. 1
• Never use sandbags and tape alone for cervical spine immobilization, as this is ineffective. 3