For articles, radiology, and case presentations on spinal trauma, click on TRAUMA.ORG. Click on Spinal Cord Injuries for a 2006 chapter from E-Medicine.A self-directed learning module on acute management of SCI was published by (Wuermser, et al 2007).

The primary objectives of emergency medical care are to:

1. Save the life of the injured patient and limit secondary damage, by maintaining an adequate airway, cardiopulmonary resuscitation, and fluid management

2. Stabilize the spine to prevent further damage to the spinal cord while the patient is being transported to a trauma canter. With the patient in a supine position, the spine is immobilized in a hard cervical collar, or sandbags, "logrolling," or a rigid spine board is used to completely immobilize the spine.

     Patients who have spinal pain, sensory or motor deficits, impaired consciousness, major systemic trauma, and/or who are injured due to a motor vehicle crash, a fall, sports, or violence are assumed to have spinal trauma, until proven otherwise (Yarkony, et al 1997).  Spinal immobilization is indicated if any of the following are present in the patient: impaired consciousness, drug and/or alcohol use, loss of consciousness, presence of spinal pain/tenderness, presence of neurologic deficit, concomitant serious injury, or presence of pain with range of motion (Muhr, et al 1999). A 4-year prospective study of 13,483 patients confirmed the use of selective stabilization for patients with altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness (Domeier, et al 2005). Selective immobilization of patients with cervical injuries can be safely applied, but should be used with caution at extremes of age (Stroh & Braude, 2001).

The primary objectives of the acute care unit are to:

1. Immobilize the spine to prevent further spinal cord trauma. A spine board and rigid cervical collar or halo orthosis, or a halo-vest are recommended (Chandler, et al 1992). This practice is widely recommended and widely used, although its effect has not been clearly established (Kwan, et al 2001). A combination of a rigid cervical collar and supportive blocks on a backboard with straps is very effective in limiting motion of the cervical spine and is recommended (Hadley, et al 2002). A risk of cervical collar-related decubitus ulceration increases with every day of Philadelphia cervical collar time and may be reduced by measures aimed at earlier cervical spine clearance (Ackland, et al 2007).

2. Medically stabilize the patient, e.g.:
   • Treat neurogenic shock with intravenous fluid replacement and by placing the patient in the Trendelenburg position (20 to 40 degrees) to facilitate the central return of venous blood, followed by intravenous atropine and cardiac pressors (dopamine) if necessary (Vaccaro, et al 1997)
   • Maintain the airway and systemic oxygen delivery to prevent hypoxemia and secondary injury and aspiration of gastric contents, via suctioning, a standard cutoff oral airway, intubation, supplemental oxygenation, etc. (Fehlings & Louw 1996; Vaccaro, et al 1997)

3. Decompress the spine, if indicated, for example, if there is an ascending lesion, an incomplete lesion with continued cord compression, or bilateral facet dislocation.  Although there is little agreement on the optimum timing of surgical treatment (Fehlings & Tator, 1999; Tator, et al 1999; Fehlings et al, 2001), early surgery may improve neurologic recovery and decrease hospitalization time in patients with cervical spinal cord injuries (Mirza, et al 1999) and for unstable thoracic spine trauma (Albert & Kim 2005). Early surgery may also decrease systemic complications in patients with thoracolumbar spinal cord injuries (Cengiz, et al 2008).
   
   Urgent decompression of bilateral locked facets in a patient with incomplete tetraplegia or in a patient with SCI with neurologic deterioration is recommended. Urgent decompression in acute cervical SCI remains a reasonable practice option and can be performed safely. There is emerging evidence that surgery within 24 hours may also reduce length of intensive care unit stay and reduce post-injury medical complications (Fehlings & Perrin, 2006).
   
   There has been an increase in the use of surgical procedures involving surgical decompression of the spine (Waters, et al 1999). Although the effect of immediate spinal cord decompression on neurological outcome is controversial, when based on magnetic resonance imaging the feasibility of this protocol for cervical SCI in a tertiary treatment center is well demonstrated (Papadopoulos, et al 2002). Supra segmentally-generated EMG discharges (SEDs) can be identified during extradural spinal cord depression and can supplement TCE MEP recording. Severe SED occurrence is associated with a 50% risk of subsequent corticospinal conduction block (Skinner et al, 2009). Prophylactic use of methylprednisolone (MP) during surgical stabilization should be avoided in patients who received MP on admission (Molano, et al 2002).

