Initial management of acute
traumatic spinal cord injuries

F. JACQUOT*, G. LOUBERT**, T. LOEB**, F. SIGNORET***, J-M. FÉRON***

*CHR Metz-Thionville - 57000 Metz

**Hôpital Raymond Poincaré - 92380 Garches

*** Hopital Tenon - 75020 Paris

 

Each year, the functional and vital prognosis of 750 to 1000 patients is threatened when a traumatic spinal cord injury (SCI) occurs. Systematic medical management and progresses in pre-hospital care considerably improved the surviving rate of these patients. The constant evolution of knowledge, especially in the physiopathology of cellular injuries, regularly generates new therapeutic approaches, some of them still controversial. We expose and tempt to clarify the current approach concerning spinal cord trauma management. Essential points during the first hours following the accident are reminded. Controversial material and data still requiring validation is also summarized.

 

Physiopathologic data and therapeutic consequences

The quality of the management arises from a good comprehension of the physiopathology.

On the functional side, cord injury is accompanied by an alteration of respiratory muscles whose importance is function of the level and the incomplete or complete status of the neurological impairment. Cardio-vascular problems, due to loss of compensatory mechanisms, may be in the forefront, and have to be preventively taken into account by a well driven resuscitation.

 

Loss of autoregulation of the spinal cord blood flow

Guha and al. depicted the loss of autoregulation of the spinal cord blood flow close to the level and to the proximity of injuries. The consequences are a decline of the spinal cord blood flow following closely the decline of the systemic arterial blood pressure. This always occurs in cases of tetraplegia or high paraplegia, secondary to the loss of the sympathetic system.
It causes so an hypoxemia to the level of the injured zones.

 

Development of the secondary injury : diagram of Hall

Experimental studies clearly show the role of the " secondary injury " in the constitution of the neurological deficit. If some cellular bodies and axonal continuations in the traumatized area are immediately destroyed (primary lesion), others are victims of vascular, biochemical and electrolytic modifications that lead to their destruction in minutes or hours. Even in cases of complete cord section, the metameric levels adjacent to the destroyed area may suffer and be lost irremediably due to the evolution of the secondary injury. In minutes and hours that follow the trauma, activation of the N-méthyl-D-aspartate (NMDA) receptors is induced by amino-acids (glutamate) liberated in great quantity, and an ionic canal opening follows the receptor activation. The intracellular entry of Ca + + activates the phospholipases and the chain of reactions that creates free radicals production. Free radicals initiate lipid peroxydation, leading to cellular destruction of neurons and micro-vessels of white and gray matters. The resulting tissular hypoxia may be worsened by the low systemic blood pressure, or by any hypoxemia, whatever its origin. While cord decompression remains an essential surgical procedure, the prevention of the extension of injuries using medical actions aiming at limiting vascular, biochemical or electrolytic modifications, seems today equally important. There are several experimental possibilities for secondary biochemical process modification.

Fig.1: Physiopathology of the secondary injury : diagram of Hall.
The release of excitatory amino-acids (Glutamate) promotes the intracellular
entry of calcium and the secondary extension of the injury.

In human care, the NASCIS II and III studies have shown the efficiency of high-dose methylprednisolone, provided it is administered early ; a Japanese study confirmed this efficiency, others have not. Secondary effects linked to the use of high doses of corticosteroids do not increase in a significant manner.

Other possibilities for fighting against ischemia:

Actions against hypoxemia include maintaining a correct hematosis and circulatory state, from the first minute that follows the accident : IV fluid, drugs to maintain blood pressure, oxygenation and even tracheal intubation may be suitable.

These general measures are initiated by the physicians in the initial care emergency medical rescue services for all polytrauma patients, and are continued in admitting hospital departments.

Pre-hospital management

The management of the patient with a potential SCI necessitates on the very place of the accident a rigorous approach. The context of the polytrauma frequently complicates the first diagnostic and therapeutic step. Early medical management from the pre-hospital period (role of the medical rescue units), has made make great progresses in term of surviving and prevention of neurological worsening.

