What are the immediate management priorities and steps for a patient with traumatic incomplete paraplegia?

Immediate Management of Traumatic Incomplete Paraplegia

In traumatic incomplete paraplegia, immediately immobilize the spine with manual in-line stabilization and rigid cervical collar, maintain systolic blood pressure ≥110 mmHg using vasopressors without delay, obtain urgent CT imaging of the entire spine, and transfer emergently to a specialized neurosurgical center for decompression surgery within 48 hours. 1, 2

Spinal Immobilization (First Priority)

• Apply immediate spinal immobilization to any trauma patient with suspected spinal cord injury to prevent onset or worsening of neurological deficit 1
• Use manual in-line stabilization (MILS) combined with rigid cervical collar placement, as this approach significantly reduces complications compared to no stabilization 1
• For transport, secure the patient on a rigid backboard with head fixation and vacuum mattress 1
• Remove the anterior portion of the cervical collar only during airway procedures while maintaining MILS 1

Critical pitfall: Never delay spinal immobilization to assess other injuries—assume spinal cord injury in any trauma patient with neurological symptoms until proven otherwise 1

Hemodynamic Management (Concurrent Priority)

• Maintain systolic blood pressure ≥110 mmHg from the moment of first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1, 2
• Administer vasopressors (phenylephrine or norepinephrine) immediately for any hypotension—do not wait for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects 1
• Target mean arterial pressure >85 mmHg to optimize spinal cord perfusion and limit secondary injury 2

Critical pitfall: Never use bolus sedation instead of continuous infusions, as this causes hemodynamic instability that can worsen spinal cord ischemia 1, 3

Airway Management (If Indicated)

• If the patient requires intubation due to respiratory compromise or altered consciousness, use rapid sequence induction with direct laryngoscopy and gum elastic bougie while maintaining MILS 1
• Confirm correct endotracheal tube placement through end-tidal CO₂ monitoring 1
• Maintain end-tidal CO₂ between 30-35 mmHg prior to obtaining arterial blood gas samples 1

Urgent Imaging

• Obtain CT scan of the entire spine (cervical, thoracic, and lumbar) without any delay to identify fractures, spinal canal compromise, and guide surgical planning 1, 4
• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows) 1
• Consider MRI to assess spinal cord parenchymal injury, ligamentous disruption, and epidural hematoma, though this should not delay surgical intervention 4

Emergency Transfer

• Transfer immediately to a specialized center with neurosurgical and spinal surgery capabilities—do not delay for "stabilization" at a non-specialized facility 1
• Incomplete spinal cord injuries (ASIA B-D) require urgent surgical decompression, as mortality and neurological outcomes are significantly better at specialized centers 1, 2

Surgical Intervention Timing

• Perform surgical decompression and stabilization within 48 hours for incomplete paraplegia, as early surgery improves respiratory function, shortens mechanical ventilation duration, and optimizes neurological recovery 2
• Surgical principles include spinal cord decompression, removal of bony fragments occluding the spinal canal, fracture reduction, and instrumented stabilization 2, 5
• Even patients with complete paraplegia (ASIA A) may benefit from early surgery in some cases, though the evidence is less definitive 2

Avoid High-Dose Corticosteroids

• Do not administer high-dose methylprednisolone protocols, as there is no clinical evidence supporting neurological recovery benefit, and these protocols increase secondary septic and pulmonary complications 2

This represents a significant departure from older practices—the evidence clearly demonstrates harm without benefit 2

Supportive Care During Initial Phase

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes 1, 3
• Monitor for and prevent post-traumatic seizures 1, 3
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function 1, 3

Key Distinction: Incomplete vs. Complete Injury

The presence of any motor or sensory function below the level of injury (incomplete paraplegia) represents a surgical emergency requiring urgent decompression 2. The potential for neurological recovery is substantially higher in incomplete injuries, making the 48-hour surgical window critical for optimizing outcomes 2.