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evaluatesforthepresenceofongoingcordcompressionbyedema,hematomas,
or soft tissues as well as delineates the discs and ligamentous structures.
However, factors such as study duration, need for a higher level of medical
stability,limitedavailability,andincreasedcostmayserveassignificantbarriers
for obtaining an MRI study in the immediate phase. While the additional
informationgainedthroughMRImayhelpguidesurgery,MRIshouldnotdelay
timelysurgicalinterventionifalreadyindicated.
Certain comorbidities should lower thethreshold for radiographic workup.
For instance, elderly individuals may have an impaired perception of pain.
Radiographicevaluationmaybebeneficialinthispopulationevenifthepatient
deniesanysymptoms.Personswithknownankylosingspondylosisshouldalso
undergoevaluationwithbothCTandMRIregardlessof symptoms.Finally,in
injuries related to cerebrovascular disruption such as fractures involving the
vertebralarterycanal,CTangiographyshouldbeconsideredtoruleoutcervical
vascularcompromise.(SeeChapters6and14forfurtherdetails)
ClinicalAssessment
In addition to radiological workup, clinical assessment of the severity of SCI
throughidentification ofthe neurologicalleveland completenessof injurycan
helpguidefurtherclinicalmanagementanddetermineprognosis.Furthermore,a
reliable and reproducible neurological examination serves as a baseline for
comparisonofanysubsequentneurologicalchanges.Currently,themostwidely
usedtoolforevaluationandclassificationofSCIistheISNCSCIexamination.
Thisneurologicalexaminationisstandardizedandcanbesafelyperformedwhile
maintaining appropriate precautions, including cervical stabilization, logroll
technique,andavoidanceofexcessivehipflexioninlowthoracic/upperlumbar
injuries. While the accuracy of neurological examination is not necessarily
affectedbyacuityofSCI,theexaminationdoesrequiresustainedattentionand
participation from the patient, which may be limited by intubation/sedation,
involvementofalcoholordrugsattimeofinjury,concomitantTBI,severepain,
orfrequentdistractionsintheERorICUsettings.
Regardingoverallneurologicalevaluation,earlydetectionofTBIfacilitates
implementationofappropriateinterventionsthatdependontheseverityofTBI,
such as intracranial pressure management (37). Continued evaluation for
concurrent TBI in addition to SCI involves routine assessment of GCS
throughouttheacutehospitalization.
Complications unique to the TBI population include mood instability,
cognitiveimpairment,seizure,anddysautonomia.Additionally,individualswith
concomitant TBI may suffer additional motordeficits that can affectstrength,
balance, and/or coordination as well as sensory deficits that can affect touch,
proprioception, and/or the special senses (10).In individuals with a suspected
TBI,durationofposttraumaticamnesia(PTA)hasalsobeenusedtocharacterize
TBI severity. The Galveston Orientation and Amnesia Test (GOAT) and
OrientationLog(O-Log)aretwocommonscalesusedtomeasurePTAseverity
andduration(38–40).EvaluationofGCSaswellasthepresenceofPTAshould
be performed along with the ISNCSCI examination to ensure TBI has been
properlyevaluated.
MEDICALNEUROTHERAPEUTICS
Thefieldofneuroprotectionandneurotherapeuticsisaheavilyresearchedarea
in acute SCI. Upon the initial insult to the spinal cord, the blood–spinalcord
barrierisdisrupted,whichleadstotheextravascularizationofinflammatorycells
andreleaseoflocalinflammatorycytokines.Concurrently,cellulariongradients
areinterrupted,leadingtoanincreaseinintracellularcalcium.Thecytokinesand
influxofcalciumdrivevariousproapoptoticpathways,whichleadtocelldeath
andnecrosis(41). Paststudies havefocused oninterventions that canhalt the
cascadeof secondary events following primaryinjury. This secondary cascade
has provided many theoretical targets for intervention; however, despite the
interest and research, there are no recommended neurotherapeutic agents
currentlyintheacutephaseofSCI(3).