Initial gathering:

A spine injury may be easily overlooked : Henry H. Bohlman brought on a series of 300 fractures of the cervical spine, 100 cases that had not been diagnosed initially on clinical and/or radiological examinations, with delays of diagnosis spreading from one day to one year. Ringenberg noticed the absence of initial diagnosis in 7% of his patients admitted for a cervical spine trauma.
A certain number of spinal injuries may secondary displace in case of an incorrect management.
This possibility has to be taken into account during the intervention of the emergency team. Therefore, the rule consists in considering all polytrauma and comatose patients as having an unstable spinal injury until the opposite is proven, and to act accordingly from the start. This implies precise rules for everyone :

1. Minerva, adapted to the patient;
2. monobloc coordinated clearance of the patient, with maintenance of the head-trunk axis, without excessive traction;
3. Installation in a depression mattress, comprising an anti-retraction device. If the anti-retraction feature is not available, avoiding casting of the vertex and the plantar arch is mandatory.

 

Neurological examination:

If no combined injury threatening the vital prognosis is present, the problem is that of the cord injury. The examination of motricity and sensitivity defines the level of injury. It has been codified by the American Spinal Injury Association, and a motor and sensory score known as "ASIA score" have been established (fig 2).

Fig. 2: ASIA Score: The standard form.

 

The motor score is based on the examination of 10 key-muscles on each side (table I). For each movement, force is measured and assigned a coefficient from 0 (absence of muscle contraction) to 5 when contraction creates a movement in all the joint amplitude against a complete resistance. The maximal total score is so 100 (50 on the Right and 50 on the Left).

Flexion of the elbow	C5	Flexion of the hip	L2
Extension of the wrist	C6	Extension of the knee	L3
Extension of the elbow	C7	dorsal Flexion of the foot	L4
Flexion of P3 3rd finger	C8	Extension of the big toe	L5
Abduction of 5th finger	T1	Plantar Flexion	S1

TABLE I : 10 key-movements of the ASIA score and corresponding metameric level.

The sensory score is established after studying tact and prick sensitivity on a key point in each of 28 dermatomes on each side. Absence of sensitivity is quoted: 0, the hypo or the hyperesthesia : 1 and normal sensitivity : 2. It is preferable to begin the examination by testing the light touch and the lower part of the body. The superior level of the neurological injury is defined in France as the first abnormal metameric level ; in the English-speaking world, it is defined as the last normal metameric level. Thus a T10 paraplegia is T9 in the US. There is a recent tendency to use the US way for result comparisons ( since our C7 quads have no triceps while the American C7 have...)

Finally, the examination seeks to specify the incomplete or complete status of the cord injury. The deficit may be complete or partial, on the sensory or motor side. The persistence of any sensitivity, even in a very limited area, or any muscle activity, below the level of injury, especially in the sacral metameric area (sensitivity of the anal margin, deep anal sensation, voluntary contraction of the external sphincter) signs by definition the incomplete status of the neurological injury. Often there is a dissociation between the sensory and motor level, especially, in complete injuries, the sensory level is usually lower than the motor level. The precise study of the sensitivity, the motricity, reflexes under the injury level, as well as of sphincters, is mandatory. One can then classify the neurological injury according to the modified Frankel scale which is shown in table II.

A	Complete neurological injury. No sensory or motor function is preserved below the level of injury, especially in S4-S5 segments.
B	Incomplete neurological injury. Only the sensory function is preserved below the neurological level, sometimes in S4-S5 segments.
C	Incomplete neurological injury. Some motor function is preserved under the level of injury and the majority of key muscles short of this level have a score inferior to 3.
D	Incomplete neurological injury. Motor function preserved under the level of injury and the majority of key muscles have a score equal or superior to 3.
E	Motor and sensory functions normal.

Table II: The modified Frankel scale.

The predictive value on the functional prognosis of the complete or incomplete status of the neurological injury is considerable. The injury is sometimes associated in the first hours that follow the trauma to an initial phase of "spinal shock" that characterizes by an abolition of all reflexes below the cord lesion. This state is transitory and disappears with the installation of cord automatism. One can assert with certainty the complete status of the injury only after resolution of the spinal shock, usually after several days.

