What is the recommended management approach for a patient presenting with paraplegia and a suspected cervical spine fracture?

Management of Paraplegia with Suspected Cervical Spine Fracture

Immediately immobilize the cervical spine with a rigid collar and manual in-line stabilization (MILS), maintain systolic blood pressure >110 mmHg, and transport directly to a Level 1 trauma center for urgent CT imaging and potential surgical decompression within 24 hours. 1, 2

Immediate On-Scene and Emergency Department Stabilization

Spinal Immobilization

• Apply a rigid cervical collar with head-neck-chest stabilization immediately upon suspicion of cervical spine injury to prevent onset or worsening of neurological deficit 3, 1
• Maintain manual in-line stabilization (MILS) continuously during all patient movements and procedures 3
• Use a vacuum mattress for transport to minimize movement 3
• Critical pitfall: Never remove the entire cervical collar without maintaining MILS, as uncontrolled movement can worsen spinal cord injury 1, 2

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg continuously before and during injury assessment to reduce mortality 3, 1, 2
• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration 1, 2
• Place an arterial line immediately for continuous accurate blood pressure monitoring 1, 2
• Each 1°C drop in core temperature reduces coagulation factor function by 10%; aggressively prevent hypothermia with target core temperature 36-37°C 1, 2

Airway Management (If Required)

Pre-Intubation Preparation

• Remove only the anterior portion of the rigid cervical collar while an assistant maintains MILS; leaving the full collar in place markedly worsens glottic view and raises intubation failure rates 3, 1
• Use jaw thrust rather than head-tilt/chin-lift for airway maneuvers during pre-oxygenation to minimize cervical spine movement 3, 1
• Multidisciplinary planning before airway management improves team performance and reduces complications 1

Intubation Technique

• Videolaryngoscopy is the preferred first-line technique, yielding superior glottic visualization compared with direct laryngoscopy 1
• Use rapid sequence induction with a gum elastic bougie without Sellick maneuver while maintaining MILS 3, 1
• Do not use Sellick maneuver as it increases cervical spine movement 1, 2
• Adding a stylet or bougie as an adjunct during intubation with cervical immobilization increases first-pass success 1
• Critical pitfall: Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid life-threatening hyperkalemia from denervation hypersensitivity 1

Diagnostic Imaging Protocol

• Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected cervical spine fracture 1, 2, 4
• For patients with suspected ligamentous injury without fracture on CT, MRI of the cervical spine without IV contrast is the appropriate next imaging modality 1, 2
• Perform CT angiography if vascular injury is suspected (sensitivity 90-100%, specificity 98.6-100%) 2

Surgical Timing and Approach

Timing of Decompression

• Early surgery within 24 hours is associated with improved neurological recovery (RR of recovery = 8.9,95% CI [1.12-70.64], P = 0.01) and reduced pulmonary complications 2, 5
• Ultra-early surgery (<8 hours) may further reduce complications and increase neurological recovery in stable patients at well-organized trauma centers 1, 2
• Emergency closed reduction should be performed as soon as possible—animal studies and rare clinical cases show profound neurological recovery when decompression occurs within 1-2 hours 5
• Critical pitfall: Do not delay surgical decompression beyond 24 hours when indicated, as this worsens neurological outcomes 1, 2

Surgical Approach Selection

• If spinal cord compression is due to bone fragments from vertebral collapse, patients should undergo surgery immediately 6
• Anterior decompression is most effective for burst fractures and compression fractures with herniated discs (88% improvement rate) 7
• Posterior approach surgery is most effective for developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries, and hematoma (87.1% improvement rate) 7
• Combined anterior and posterior approach surgery in a single sitting may be required for complex injuries 7

Respiratory Management

Early Tracheostomy Considerations

• 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
• 40% of patients with cervical spinal cord injury present with high fever and difficulty breathing requiring immediate intervention 7
• Oxygen support and tracheotomy should be performed for patients with serious difficulty in breathing 7

Respiratory Bundle

• Implement a comprehensive respiratory bundle combining abdominal contention belt during spontaneous breathing periods, active physiotherapy with mechanically-assisted insufflation/exsufflator device (Cough-Assist), and aerosol therapy combining beta-2 mimetics and anticholinergics 1, 2
• Tetraplegic patients tolerate lying down better than sitting due to gravity effects on abdominal contents 1

Pain Management

• Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain 1, 2
• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain 1, 2
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 1

Early Rehabilitation

• Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities 1, 2
• Perform stretching for at least 20 minutes per zone 1, 2
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening) 1, 2
• Use proper bed and chair positioning to correct and prevent predictable deformities 1, 2

Monitoring and Prevention of Complications

• Maintain continuous hemodynamic monitoring with arterial line for accurate MAP measurement 1
• Perform hourly vital signs and neurological assessments 1
• Actively prevent and treat bedsores and infections of the respiratory and urological systems 7
• Remove all wet clothing immediately, cover the patient, and increase ambient temperature in treatment area to prevent hypothermia 1
• Administer only warm intravenous fluids; never use cold IV fluids 1

Prognostic Considerations

• At least one Frankel grade improvement occurs in 60.3% of patients with appropriate management 7
• Most patients with Frankel D neurological deficit recover normal neurological function after surgery 7
• The majority of patients with Frankel C neurological deficit (82.3%) regain the ability to walk postoperatively 7
• Most seriously injured patients (Frankel A and B) have limited improvement in neurological function, but ultra-early decompression may improve outcomes 7, 5
• Overall neurological complication rate after tracheal intubation in cervical spine injury patients is low (0.34%, 4/1177) when proper technique is used 1