Spinal Cord Injury Management
Acute spinal cord injury (SCI) is a devastating condition resulting in high morbidity and long-term disability. Management focuses on rapid diagnosis, spinal immobilization, airway protection, and maintenance of perfusion with a target mean arterial pressure of ≥85–90 mmHg. The pathophysiology involves a primary mechanical insult followed by secondary injury cascades—ischemia, inflammation, and apoptosis—which are key therapeutic targets. High-dose steroids are no longer routinely recommended due to limited benefit and adverse effects.
Early surgical decompression, ideally within 24 hours, has been shown to improve neurological outcomes in selected patients (STASCIS trial). Emerging therapies such as neuroprotective agents, stem cell transplantation, and neuroprosthetic technologies are under investigation. A structured multidisciplinary approach combining early stabilization, evidence-based acute care, and long-term rehabilitation remains the cornerstone of SCI management.
Introduction
Acute spinal cord injury (SCI) is a catastrophic event that results in significant morbidity and long-term disability.
The annual incidence ranges from 10 to 80 cases per million worldwide, with motor vehicle accidents, falls, sports injuries, and violence being the most common etiologies.
· Pathophysiology of SCI involves two major phases:
Primary Injury
- Mechanical disruption due to fracture, dislocation, compression, or penetrating trauma.
- Immediate axonal disruption and vascular damage.
Secondary Injury
- Occurs minutes to weeks after trauma.
- Mechanisms: ischemia, excitotoxicity, ionic imbalance, oxidative stress, lipid peroxidation, apoptosis, and inflammation.
- Secondary injury is the main target of medical and surgical interventions.
Initial Evaluation and Assessment
Prehospital Care
- Immobilization: Rigid cervical collar and spinal board use until spinal injury is excluded.
- Airway, Breathing, Circulation (ABC): Prioritize airway control with cervical spine protection.
- Rapid transport to a designated trauma center.
Emergency Department Assessment
- Neurological Examination: American Spinal Injury Association (ASIA) Impairment Scale (AIS) used to grade severity.
- Imaging: Plain radiographs, CT scan (gold standard for bony injury), MRI (superior for cord compression, hemorrhage, disc, and ligamentous injury).
Acute Medical Management
Airway and Breathing
- High cervical injuries (C1–C4) may require immediate intubation or tracheostomy.
- Mechanical ventilation as indicated.
Circulatory Support
- Neurogenic shock: Characterized by hypotension and bradycardia.
- Target mean arterial pressure (MAP): Maintain ≥85–90 mmHg for the first 7 days (AANS/CNS guidelines).
- Vasopressors (e.g., norepinephrine) preferred.
Pharmacological Management
- Methylprednisolone (NASCIS trials): Historically used but remains controversial due to infection and GI complications.
- Riluzole: sodium channel blocker; phase II–III clinical trials ongoing.
- GM1 ganglioside: promising in preclinical studies but failed in phase III trials.
- Minocycline: anti-inflammatory antibiotic; phase II showed motor improvement, phase III underway.
-Granulocyte Colony-Stimulating Factor (G-CSF): early trials suggest improved outcomes.
- Other preclinical agents: magnesium, fibroblast growth factor, hepatocyte growth factor.
DVT and Ulcer Prophylaxis
- Low molecular weight heparin, compression devices, frequent repositioning, specialized mattresses.
Neuroregenerative Approaches
- Rho-ROCK inhibitors (e.g., Cethrin): early promise, but phase III trial stopped for futility.
- Anti-Nogo-A antibody: enhances axonal sprouting in animal models, not yet in clinical trials.
- Cell-based therapies: Schwann cells, olfactory ensheathing cells, mesenchymal stem cells under investigation; clinical results remain inconsistent.
Surgical Management
· Indications for Surgery
- Persistent spinal cord compression.
- Instability of the vertebral column.
- Progressive neurological deficit.
- Associated unstable fractures or dislocations.
Timing of Surgery
- Early decompression (<24 hours): Supported by STASCIS trial, associated with improved neurological recovery.
Prognosis
- Complete injuries (AIS A): Lower likelihood of neurological recovery.
- Incomplete injuries (AIS B–D): Higher potential for improvement, especially if early surgical decompression is performed.
- Factors influencing prognosis: age, initial severity, level of injury, timing of intervention.
Future Directions
- Neuroregeneration and stem cell transplantation.
- Neuroprosthetics and brain-computer interfaces.
- Biomarkers for prognosis and individualized treatment.
- Advanced rehabilitation technologies: robotic-assisted gait training, exoskeletons, virtual reality therapies.
Key Points
- Acute SCI requires rapid diagnosis and structured management.
- Initial management: immobilization, airway protection, hemodynamic stabilization, early imaging.
- High-dose steroids are no longer routinely recommended.
- Early surgical decompression (<24 hours) improves neurological outcomes in selected patients.
- Long-term rehabilitation is critical for maximizing functional recovery and quality of life.
References
1. Fehlings MG, et al. Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the STASCIS Trial. PLoS ONE. 2012.
2. Hadley MN, Walters BC, et al. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery. 2013.
3. AANS/CNS Joint Section. Management of Acute Cervical Spine and Spinal Cord Injuries. J Neurosurg Spine. 2013.
4. Tator CH, Fehlings MG. Review of the Secondary Injury Theory of Acute Spinal Cord Trauma. J Neurosurg. 1991.
5. Wilson JR, et al. Acute Traumatic Spinal Cord Injury: Current Evidence and Future Directions. Spine. 2020.