The incomplete status of the cord injury allows to classify it among one of the different incomplete clinical syndromes, that gives a first idea of the functional recovery potential. These clinical syndromes are by definition:

• Central cord syndrome: occurs almost exclusively in the cervical region, produces a sacral sensory sparing and typically more important a motor impairment in the upper limb than the lower limb.
• Syndrome of Brown-Séquard : a unilateral lesion that produces a motor and proprioceptive impairment on the same side as the injury, and a loss of thermal and pain sensitivity on the contralateral side.
• Anterior cord syndrome: an injury that produces a variable motor, thermal and pain impairment, but preserves the proprioception.
• Conus medullaris syndrome : injury to the cone and lumbar roots, that produce areflexia to the bladder and lower limbs. The sacral reflexes may be preserved (bulbocavernosus reflex, miction)
• Cauda equina syndrome : lumbosacral nerve root injury, with areflexia of the bladder and lower limbs.
  The examination is difficult in the context of an ambulance setting ; however, a prospective multicenter pre-hospital trial has shown the feasibility and reliability of the pre-hospital examination.
  

 

Hospital management:

Upon arrival at the hospital, the junction with the medical team that has managed the initial gathering transmits the precise circumstances of the accident, timing, clinical examination data, treatment done, presence of combined initial injuries that are frequently met. The clinical examination is renewed and guides radiological examinations. The neurological examination (ASIA scoring) will be repeated at admission and during the clinical course to get an idea of evolution towards improvement or aggravation.

 

Complementary examinations

Face and profile conventional radiographs permit in the majority of cases to suspect a spine injury. They give only indirect signs of disco-ligamentous and cord involvement. They explore unreliably the cervico-dorsal junction and high thoracic spine. They remain however the basic examination in the trauma patient.

Fig. 3: A typical Tear drop fracture on a plain lateral radiograph

 

Tomographies are given the same role than CT scan by eliminating superpositions (shoulders, different spinal planes). They are seldom realized now, for practical reasons.

The CT scan is not a substitute for standard radiographs. It shows bony injuries and the status of the spinal canal (stenosis, abnormal content), the cervico-thoracic junction and foramina. Tridimensional software reconstruction after helical acquisition sometimes shows injuries that could be easily overlooked otherwise, and better analyzes displacement. The examination is fast and is made with no mobilization of the patient, it may be combined to the search for associated traumatic injuries (thoracic trauma, lesions of intra-abdominal organs, etc).

Fig. 4: A C2Tear drop Fracture combined to a fracture
of the anterior arch of C1 that is visible only
on 3D CT scan software reconstructions


Fig. 5: CT scan showing a very unusual displacement pattern of the vertebral body.


Fig. 6: CT scan with 3D reconstruction: same patient as above.

Magnetic Resonance Imaging (MRI) is a major advantage to explore the cord, discs and ligaments, and to look for an haematoma. Nevertheless, the indication is very carefully weighted in polytrauma patients because of monitoring difficulties during the examination that may be very long.

Anyhow, treatments aiming to minimize the extension of the secondary injury do not have to be delayed by any superfluous radiological exploration.

 

Functional issues

The paralysis of abdominal muscles is responsible for the loss of the cough. Paralysis of intercostal muscles more or less extensive according to the neurological level decreases alveolar ventilation ; the secondary increase of the blood carbon dioxide leads to a modification of the acid-base balance and a diminution of the spinal cord blood flow.

For injuries lower than C4, the alteration of the respiratory function may be obvious only several days after the initial trauma. Artificial ventilation has to be begun without waiting for signs of hypoventilation or hypoxemia. The necessary emergency intubation is particularly delicate (full stomach, immobilization of the cervical spine, circulatory and respiratory instability). However, whatever the chosen technique for intubation, maintaining the cervical spine straight by an assistance is mandatory. Pre-oxygenation is systematic. The Sellick maneuver (manual compression of esophagus) is controversial in cases with great spinal instability. The hemodynamic objective is the maintenance of an adequate blood pressure in the cord while avoiding liquid overload. Indeed any systemic hypotension is susceptible to alter the perfusion of injured cord areas. Vascular filling has to compensate possible blood losses (scalp, haemothorax). the use of vasopressive drugs (Dopamine) is necessary to compensate for vasoplegia induced by the loss of the sympathetic in cervical and high thoracic cord injuries.

