Overview
This lecture covers comprehensive management of spinal cord injury (SCI), including acute clinical care, surgical options, long-term complications, and the importance of multidisciplinary protocols.
Pathophysiology of Spinal Cord Injury
- SCI involves both primary injury (initial trauma) and secondary injury (progressive cellular and biochemical damage).
- Primary injury is irreversible and best prevented; secondary injury can be minimized by medical management.
- Secondary injury involves inflammatory responses, hypoperfusion, oxidative stress, and worsened outcomes from avoidable hospital events.
Initial Assessment and Acute Management
- Follow trauma ABCDEs: Airway, Breathing, Circulation, Disability (neuro exam), Exposure.
- Immobilization prevents worsening primary SCI; use cervical collars/backboards with careful log rolling.
- Obtain full-spine CT for suspected SCI; MRI reserved for further evaluation based on neuro exam or CT findings.
- All SCI patients require ICU care to monitor and prevent secondary injury, especially hemodynamic and respiratory instability.
- Maintain mean arterial pressure (MAP) 85–90 mmHg for 7 days post-injury to optimize cord perfusion; treat hypotension aggressively.
Respiratory and Pharmacologic Management
- Cervical SCI often impairs diaphragm/intercostal function; injuries above C3 require immediate ventilatory support.
- Monitor for signs of respiratory failure; consider early intubation if declining.
- Routine use of high-dose steroids (e.g., methylprednisolone) is controversial due to limited benefit and increased risk of infection and GI complications; strict protocols are recommended if used.
Surgical Management
- Surgical goals: decompress spinal cord and stabilize fractures, enabling early mobilization.
- Techniques include traction (e.g., Gardner-Wells tongs for cervical jump facets) and surgical fixation (e.g., pedicle screws).
- Weigh risks of traction and timing of MRI; monitor neuro status closely.
- Mobilization post-surgery reduces risk of DVT/PE and pressure ulcers.
Prevention of Complications
- Initiate VTE prophylaxis (mechanical and/or pharmacologic) within 72 hours if possible; continue for at least 3 months.
- Prevent pressure ulcers with frequent repositioning, padding, nutrition, and early mobilization.
- Manage orthostatic hypotension, autonomic dysreflexia, and address equity in access to rehab and long-term care.
Chronic and Late Complications
- Chronic pain (somatic, visceral, neuropathic) is highly prevalent and disabling; requires multimodal management.
- Overuse syndromes (shoulder, wrist, carpal tunnel) arise due to compensatory upper extremity use.
- Increased risk for cardiovascular disease, osteoporosis, and heterotopic ossification below lesion level.
- Spasticity, syringomyelia, and Charcot spine are late complications requiring individualized treatment.
- Multidisciplinary rehab is essential for maximizing function and quality of life.
Key Terms & Definitions
- Primary injury — Immediate mechanical damage to the spinal cord at the time of trauma.
- Secondary injury — Ongoing cellular and biochemical processes causing further neural damage post-injury.
- Autonomic dysreflexia — Sudden, severe hypertension and headaches triggered by stimuli in SCI above T6.
- Orthostatic hypotension — Drops in blood pressure upon standing due to impaired autonomic response.
- Charcot spine — Degenerative spinal destruction from lack of sensation below injury, causing a false joint.
- Syringomyelia — Formation of a fluid-filled cavity (syrinx) in the spinal cord post-injury.
- Spasticity — Involuntary muscle stiffness/spasms following SCI.
Action Items / Next Steps
- Review and follow your institution’s protocols for acute SCI management and immobilization procedures.
- Study guidelines for blood pressure and respiratory management in SCI patients.
- Familiarize yourself with rehabilitation referral processes and support services for SCI patients.
- Prepare for the next lecture/readings on spinal fracture classification and advanced surgical interventions.