4. Administer 30 mg/kg methylprednisolone for 24 hours per the National Acute Spinal Cord Injury Studies (NASCIS) and within the first 8 hours after injury to decrease the extent of the injury and the duration of rehabilitation and improve functional recovery (Bracken, et al), unless there is systemic fungal infection, hypersensitivity, or other contraindications, such as penetrating wounds, pregnancy, patient age <13 years, infection, and diabetes (Vaccaro, et al 1997). Other contraindications are patients aged more than 60 years with cervical spinal injury who are more likely to have pulmonary side effects (Matsumoto, et al 2001).
   
   Patients who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours.  If methylprednisolone therapy is initiated 3-8 hours after injury, it should continue for 48 hours (Bracken, et al 1998; Bracken, 2005; Delamarter & Coyle, 1999).  Although therapy with Solu-Medrol may promote early infectious complications, it has no adverse impact on long-term outcomes in patients with acute SCI (Gerndt, et al 1997).

   There has been some controversy over the efficacy of high dose methylprednisolone (Nesathurai, 1998; Short, et al 2000; Pointillart, et al 2000), over administering methylprednisolone within the first 8 hours (George, et al 1995), over the effects of administering methylprednisolone following the initial high dose (Fehlings & Louw, 1996; Bracken, 1990; Bracken, 1991), over the routine use of methylprednisolone in acute non-penetrating SCI (Hurlbert, 2001; Qian, et al 2005) and over the higher acute care charges and longer hospital stays associated with its use (McCutcheon, et al 2004). MRI suggests methylprednisolone therapy may decrease the extent of intramedullary spinal cord hemorrhage (Leypold, et al 2007).
   
   However, a recent Cochrane Systematic review concluded that high dose methylprednisolone therapy is the only pharmacological therapy shown to have efficacy in a Phase III randomized trial when it is administered within 8 hours of, that additional benefit is realized if the maintenance dose is extended from 24 to 48 hours if the initial dose is delayed between 3 and 8 hours after injury, and that there is an urgent need for more trials of pharmacological therapy (Bracken, 2005).

   Other drugs have also been found useful, such as:

   • 21 - Aminosteroids, specifically tirilazad mesylate (Bracken, et al, 1997)
   • GM-1 gangliosides, oxygen free radical scavengers (such as Vitamin E), calcium channel blockers, and potassium channel blockers (Vaccaro, et al 1997; Geisler, 1998) However, evidence available does not support the use of ganglioside treatment to reduce the death rate in SCI patients. No evidence has yet emerged that ganglioside treatment improves recovery or quality of life in survivors (Chinnock & Roberts, 2005).
   • Cysteine precursors (such as N-acetylcysteine), platelet-activating factor antagonists (such as BN 52021), and aggressive nutritional support (Juurlink & Paterson, 1998).
   • Protease inhibitors to prevent apoptosis which probably occurs following SCI as part of the secondary injury process (Emery, et al 1998).

   Future therapy to mitigate secondary damage in acute SCI may involve:

   • combination therapies (Amar & Levy, 1999)
   • antiapoptotic drugs, free radical scavengers, and anti-inflammatory agents (Lu, et al 2000)
   • Naloxone, an opiate antagonist, to lower CSF levels of excitatory amino acids, elevated in patients with SCI. CSF glutamate is the strongest independent predictor of SCI (Kunihara, et al 2004).
   • CSF drainage to lower intrathecal pressure (Kwon, et al 2009).