Serious bradycardia, and even asystolia, may occur during vagus stimulation (tracheo-bronchic aspiration, laryngoscopy...). Their frequent occurrence after the 4th to 5th day, justifies the continuous perfusion of atropin on 24 hours, and systematic cardiac monitoring using a cardioscope.

Finally, thermal regulation is immediately altered in parallel with the aggressiveness of external conditions. It is necessary to avoid all supplementary caloric exchange by enveloping the patient in an isothermal cover, and subtracting him or her to the external atmosphere. The quadriplegic is "poïlkilotherm", and able cool by great cold as well as to reheat excessively by hot weather.

 

Combined injuries

Circumstances capable of injuring the supple osteodiscoligamentous thoracic or lumbar spinal structure, to the point of endangering the integrity of its content, are violent trauma and combined visceral or peripheral injuries are frequent. All combinations may occur. Cervical trauma may be combined to injuries to the face and hair, that make them suspect immediately. Trauma to the thoracic spine may frequently come along with combined haemothorax (one third of cases, bilateral once on two), pneumothorax and flailed chest, or organ injuries especially of the spleen. Such injuries make take an important vital risk, particularly at the moment of emergency spinal surgery, and the mortality rate of the thoracic spine injured is not null. The benefit / risk ratio of emergency spinal surgery deserves to be very carefully weighed, particularly in the case of a complete neurological injury. Particularly frequent in thoracic spine trauma, combined injuries have to be sought-after and treated according to their degree of emergency. A discussion between specialist surgeon, anesthetist and radiologist is necessary to establish the hierarchy of the gravity of lesions and their management. Combined injuries, by their hemodynamic consequences and effects on the hematosis, may worsen by themselves the cord injury.

.
Fig. 7: CT scan: bilateral haemothorax complicating a thoracic burst fracture


Fig. 8: MR Imaging: a highly displaced fracture causing a complete SCI..

 

Prevention of the secondary injury (fig 9):

The correct immobilization of the spine is maintained during complementary exploration duration. The maintenance of respiratory and circulatory functions in optimal conditions of homeostasis is mandatory at this time.

Fig. 9: MR Imaging: Extension of intramedullary hypersignal
to areas adjacent to the fracture was thought here
to be a direct visualization of the secondary cord injury.

Many specific medical treatments, aiming at the prevention of secondary injuries have been proposed.

In the NASCIS II study (National Acute Spinal Cord Injury Study, 1992), Bracken and al. recommended precocious administration of methylprednisolone (30 mg/ kg in 30 min. then 5.4 mg/ kg/ h during firsts 23 hours). The former would allow to partly inhibit the extension of the secondary lesion. Authors would show, in a randomized prospective manner against placebo, a statistically significant beneficial effect on the motor function, provided that the treatment had been administered in the first eight hours following the trauma. The complication rate and the mortality were identical. In the US, its administration in the pre-hospital course is currently recommended and largely spread in the initial management of spine trauma with deficient neurological signs. This study was criticized, considering inclusion bias, the stratification before 8 hours/ after 8 hours been realized a posteriori, and also because its conclusions had been largely divulged to the main press before appearing in scientific journals. Other studies, under way, are necessary to validate these results, but these are multicenter studies that are difficult to manage to their end.

The NASCIS III study, whose results have been published in 1997, compared the administration of methylprednisolone (30 mg/ kg then 5.4 mg/ kg/ hour) for 24 hours to same dose methylprednisolone for 48 hours, and to the administration of tirilazad mesylate 2.5 mg/ kg every 6 hours for 48 hours. Patients processed for 48 hours had a better functional recovery (but higher infectious complication rate as pneumonia) than those treated for 24 hours only when the process was initiated between 3 and 8 hours after the trauma. For those patients that were treated before 3 hours, the three protocols were identical. Rates of mortality were similar. There was no placebo control.

