Medical Care
Discussing each therapeutic strategy separately is difficult because of the diversity of etiologic processes and manifestations. Instead, this article focuses on general guidelines for the management of patients with spinal cord injury (SCI), especially after traumatic SCI.
Important advances in the medical and surgical management of SCI have occurred in recent years. The primary goal is to limit secondary injury.
Spinal stabilization, immobilization, and management of hemodynamic and/or autonomic disturbances are crucial in the acute injury phase, while management of gastrointestinal (eg, ileus, constipation, ulcers), genitourinary (eg, urinary tract infections, hydronephrosis), dermatologic (eg, bed sores), and musculoskeletal (eg, osteoporosis, fractures, overuse syndromes, acute and chronic pain) complications is the long-term goal.
Patients with acute traumatic central cord syndrome should have intensive care unit management, particularly if severe neurological deficits are present. Medical management should include hemodynamic and respiratory monitoring with maintenance of mean arterial pressure at 85-90 mmHg for the first week after injury to improve spinal cord perfusion.
If trauma is suspected, stabilize the head and neck manually or with a collar. Move the patient very carefully using the logroll technique to prevent lateral displacement. A spine board with restraints is recommended, but other items, such as head blocks, pillows, and cushions, may be useful. Careful and fast transportation of patients from the site of injury to the nearest medical facility is recommended; whenever possible, transportation to a specialized acute spinal cord injury treatment center is preferred.
Emergent radiation therapy may be required for metastatic disease. For spinal tumors causing mass effect, a few anecdotal protocols use dexamethasone in high doses of 10-100 mg IV followed by 6-10 mg IV q6h for 24 hours, potentially tapered intravenously or orally over 1-3 weeks.
A multicenter study reported reduced mortality rates after SCI with high doses of methylprednisolone administered within 8 hours, and this practice has been considered the standard of care in the United States. [9] However, this remains controversial because of increased risk of gastric bleeding and wound infection.
The Third National Acute Spinal Cord Injury Randomized Controlled Trial (NASCIS III) revealed that patients with acute spinal cord injury who receive methylprednisolone within 3 hours of injury should be maintained on therapy for 24 hours. When methylprednisolone is initiated 3-8 hours after injury, patients should be maintained on therapy for 48 hours. [10]
A small, 2-year, prospective study from Japan with 79 patients found no benefit from acute treatment and reported a higher incidence of pneumonia in the treated group. [11]
Several societies, including the Canadian Association of Emergency Physicians are no longer recommending this protocol as a standard of care for acute spinal cord injury management. The second iteration of guidelines for the management of acute cervical spine and spinal cord injuries, published in Neurosurgery in 2013, also did not recommend the use of methylprednisolone and down-graded the evidence to level III, as well as reporting that class I, II, and III evidence that steroids are associated with harmful effects, including death. [12, 13]
GM1 ganglioside, naloxone, and tirilazad had no benefit in a multicenter trial despite beneficial results in experimental animals.
Surgical Care
Early surgery to remove damaging bone, disk, and foreign bodies is controversial unless severe compromise of the canal is clear, but surgical decompression of the spinal cord, particularly if the compression is focal and anterior, is recommended. Early reduction of fracture-dislocation injuries is also recommended. Surgical interventions in the subacute phase (ie, 24-72 h later) have yielded unsatisfactory results because most tissue damage is irreversible at that point.
Consultations
In the acute phase, severe SCI, especially after high lesions, requires the attention of a specialized trauma team.
For long-term management, consultations with many specialists are often necessary because of the multiple organ complications that follow SCI.
Specifically, referral to a urologist, a gastroenterologist, a psychiatrist, a plastic surgeon, a dermatologist, and a pain management specialist may be necessary. Rehabilitation specialists such as physiatrists or neurologists become involved after the immediate hospitalization.
Diet
Dietary changes to maximize bowel function may be indicated. Calcium and vitamin D supplementation should be considered to avoid osteoporosis.
Activity
Early rehabilitation is encouraged once stabilization of the spine has been achieved.
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A T1-weighted MRI that depicts a lesion with high signal enhancement inside the cervical spinal cord. This type of signal enhancement is consistent with blood and is most commonly observed secondary to cord trauma.
