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

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

Surgical indication

• Risk of spine instability and spinal cord compression depends on intensity and mechanism of trauma