Gangliosides are purified extracts from bovine brain. Experimentally it has been shown that they favor neuronal growth after a traumatic injury or in the course of an ischemic accident. In a study on a limited sample of 34 patients, the efficiency of such a therapy after cord trauma was likely (Geisler). The efficacy on the recovery of muscles initially paralyzed in the lower limbs was attributed to the favorable effect of the GM-1 ganglioside on axons crossing the lesion. However, the results of Geisler have not been confirmed. Studies of greater extent are under way to test the effects and the innocuousness of gangliosides in this indication.
As we said, the calcium ion plays an important role in ischemic phenomenon and enzyme activation. Calcium inhibitors, especially Nimodipin, have been studied extensively in animal models. Experimentally, a positive effect and improvement of cord blood flow was found after trauma. The clinical interest of calcium inhibitors remains to demonstrate.

Finally, cell-protecting agents and inhibitors of NMDA receptors are under evaluation. The GK11-FLAME study (multicenter study testing a NMDA receptor inhibitor) has shown the feasibility of a multicenter study with standardized patient management. Unfortunately it has not allowed to conclude as for the efficiency of the tested drug, because of a high number of complete thoracic cord injuries reducing the sample size of the group available for neurological improvement.

This study illustrated the difficulty to test the numerous molecules whose efficiency has been shown during the course of phase II studies.

Currently, the only medication that showed a possible positive effect in randomized clinical studies is high-dose methylprednisolone. There are today strong arguments, although not irrefutable, to use it in routine before the 8-hour delay and especially before the 3rd hour post injury.

 

Surgical indications:

Surgery finally has two indications only :, immediate or late instability, and persistent neurological compression. We will discuss only general principles.
The agreement is largely shared on the necessity of cord decompression and spine fixation, but the methodology is still controversial. Progress in surgical management, as underlined by Waters and al., make give an important role to surgery.

-- Operative period --

Whilst many animal studies have shown the interest of early releasing cord compression, no study has been able to confirm it in humans (Fehlings). Only one prospective randomized study by Vaccaro has taken into account the operative delay, but it compared " early " surgery realized before 72 hours (after an average 1.8 days of hospital stay ) to " delayed " surgery, that was performed after 5 days : the difference of almost 10 points in the ASIA score (64 versus 54.2) in favor of the " early " group was not statistically significant on respectively 34 and 28 patients ; however, the power of the study was not indicated. Retrospective studies suggest that decompressive surgery improved recovery, but there is no consensus as for the ideal moment of the operation, neither data to estimate odds of delayed decompression. In human practice, the cord trauma is made of the initial trauma (causing complete transsection, contusion, or simple sideration), persistent cord compression, and potential trauma due to the spine instability. Surgery only acts on the last two components. In case of persistent cord compression, it is desirable that cord release occurs as soon as possible, as much as the injury is incomplete. The six hours period after the trauma is a reasonable objective. There is no argument to indicate that it is not already a lot too long, neither that cord release performed well beyond this period has no odds to be beneficial. To note that referral to a specialized center with an intermediate stop by a general hospital induces a supplementary delay of 2 hours 30 on average.

In practice, the benefit / risk ratio of an emergency operation is to be discussed, especially in thoracic spine injuries : the patient with a cord trauma arriving at the emergency is not always perfectly explored, some surgical interventions, especially to the thoracic level, may be hemorrhagic, they suppose a long stay in the prone position ; operative teams are restrained, the supervision is complex.

 

-- General principles --

Whatever the chosen procedure, the essential is to obtain a free cord in a stable spine : when facing trauma of the spine and cord, the objectives are reduction of the displacement, spinal canal clearance, and stabilization.

Cervical spine injury

Reduction may be obtained in some cases by traction or external manipulation. This may allow to rapidly release the compression in emergency. There are some contraindications to traction (especially fractures of the pedicles of C2 type IIA of Levine), so there is no way a traction should be applied without a precise diagnosis. Dislocations of the lower cervical spine pose two problems : On the one hand, reduction of bilateral dislocations with locking of the facet joints are very difficult with simple traction, so it is not advisable to put in traction and wait for a hypothetical reduction while losing of a precious time. On the other hand, there are undoubtedly cases of expulsion of disc material in the canal responsible for neurological complications at the very moment of the reduction : it is so logical to realize an MRI study to look for such a fragment threatening the cord before reducing unilateral or bilateral dislocations by external manipulation or traction. Bursting fractures of the vertebral body with kyphosis, bony canal stenosis and neurological impairment may be put into traction if it does not delay surgical liberation.

