Management of spinal injury

Recognition of the presence or risk of spinal injury is essential at all levels of the health care system. The only resource needed for this is training. Included in this is the necessity to monitor neurological function at regular intervals, such as hourly, in the acute phase of injury, and this should be considered essential for all levels of care.

It is increasingly recognized that patients with spinal cord injury, especially acute cervical spinal cord injury, may experience severe hypotension and severe problems in maintaining an airway and adequate ventilation. The risk of further neurological deterioration is increased when the ABC's of trauma management are neglected. Therefore, as with prevention of secondary brain injury, recognition of the importance of these factors in patients with spinal injury is deemed essential at all hospital levels.

A holistic approach to the prevention of complications should be considered essential at all hospital levels of care and during all phases of management, from the acute phase to the rehabilitation phase (39). The most common complications, which increase morbidity and mortality, are pressure sores, urinary retention, urinary infection and deep venous thrombosis. To prevent pressure sores, patients should be log-rolled every two hours. These items are also desirable at basic levels.

For several years, there has been an international movement towards a uniform methodology for the classification and scoring of acute spinal cord injury. A convention among specialists has established the International Classification System, which is the successor to the American Spinal Injury Association (ASIA) system (40). Although basic facilities and general practitioners would not be expected to use this system, it should be essential for all specialists caring for patients with injuries of the spinal cord in tertiary care centres to use this system.

It is anticipated that patients with spinal injuries or suspicion thereof would be rapidly referred to the next highest level in the health care system, where they could be more adequately managed, in terms of diagnosis and treatment. Ideally, patients should arrive at tertiary care centres within two hours of injury. Appropriate handling of patients, with the use of simple techniques such as log-rolling and the avoidance of undue movement during transport, is likewise essential at all levels of the health care system. Devices for immobilization, such as a spinal backboard, collar for cervical spine injuries and sandbags or head blocks to prevent movement of the head and spine, are essential at all hospitals and should also be utilized appropriately, not only during stays in these hospitals, but during inter-hospital transfer as well. These would be considered desirable, even at basic facilities. However, if the volume of blunt trauma at such a facility is low, the cost of such formal immobilization materials will prevent them from being designated essential. Countries in which such basic facilities have greater trauma volumes might reasonably consider designating these materials as essential at such facilities as well.

With respect to diagnosis, plain X-rays of the spine are still used by most specialists and tertiary centres. The simple X-ray is addressed in more detail in sections 5.8 (Management of extremity injury) and 5.13 (Diagnosis and monitoring). Computerized tomography (CT) and magnetic resonance imaging (MRI) have great utility in the management of patients with spinal injury. However, their high cost prevents them from being designated essential. When they are deemed essential as part of a national plan, their continual functioning and availability on an emergency basis (24 hours a day, 7 days a week) should be considered as an integral part of essential status.

Recently, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons have disseminated Guidelines for management of acute cervical spinal injuries (41), which cover many of the issues related to acute spinal cord injury including surgical management. It would be highly desirable for specialists caring for spinal cord injuries (e.g. neurosurgeons and orthopaedic surgeons) to be aware of these. As with similar guidelines for the management of head injury (section 5.4), full compliance with these guidelines is deemed desirable at specialist and tertiary facilities. The cost of the infrastructure needed for full compliance prevent these from being deemed essential.

A variety of spinal injuries may be managed non-operatively. These include stable fractures with or without neurological injury. They also include some unstable bony and ligamentous injuries for which either surgical fixation or nonoperative management could be used. Adjuncts to such non-operative therapy include bed rest, cervical spine braces, halo devices and cervical spine traction.

TABLE 9 Spinal injury

Facility level

TABLE 9 Spinal injury

Facility level

Resources

Basic

GP

Specialist

Tertiary

Assessment—recognition of presence or risk of spinal injury

E

E

E

E

Immobilization: C-collar, backboard

D

E

E

E

Monitoring of neurological function

E

E

E

E

Assessment by International Classification System

I

I

D

E

Maintain normotension and oxygenation to prevent secondary neurological injury

D

E

E

E

Holistic approach to prevention of complications— especially pressure sores and urinary retention/infection

D

E

E

E

CT1 scan

I

D

D

D

MRI2

I

I

D

D

Full compliance with AANS3 guidelines

I

I

D

D

Non-surgical management of spinal injury (as indicated)

I

PR

E

E

Surgical treatment of spinal injury

I

I

PR

E

Surgical treatment of neurological deterioration in the presence of spinal cord compression

I

I

PR

E

1 CT: Computerized axial tomography

2 MRI: Magnetic resonance imaging

3 AANS: American Association of Neurological Surgeons

1 CT: Computerized axial tomography

2 MRI: Magnetic resonance imaging

3 AANS: American Association of Neurological Surgeons

Halo devices are especially useful in centres with limited surgical capability. The ability to manage selected spinal injuries non-operatively includes the training to recognize which injuries are appropriate for such management, and the equipment to provide non-operative management. Such capabilities are deemed essential in specialist and tertiary care hospitals. In more remote rural low-income areas, such capabilities might be possibly required at GP-level hospitals.

Management of complicated spinal cord injuries as appropriate by surgical means should be essential at tertiary care facilities. This would imply the presence of an orthopaedic or neurological surgeon with appropriate training. In some cases, it would be possibly required at specialist level hospitals, if the availability of tertiary care facilities was limited and if the personnel with the necessary expertise were available.

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