5. Determine the extent of neurologic impairment - 2005 guidelines of the American College of Radiology recommend that patients who are not alert, have lost consciousness, are under the influence of alcohol and/or drugs, have distracting injuries, have cervical tenderness, and have neurologic findings should have at minimum a three-view cervical radiographic series followed by helical computed tomography (CT). In certain instances, the cervical CT examination will be performed immediately after a cranial CT while the patient is still in the CT suite. This is both time-effective and cost-effective.
   • Flexion/extension radiography is not recommended
   • Supine oblique views are no longer necessary if CT examination is done
   • MRI should be reserved for patients with clear-cut neurologic findings and those suspected of ligamentous instability
   
   Other methods include:
   • Standard radiographic study (5 view series) for all patients with cervical trauma who are alert and sober; have neck pain or tenderness, a neurologic deficit, polytrauma, or craniofacial injuries; and for all inebriated or unconscious patients with sustained trauma. Additional radiographs of the thoracic spine, the lumbar spine, and extremities for all patients with multiple injuries, or who are unconscious or neurologically compromised (Slucky & Eismont, 1995).

     A three view cervical spine series (AP, lateral, and odontoid views) is recommended for radiographic evaluation of the cervical spine in patients who are symptomatic following traumatic injury. This should be supplemented with computed tomography to further define areas that are suspicious or not well visualized on the plain cervical x-rays (Hadley, et al, 2002).

     Less than 1% of SCI in adults is undetected by a technically adequate plain radiographic series. The most common magnetic resonance imaging findings among SCI without radiographic abnormality are central disc herniation, spinal stenosis, and cord edema or contusion (Hendey et al 2002).
     
     

   • CT  scans for patients who are unconscious or have suspicious or inadequate cervical radiographic findings.  For example, cervical plain films that do not adequately image the cervical vertebrae, are abnormal, or are negative but the patient has clinical symptoms consistent with cervical injury (Petri & Gimbel, 1999). CT scans can reveal the ratio of sagittal-to-transverse diameter of the spinal canal at the level of injury; a significantly smaller ratio is predictive of neurological deficit (Vaccaro, et al 2001). CT is recommended for fractures of the posterior elements of the spine and injuries of the craniocervical junction (Crim, et al 2001). In the unconscious patient, the cervical spine can be reliably cleared using helical CT alone (Spiteri, et al 2006).
     
     
   • MRI scans (Nichols, et al 1997; Levitt & Flanders 1991) for patients with neurologic deficit or deteriorated neurologic status; to assess the type of SCI, the cause and degree of spinal cord compression, and the stability of the spinal column in patients with cervical SCI (Fehlings, et al 1999; Takhtani & Melhem, 2002); if there is suspicion of disk retropulsion with canal compromise or possible posterior ligamentous injury; for excellent visualization of spinal soft tissue structures (Slucky & Eismont, 1995); and for prognostic information regarding neurological function (Slucky & Potter, 1998) based on four MRI characteristics: presence of intra-axial hematoma, extent of spinal cord hematoma, extent of spinal cord edema, and spinal cord compression by extra-axial hematoma (Selden, et al 1999).
     
     
6. Determine the expected functional outcome, based on the:
   • American Spinal Cord Injury (ASIA) protocol for acute SCI (Hadley, et al 2002); SCI impairment is more accurately characterized by using separate ASIA upper- and lower-extremity motor scores than by using a single motor score (Marino & Graves, 2004)
   • The ASIA protocol and somatosensory evoked potentials (SSEP) (Curt & Dietz 1997)
   • The ASIA protocol, motor-evoked potentials (MEP), and clinical examination (Curt, et al 1998)
   • An equal-interval measure of neurologic impairment from the ASIA International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients (Bode, et al 1999)
   • The functional independence measure (FIM) scores (Saboe, et al 1997; Hall et al, 1999); the short version of the FIM (Dijkers & Yavuzer, 1999)
   • The Self-Reported Functional Measure (SRFM), a measure derived from the FIM instrument with predictive validity for hospitalization, lengths of stay, and discharge destination (Hoenig, et al 2001)
   • The modified Barthel Index (MBI) is recommended as a functional outcome assessment tool for clinicians involved in the assessment and care of acute spinal cord injury patients (Hadley, et al 2002).
   • Although MEP and SSEP are similar to the clinical examination in predicting functional outcome of ambulatory capacity, EMG, neurographic and reflex recordings are more sensitive than clinical examination in assessing associated damage of the peripheral motor pathways (which allow for the possibility of predicting the development of muscle tone or muscle atrophy), and SSP can provide information about lesions of the spinal sympathetic nervous system which relate to autonomic dysfunction (Curt & Dietz, 1999).
     