The surgical approach is most frequently posterior ; the laminectomy is not systematic if radiographs show complete reduction.
Anterior approach (discectomy or corporectomy) may be favored when residual cord compression is mostly anterior (post-traumatic disc hernia or bony fragment encroaching the canal). Some injuries are better reduced through a posterior approach as we said of tear-drop fractures. The anterior approach may pose problems in patients that may have or had a tracheostomy.

In all cases, it is logical to use a stable fixation system that may avoid a certain number of mechanical failures : steel wire is no longer up to date.

Thoracic and lumbar injuries

Reduction is performed per-operatively by direct or instrumental manipulation ; it may necessitate resection of posterior elements, laminae or facet joints.

Fixation necessitates the use of a stable and modern system, with a short or long setting, and has a double objective : to avoid a secondary cord or root injury from immediate instability, and to avoid secondary deformations with progressive kyphosis and painful instability, that may cause local irritation and contractures in neurological patients.

In the thoracic and lumbar level, the frequency of loss of correction and implant breakage is high enough to justify completing the fixation by a posterolateral arthrodesis even in case of a satisfactory reduction of the anterior elements.

Some surgeons make a systematic laminectomy. Others consider that one can verify the complete canal clearance after reduction by realizing a peroperative myelography, with the condition to obtain good images. After reduction, freedom of the dural sheath is controlled, and if found defective is completed without manipulation of nervous elements, by removing upon request any aggressive bony or disc elements. One can have to take out the pedicle or facet joints so as to reach fragments located more anteriorly. Wounds to the dura are closed as possible. Noticing gross lesions to the dura or cord per-operatively is of very bad prognosis.

Whenever some anterior compression, or anterior instability with a high risk of non union persists (as in the "diabolo" fracture), a complementary anterior procedure may be warranted. Anterior cord compression is considered significant if antero-posterior diameter of the canal is reduced by 50% at least. There are observations of spontaneous resorption of smaller fragments. Anterior canal decompression may bring neurological improvement even as a late procedure if neurological impairment is truly incomplete. It may also aggravate the deficit, and that is why indications are carefully weighed. Simple anterior graft fixation of unstable fractures has lesser neurological risks, but it is also a major procedure and a potentially hemorrhagic one. Thoracoscopic, retroperitoneoscopic, or video-assisted procedures are alternatives that still require evaluation.

Fig. 10: Anterior residual cord compression after posterior reduction
and fixation of a D12/L1 traumatic dislocation. Incomplete conus medullaris syndrome .


Fig. 11: MR Imaging: same patient as above.


Fig. 12: Complementary anterior surgery after 5 months.
Cord decompression, tricortical bone graft and fixation.
The patient experienced an important functional improvement.

In a certain number of cases, the availability of high-performance anterior fixation devices and the expectation of difficulties for posterior fixation (small diameter of pedicles) may make propose an isolated anterior approach. There is a risk of added injury during reduction if posterior elements are fractured and entrap nerve tissue so it is necessary to verify this occurrence before the procedure.

The indication of an emergency procedure is guided by the degree of neurological impairment and the existence or not of combined injuries. In case of polytrauma, hemodynamic control, evaluation and control of thoracic and intra-abdominal injuries may make delay the emergency of cord liberation so as to control the vital risk. Surgery in delayed emergency first concerns unstable spine injuries with neurological radicular impairment and unstable injuries without neurological impairment. The delay to the operation is used to make a complete evaluation of the injury, to best prepare the patient to the surgical procedure and to operate in the conditions of planned surgery, in the best possible hospital staff conditions.

-- Other problems --

Respiratory problems

The loss of the cough leads to tracheo-bronchic obstruction a high risk of pulmonary atelectasia and pulmonary infection, threatening the vital prognosis.