The most widely studied intervention in the treatment of traumatic SCI is
methylprednisolone (MP). The anti-inflammatory properties of steroids have
generated interest since the 1960s. Although MP administration was
recommendedwith some reservation in the2002CNNS/ANSguidelines, their
most recent updates published in 2013 no longer recommend MP for persons
with new SCI. Clinical practice guidelines published by AOSpine in 2017
providethemostrecentupdatesonthetopic.Itissuggested(withweakstrength
ofrecommendation)thata24-hourMPinfusionbeofferedasatreatmentoption
inadultswithacuteSCIpresentingwithin8hoursofinjury(42).However,48hourMPinfusionwasnotrecommendedforadultswithacuteSCI(42).
InarecentsurveyconductedbyAOSpine,theadministrationofMPbyspine
surgeonsfromNorthAmerica,Europe,andAsiaPacificwasfoundtobe24.0%,
46.9%, and 64.1%, respectively (43). When exploring reasons for MPuse by
North American surgeons, 20.3% of responses indicated use was due to
perceivedimprovement inpatient recoveryand5.2% wasused “toavoidlegal
problems.”In comparison,thesepercentages weresignificantly lessthanthose
foundinotherregions,whichrangefrom30.3%to44.3%and15.8%to18.7%,
respectively.Inreflection,these numberssuggestamorejudicialuseof MPin
NorthAmerica,wherethemajorityofresearchon MPusehasbeencompleted
andalsohighlightstargetsforfutureeducationinitiatives(43).
Today,the use of MPin SCI varies by institutional practices and surgeon
discretion.Aswithalltreatments,theapproachshouldbeindividualizedtothe
patient. Some considerations that should be noted include age, comorbidities,
andinjury levels. An elderly patientwhois at a higher riskforinfectionsand
poor wound healing may be more susceptible to steroids than an otherwise
healthy young patient who is at a lower risk for developing secondary
complications.
Currently, many other pharmacological agents and cell-based therapies
gearedtowardneuroprotectionandneurotherapeuticsforpersonswithacuteSCI
are being researched. At this time, these agents have reached various clinical
trialsandarefarfromwidelyacceptedclinicaluse.Amoredetaileddiscussion
onthesecanbefoundinChapter52.
RESPIRATORYCOMPLICATIONS
Respiratorycomplications are the primarycauseof morbidity and mortalityin
acuteSCI(44).Thelikelihoodofthedevelopmentofrespiratorycomplications
is directly related to the level of neurological injury and the degree of motor
impairment (44). In one study, 87.5% of patients with injury level above C5
required intubation versus 61% of patients with injury level C5–C8 (45).
Additionally, 90% of persons with complete tetraplegia required intubation
duringtheirhospitalcourseversus48.5%ofthosewithanincompletetetraplegia
(45).
Frequentmonitoringofrespiratorystatusiscriticalwithinthefirst72hours,
as90%of individualswhodevelop respiratoryfailuredo sointhistimeframe
(2). By the first 24 hours, approximately one-third of individuals with acute
cervicalinjuriesrequireintubation(2).Withinthefirstweek,thevitalcapacity
for a C4-level injury decreases to 24% of the predicted capacity (4,46).
Deteriorationinvitalcapacity(or negativeinspiratoryforce)maybeindicative
of need for intubation and mechanical ventilation and should be serially
monitoredincervicalinjuriesduringtheacutephase(2).Additionalmonitoring
of pulmonary status during the first several days postinjury includes further
radiographic imaging as indicated, continuousoxygen saturation, and periodic
evaluationof end-tidal CO2(11).The presence of comorbidities suchas older
age, major traumatic injuries, history of smoking, or prior pulmonary disease
increasesthechanceofpulmonarydeclineduringtheacutephaseofinjury(44).
ThedevelopmentofrespiratoryfailureinacuteSCImaybeduetoimpaired
inspiratorycapacity,retainedsecretions,andformationofmucusplugsaswellas
autonomicnervoussystemdysfunction(44).Intubationshouldbeconsideredin
individuals with impending respiratory failure unresponsive to noninvasive
ventilation measures, or with signs ofor at high likelihood ofaspiration (11).