   • Digital Imaging. Cord hemorrhage, contusion, and edema on MRI were not associated with diagnosis of a complete cord injury after neurological assessment from initial clinical examination was taken into account (Shepard & Bracken, 1999). Patients with initial hemorrhage had a poor prognosis, whereas those with spinal cord edema had a good clinical outcome (Andreoli, et al 2005).
   • Maximum spinal cord compression (MSCC), spinal cord hemorrhage, and cord swelling are associated with a poor prognosis for neurologic recovery. Extent of MSCC is more reliable than presence of canal stenosis for predicting the neurologic outcome after SCI (Miyanji, et al 2007). For cases with minimal cord compression, the measurement of canal stenosis (MCC) proved more accurate. In contrast, in cases with severe cord compression, the assessment of MSCC was more accurate. It is anticipated that the use of digital imaging technologies will further enhance the precision of these outcome measures (Fehlings, et al 2006).
   • Patients with isolated cervical SCI have significantly greater frequency of RHC, leukocytosis, lymphopenia, and thrombocytopenia than controls during the first week posttrauma. The degree of RHC and lymphopenia was significantly associated with the severity of SCI (Furlan, et al 2006).
     
     

7. Prevent joint contractures (a complication of immobilization in which there is resistance to passive stretch of a muscle due to fibrosis of the muscles or disorders of muscle fiber) by:
   • Range of motion exercises, and additional passive ROM, 2 -3 times daily, if spasticity develops
   • Orthotic management of the wrists, hands, shoulders, hips, ankles, and knees, such as resting hand splints or long opponens orthoses, splinting the ankle in neutral while preventing pressure ulceration of the heels, and abducting the shoulder to 90 degrees when possible
   • Proper positioning
     
     
8. Use special, well-padded, rotating beds, if available, to prevent pressure ulcers and respiratory problems in patients with thoracic and lumbar fractures

9. Diagnose and treat the anemia, hypoproteinemia, and hypoalbuminemia commonly seen in the acute SCI population (Lipetz, et al 1997). The presence of either proteinuria with protein of 500 mg/d or greater or creatinine clearance less than 60 mL/min is associated independently with increased mortality in the chronic spinal cord injury population. The presence of both conditions further increases this risk (Greenwell, et al 2007).

10. Prevent or diagnose and treat complications, such as pressure ulcers, urinary tract infections, gastrointestinal dysfunction, pulmonary problems, deep venous thrombosis and pulmonary embolism, autonomic dysreflexia, and heterotopic ossification

11. Begin rehabilitation within the constraints of possible life support measures.

     Acute short-term care provided in a spinal cord center, as opposed to a general hospital, ensures the best medical and functional outcomes with the shortest possible lengths of stay (DeVivo, et al 1999). Most studies support the cost effectiveness of care for SCI in dedicated units or centers rather than in a general medical unit (Cardenas, et al 2001). Only 4.3% of patients treated in a model SCI system in the U.S. are discharged to nursing homes (DeVivo, 1999). Age at injury, number of days to rehabilitation admission, number of pressure ulcers and medical complications, level of injury, and sponsor of initial hospitalization are effective predictors of rehabilitation length of stay (Burnett, et al 2000). In acute cervical spinal injury without concurrent thoracic injury, the number of respiratory complications during the initial acute-care hospitalization is a more important determinant of length of stay than level of injury (Winslow, et al 2002). Between 1990 and 1997, acute rehabilitation lengths of stay decreased from 74 to 60 days , while discharges to nursing homes and rehospitalizations increased (Eastwood, et al 1999) and medical complications previously seen in acute care occur in the rehabilitation setting (Chen, et al 1999). Between 1995 and 2002, despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations (Cardenas, et al 2004). If rehabilitation services are to be evidence-based, relevant and effective in meeting the needs of people with SCI they must be informed by the perspectives of people with SCI. The findings of this review suggest that the most important dimension of rehabilitation for people with SCI is the calibre and vision of the rehabilitation staff (Whalley Hammell, 2007).