There is a linear relationship between the duration of the presence of a laryngeal tube and the risk of pulmonary infection ; hence the question : is intubation and artificial ventilation of all high cord injured patients necessary, the counterpart being an increased infectious risk ? In fact the question is posed in a different way, because most often the patient is intubated in the operative room, and the question is : when is it necessary to take the laryngeal tube off ?

Then it is necessary to reply to several questions:

1. respiratory history (cigarette smoking, chronicle bronchitis, overweight)

2. thoracic trauma, polytrauma, comatose patient, massive blood transfusion, that will necessitate by themselves a respiratory assistance.

3. level of cord injury, knowing that the diaphragm alone can not ensure an efficient ventilation during this initial phase, that the external intercostal muscles may no longer be functional, and that the loss of abdominal muscles eliminates the cough.

4. The complete status or not of the cord injury, the existence or not of spasticity.

5. in case a new tube proves necessary, will reintubation be easy ?

Hence it is necessary to evaluate the benefit-risk ratio between mechanical ventilation and non-ventilation in these patients.

 

Deep venous thrombosis

Very frequent in patients with SCI, with a high risk of pulmonary embolism. Its prevention is systematic by low molecular weight heparin from hours that follow the trauma.

Denutrition

The feeding of the patients with a SCI in its high variety is necessary to favor the struggle against denutrition, infection, and healing problems, the fearsome "cast" syndrome (syndrome of the common mesenteric artery). However, the resumption of feeding is hindered by the prolonged stop of the transit that usually takes place in days that follow the trauma. We begin parenteral nutrition, in 24-48 hours that follow the trauma, rapidly completed by enteric feeding, then by mouth, to reach caloric levels of approximately 2000-2500 kcal/ day.

Urinary infection

Extremely frequent in patients with a SCI having a permanent bladder tube, in fact it is not a forefront problem at the initial phase of the management. If antibiotics are initiated, it will have to induce little mutations, so as to avoid the emergence of multi-resistant bacterias. The practice of repeat tube insertion remains to evaluate in this emergency setting.

 

In conclusion

The patients with a SCI is extremely fragile, especially at the initial phase. It fully justifies a specialized management. The conjunction of efforts of the emergency units and specialized services has to allow after the stay in the intensive care unit, the referral in reeducation and rehab departments with a recovered respiratory autonomy, a stable spine, and an intact recovery potential. If specific medical procedures as methylprednisolone open a hopeful way, simple general principles of medical management favoring oxygenation and cord blood flow should not be neglected. The place of surgery or conservative procedures seem to be better specified ; if simple logic would favor early decompression and fixation, elements of certainty are again missing in human practice.

 

Key-points

* Any polytrauma patient is suspect of having an unstable spine fracture until the contrary is proven, all manipulations have to be made in rectitude of the head-trunk axis. * The vital prognosis is threatened in the first days essentially by the assault on respiratory muscles and cardiovascular troubles induced by the breach of the autonomous nervous system. * Medical management is made as early as possible in the pre-hospital setting. * Hospital management is made as early as possible by specialized medico surgical teams. * Examination of the voluntary motricity and the sensitivity allows to define the level of cord injury. It is codified (modified Frankel score, ASIA score). * The predictive value on the functional prognosis of the complete or incomplete status of neurological impairment is considerable. The complete status can generally be asserted only from a distance of the accident. * Exploration of the spine by conventional face and profile radiographs remains the basic examination. * Spinal cord injuries continue to evolve on their own in hours that follow the initial trauma. * Many specific medications remain to evaluate (cortico-steroïds, calcium inhibitors, inhibitors of the NMDA...). * The maintenance of the spinal cord blood flow is an essential objective of the resuscitation begun in the pre-hospital setting. * Cord decompression has to be performed as fast as possible, but privileging the hemodynamic control and the vital risk and by weighing the benefit / risk ratio at any moment. * The objectives of the surgical procedure are to obtain a free cord in a stable spine. * Indications for emergency surgery are guided by an existing persistent cord compression, the degree of neurological impairment and existing combined traumatic injuries.

 

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