What is the treatment approach for spinal injuries?

Treatment Approach for Spinal Injuries

Begin comprehensive rehabilitation immediately upon medical stability in the ICU—do not wait for transfer to a dedicated rehabilitation unit—while simultaneously implementing multimodal analgesia and strict attention to preventing secondary complications. 1

Immediate Acute Phase Management

Rehabilitation Must Start in the ICU

• Initiate rehabilitation as soon as the patient is medically stable, even while still in the intensive care unit, as early intervention maximizes neurological recovery. 1
• Modern management of spinal cord injury requires strict attention to rehabilitation during all phases of care from the first days of injury. 2
• Do not delay rehabilitation until transfer to a dedicated rehabilitation unit; this is a critical pitfall that worsens outcomes. 1

Multimodal Pain Control During Acute Phase

• Combine non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain and reduce the occurrence of chronic neuropathic pain. 1
• For neuropathic pain that develops, initiate gabapentinoids (gabapentin titrated to 2400 mg daily in divided doses or pregabalin) as first-line treatment. 3, 4
• Alternatively, start tricyclic antidepressants such as amitriptyline at 10-25 mg/day, particularly in patients over 40 years, but obtain baseline ECG screening first due to cardiac risks. 3, 4

Critical Early Interventions in the ICU

Musculoskeletal Management

• Perform stretching exercises for at least 20 minutes per anatomical zone to maintain joint amplitudes and prevent contractures. 1
• Apply simple posture orthoses including elbow extension, flexion-torsion of metacarpophalangeal joints, and opening of thumb-index commissure. 1
• Position the patient correctly in bed and chair to prevent predictable deformities. 1
• Focus on strengthening existing musculature from the earliest phase. 1

Bladder Management Protocol

• Remove the indwelling catheter as soon as the patient is medically stable—prolonged use increases urological complications including infections, urolithiasis, and reduces continence probability. 1
• Initiate intermittent urinary catheterization once daily diuresis volume is adequate, as this is the reference method that reduces urinary tract infections and urolithiasis while increasing continence probability. 1
• Use a micturition calendar to adapt frequency and schedule of catheterization. 1
• Do not treat asymptomatic bacteriuria with antibiotics, as this creates antimicrobial resistance. 1

Respiratory Management

• Position the patient in semi-recumbent or recumbent position rather than sitting when possible, as this is better tolerated due to gravity effects on abdominal contents and inspiratory capacity. 1
• Consider an abdominal contention belt to increase tolerance of spontaneous ventilation, particularly in sitting position. 1
• For upper cervical injuries or complete injuries, anticipate potential need for tracheostomy if vital capacity is reduced by >50%. 1
• Perform tracheostomy after 7 days if anterior cervical surgical approach was used; earlier timing is possible with posterior approach. 1

Pressure Ulcer Prevention

• Implement early mobilization as soon as the spine is stabilized. 1
• Perform visual and tactile checks of all at-risk areas (sacrum, heels, ischium) at least once daily. 1
• Reposition every 2-4 hours with pressure zone checks. 1
• Utilize high-level prevention supports to avoid interosseous contact. 1

Surgical Considerations

Indications for Surgery

• Surgical intervention is indicated for spinal cord compression and vertebral instability. 5
• Expedient delivery of surgical care during the critical period following initial mechanical trauma can improve long-term functional outcomes, following the concept of "Time is Spine". 6
• The pathophysiology includes initial mechanical trauma followed by significant secondary injury with local ischemia, pro-apoptotic signaling, release of cytotoxic factors, and inflammatory cell infiltration. 6

Surgical Approaches

• Use dorsal and dorsolateral approaches for lumbosacral and thoracolumbar spine injuries. 5
• Use dorsal and ventral approaches for cervical spine injuries. 5
• Hemilaminectomy (unilateral or bilateral) causes less instability than dorsal laminectomy and should be used when practical. 5
• The preferred approach for atlantoaxial subluxation is ventral, using cross pinning and vertebral fusion technique for stabilization. 5

Staffing Requirements

• Ensure rehabilitation centers have the equivalent of 2.5 full-time physiotherapists per 15 patients to provide adequate care. 1

Management of Refractory Pain Syndromes

When First-Line Treatments Fail

• If gabapentinoid monotherapy is insufficient, add tricyclic antidepressants or serotonin reuptake inhibitors for treatment duration exceeding 6 months. 1
• Consider topical compounded creams containing amitriptyline, or a combination of topical baclofen, amitriptyline, and ketamine gel, which has shown effectiveness after 4 weeks with minimal systemic effects. 3

Ketamine Infusion for Refractory Cases

• Use ketamine infusion as second-line or rescue therapy for patients with central sensitization and "clinical wind-up" who have not responded to first-line treatments. 4
• Administer a 5-day inpatient protocol at subanesthetic doses of 0.1-0.35 mg/kg/h over 6 hours daily. 3, 4
• Use extreme caution in elderly patients due to significant risk of postoperative confusion and delirium. 3, 4
• Monitor respiratory parameters closely, as concomitant use with opioids, benzodiazepines, or other CNS depressants may result in profound sedation and respiratory depression. 3, 4

Interventional Procedures

• Consider spinal cord stimulation for patients who have not responded to other therapies. 3
• Perform a temporary spinal cord stimulation trial before permanent implantation, demonstrating adequate pain relief (typically >50% reduction) and measurable functional improvement. 3

Long-Term Complications Requiring Ongoing Management

• Monitor for respiratory complications, cardiovascular complications, urinary and bowel complications, spasticity, pain syndromes, pressure ulcers, osteoporosis and bone fractures. 7
• Prevention, early diagnosis and treatment of chronic secondary complications is critical for limiting these complications, improving survival, community participation and health-related quality of life. 7
• The treatment and rehabilitation period is long, expensive and exhausting, requiring an interdisciplinary approach led by a physiatrist and consisting of the patient's family, physiotherapist, occupational therapist, dietician, psychologist, speech therapist, social worker and other consultant specialists as necessary. 8