Respiratoryfailure is defined aspO2less than 50 mmHg and/or pCO2greater
than50mmHgbasedonABGtestingperformedwhenanindividualremainson
roomair(11).Serialmonitoringofvitalcapacity,asmentionedearlier,maybe
usefulinassessing fatiguefrom apulmonarystandpointoverthe courseof the
firstweek(44).Avitalcapacitylessthan10to15mL/kgofidealbodyweight
(IDW) that continues to deteriorate is strongly suggestive of the need for
mechanical ventilation (11). In a 1994 study, respiratory failure requiring
mechanicalventilationdevelopsonaverageat4.5dayspost-injuryandlastsan
averageof35.9days(47).
For individuals who require mechanical ventilation, the Consortium for
Spinal Cord Medicine CPG on Respiratory Management Following SCI
recommends higher tidal volumes (15 mL/kg) than normally used in the ICU
settingtoreduceorpreventatelectasis(11).Petersonetal.demonstratedthata
higher tidal volume was associated with a decreased rate of atelectasis, from
84%to16%,overa2-weekperiodaswellasfewerdaysforcompleteliberation
fromtheventilator(48).Despitetherecommendationforhighertidalvolumesin
personswithacuteSCI,concernsexistregardingtheuseofahightidalvolume
protocol given that mechanical ventilation with lowertidal volumes (6 mL/kg
IDW) is associated with lower mortality in individuals diagnosed with either
acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) (49).
ARDSandALIarecommonrespiratorycomplicationsfollowinginitialSCI(see
Chapter18foradditionaldetails).Indeed,lowertidalvolumeprotocols should
be employed in individuals with acute SCI who remain at higher risk for the
development of ARDS/ALI. In an effort to study the safety of higher tidal
volumes, Fenton et al. demonstrated that a high tidal volume regimen of 20
mL/kgIBWwasasequallysafe asa lowertidalvolumeprotocolof 10mg/kg
IBW during the subacute phase of SCI (>2 weeks) with no difference in the
numberofdaysneededforweaning(50).SeeChapter18forfurtherdetails.
Persons with traumatic cervical SCI may benefit from early tracheostomy
within1weekofintubation,asearlytracheostomyplacementisassociatedwith
fewer ventilator days (23.9 ± 16.5 vs. 36.9 ± 26.7 days), fewer days to
decannulation,andshorterstayintheICU(20.7±6.5vs.26.0±11.4days)(51).
Tracheostomy offers several benefits over endotracheal intubation, including
improved patient comfort, enhanced secretion management, progress toward
swallowing/phonation, and reduced airway resistance to facilitate ventilator
weaning.Moreover,Flanaganetal. also demonstrated no differencein90-day
mortalityor 90-day readmissionratesafter tracheostomy,suggestingthat early
tracheostomyisasafeoption(51).Inanotherstudy,individualswhounderwent
tracheostomybeforeday 7of mechanicalventilationalsodemonstratedshorter
durationofventilation(26.07±1.69vs.48.75±3.45days),decreasedICUstay
(36.52 ± 1.59 vs. 54.58 ± 2.92 days), and reduced endotracheal intubation
complications,includingtrachealgranulomaandstenosisformation(52).Factors
associatedwith early tracheostomy placement includedmoresevere AIS score
andhigherlevel of neurological injury (51). However,one retrospective study
thatexaminedtraumacasesbetween1998and2004showedthat68%oflower
cervicalspinalinjury(C5–T1)requiredintubation,ofwhich,69%laterrequired
tracheostomyduringthe acutecare hospitalizationperiod(53).Ifthe patientis
placedonaventilator,monitoringofvitalcapacityisausefulguidetodetermine
whentostarttheventilatorweaningprocess.Inoneweaningprotocol,reduction
of vital capacity by more than 50% of patient’s baseline is a criterion to
discontinueweaning(11).Forcedvitalcapacitylessthan1,000mL,agegreater
than50 years, andassociatedinjuries were foundtoadversely affectability to
liberate from ventilator (4). Postoperative patients should be weaned slowly
from the ventilator when the following are present: weak cough, premorbid
illnesses,historyofsmoking,oragegreaterthan45years.Oftentimes,patients
may be able to breathe on their own initially, but fatigue secondary to
hypoventilation, atelectasis, or difficultyin coughing up secretions. