Chapter 114. Initial Management of Spinal Cord Injury (SCI)

Karim Tazarourte, MD; Eric Cesareo, MD; David Sapir, MD

Always suspect spine injury in significant trauma, even if no initial neurologic sign

DO NOT WORSEN LESIONS: immobilize, treat as unstable spine until cleared.

Beware of secondary SCI due to mechanical trauma (spine lesions) and/or ischemia

Spinal cord injury above C4 will block the diaphragm; high thoracic lesion will block abdominal and thoracic accessory muscles and weaken cough.

Conscious patient: motor or sensory deficit often obvious.

Comatose patient: diagnosis more difficult. Treat as unstable spine until cleared (CT-scan). Additional suspicion if hypotension without tachycardia.

Be thorough. Do not miss other lesions.

Spine immobilization by cervical collar and spinal board systematically
Only exception: alert, normal neurologic status, AND no pain: no imaging needed, remove collar

Airway

Assess need for intubation: in-line stabilization with RSI. FOB or video laryngoscope if available
Consider retrograde intubation if facial trauma
No nasal intubation in trauma patient
Avoid succinylcholine, especially if neurogenic shock (risk of extreme bradycardia); if necessary, administer atropine prior to succinylcholine

Breathing

Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg
Gastric atony and distention: decompress stomach to facilitate ventilation

Circulation

Insert A-line and CVL
MAP > 80 mm Hg with isotonic crystalloids (fluid will not increase ICP in a hypotensive TBI patient)
If needed, initiate norepinephrine infusion through a CVL
Transfuse as needed for Hb > 8 g/dL
If severe hemorrhage due to other lesions, emergent surgical hemostasis might be needed

Neuro

Thorough clinical examination to document neurologic deficit, including assessment of anal sphincter tone and contraction
- Level of lesion? (Not always the same on both sides)
- Complete or incomplete lesion? (Any sensory/motor preservation below lesion, and/or anal sphincter tone maintained = incomplete lesion)
- ASIA score (see scoring sheet = Figure 114-1)
30% spinal cord injuries are at multiples levels
Assess for traumatic brain injury (see Chapter 113): GCS, neurological exam
Whole body (vertex to pelvis) CT scan to diagnose associated lesions
Transfer the patient to a specialized center as soon as possible
Methylprednisolone probably not helpful, but still widely used as there is no effective therapy