CHAPTER 122: Spinal Injuries

KEY POINTS

• In acute spinal cord injury (SCI), primary injury determines the extent of potential recovery, and mitigation of secondary injury determines how much neurological recovery is obtained.

• The prevention of secondary injury, or “neuroprotection,” consists of spine immobilization, timely surgical intervention, and early recognition and treatment of hemodynamic instability, respiratory failure, and hypoxemia.

• The baseline neurological examination to determine a neurological level and the completeness of injury, coupled with the results of computed tomography and magnetic resonance imaging, form the basis of the neurosurgical intervention decision.

• Acute SCI patients, particularly those with cervical level and severe SCI, are at risk for respiratory arrest, hypoxemia, and cardiovascular instability. Many patients with level spinal injuries will require intubation and tracheostomy.

• The term “neurogenic shock” refers to hypotension due to vasodilation that may be accompanied by absolute (heart rate <60) or relative bradycardia caused by the loss of outflow from the sympathetic autonomic component of the spinal cord arising from the high thoracic and cervical regions. This can be seen at injuries to the T6 level and above.

• The American Association of Neurological Surgeons level III recommendation is to maintain mean arterial pressure 85 to 90 mm Hg for the first 7 days after acute SCI.

• Among trauma patients, the risk of venous thromboembolism (VTE) is likely highest after acute SCI, with an odds ratio of 8.6 compared to trauma patients without SCI. Start mechanical thromboprophylaxis with intermittent sequential compression-decompression devices as soon as feasible, followed by chemoprophylaxis; low-molecular weight heparin lowers VTE rates when initiated within 48 hours of surgery for SCI and is safe without increasing the risk of bleeding and mortality.

• Pulmonary embolism (PE) has fallen from the third leading cause of death within the first year after acute SCI (14.9%) to the sixth (3.3%) leading cause of death. After any sudden hemodynamic compromise, unexplained dyspnea, or hypoxemia, PE must be considered.

• Rehabilitation specialists should be consulted early in the management of persons with SCI, following spinal decompression or stabilization and resolution of life-threatening cardiac and respiratory events.