How should I assess and initially manage an acute traumatic spinal cord injury?

Assessment and Initial Management of Acute Traumatic Spinal Cord Injury

Immediate Prehospital Stabilization

Apply manual in-line stabilization (MILS) immediately combined with a rigid cervical collar to all patients with suspected spinal cord injury, and transport on a rigid backboard with vacuum mattress maintaining head-neck-chest stabilization throughout. 1, 2

• Remove the patient from danger only if there is immediate life threat; otherwise, stabilize in place 1
• Maintain full spinal precautions (log-roll technique, keep flat, hold C-spine) until the spinal column has been fully evaluated by a spine surgeon 3
• Direct admission to Level 1 trauma centers within the first hours after trauma reduces morbidity and mortality, enables earlier surgical procedures, reduces ICU length of stay, and improves neurological outcomes 1, 4

Airway Management

For high cervical cord injuries (C4 or higher), perform immediate intubation using rapid sequence induction with direct laryngoscopy. 2, 3

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining posterior stabilization 2, 5
• Use a gum elastic bougie to increase first-attempt success rate 1, 2
• Maintain cervical spine in neutral axis without Sellick maneuver 2, 4
• Critical pitfall: Succinylcholine can be safely used ONLY within the first 48 hours after spinal cord injury; after 48 hours it risks life-threatening hyperkalemia due to denervation hypersensitivity 2, 5, 4
• For lower cervical injuries (C5-C7), evaluate respiratory mechanics on a case-by-case basis, but recognize that any spinal cord lesion above T11 will disrupt respiratory mechanics in the acute setting 3

Hemodynamic Management: The Priority for Preventing Secondary Injury

Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality, then target mean arterial pressure ≥70 mmHg continuously during the first 7 days post-injury. 1, 2, 4

• Hypotension at hospital admission (SBP <110 mmHg) is an independent factor of patient mortality after spinal cord injury 1
• Time spent with MAP <65-70 mmHg shows reverse correlation with neurological improvement 1
• Continuously monitor blood pressure as achieving target MAP is difficult—patients spend approximately 25% of time below target 1
• Use vasopressors aggressively to maintain these targets, particularly in neurogenic shock from injuries above T6 4

Diagnostic Imaging

Obtain CT of the spine without IV contrast as the initial imaging study for all patients with suspected spinal cord injury when imaging is indicated by clinical criteria. 1

• CT is the gold standard for identification of spine fractures, outperforming radiographs 1
• CT detects fracture, subluxation, and dislocation requiring immediate stabilization 1
• Reconstruct thoracic and lumbar spine images from existing chest, abdomen, and pelvis CT data when available—this is both effective and radiation dose sparing 1

Obtain MRI of the spine without IV contrast within 48-72 hours from time of injury for all patients with confirmed or suspected spinal cord injury. 1, 3, 6

• MRI is complementary to CT, allowing detailed assessment of soft tissues, ligamentous integrity, intervertebral disc injury, and spinal cord injury 1
• MRI should include T2-weighted images and gradient-echo sequences to characterize cord compression by disc herniation, bone fragments, and hematomas 1
• The BASIC score (Brain and Spinal Injury Center score) on MRI is the most accurate predictor of short-term and long-term neurological outcomes, superior to other MRI measures 7
• MRI is mandatory for patients with neurological deficits, suspected cord compression, or suspected ligamentous instability 1

Neurological Assessment

Grade all patients daily using the American Spinal Injury Association (ASIA) classification, with the first prognostic score at 72 hours post-injury. 3

• The 72-hour ASIA score provides the most reliable initial prognostic information 3
• Continue daily ASIA assessments to monitor for neurological deterioration or improvement 3

Surgical Consultation and Timing

Consult a spine surgeon immediately for all patients with spinal cord injury to discuss operative versus nonoperative management. 3

• Current guidelines recommend surgery within 24 hours after trauma, with emerging evidence suggesting potential benefit from ultra-early surgery 8
• Indications for surgery include: partial or progressive neurological deficit, instability of the spine preventing mobilization, correction of deformity, and prevention of potential neurological compromise 3
• Early surgical decompression within 24 hours appears to have beneficial effect on neurological recovery 8

Respiratory Management

For high cervical injuries (C2-C5), perform early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times. 2, 5, 4

• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures 5
• Implement comprehensive respiratory bundle including abdominal contention belt during spontaneous breathing, active physiotherapy with mechanically-assisted insufflation/exsufflation device, and aerosol therapy combining beta-2 mimetics and anticholinergics 5

Prevention of Secondary Complications

Begin aggressive prevention measures immediately, including early mobilization once spine is stabilized, visual and tactile checks of all at-risk areas at least once daily, and repositioning every 2-4 hours. 2, 5

• Use high-level prevention supports (air-loss mattress, dynamic mattress) 4
• Implement IVC filters in bedbound patients and low-molecular weight heparins (superior to unfractionated heparin) to prevent pulmonary emboli from deep venous thromboembolisms 3
• Initiate intermittent urinary catheterization as soon as daily diuresis volume is adequate; self-intermittent urethral catheterization is the gold standard 2, 5, 4
• Remove indwelling catheters as soon as the patient is medically stable 5, 4
• Provide robust nutritional support as a mainstay of treatment 3

Pain Management

Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute management. 2, 4

• For neuropathic pain developing later: prescribe oral gabapentinoids for more than 6 months 2, 4
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 5

Pharmacologic Therapy: What NOT to Do

Do not administer steroids for acute spinal cord injury. 4

• Professional neurosurgery societies in the United States have given a level 1 statement against steroid use in all patients due to study design flaws and data analysis inconsistencies in NASCIS II and III trials 4, 3
• No other evidence-based pathomechanistically targeted therapies are currently available 2

Early Rehabilitation

Begin rehabilitation immediately after stabilization to maximize neurological recovery. 2, 5, 4

• Physical exercise enhances central nervous system regeneration through neurotrophic factors 2, 4
• Implement stretching techniques for at least 20 minutes per zone 2, 4
• For incomplete injuries, initiate gravity-assisted ambulation or body weight support with treadmill training 5
• Recognize that neurological recovery is a several-year process with most recovery occurring in the first year, making aggressive rehabilitation crucial 3

Critical Pitfalls to Avoid

• Delaying immobilization in suspected spinal cord injury leads to worsening neurological outcomes 2, 5, 4
• Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia 2, 5, 4
• Inadequate blood pressure support below target thresholds increases secondary ischemic injury to the spinal cord 2, 4
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 2, 5, 4
• Missing occipitocervical dislocation on CT—maintain high clinical suspicion even with negative imaging 3
• Failing to assess for other bodily injuries—there is high incidence of visceral, pelvic, and long bone injuries in patients with spinal cord injury 3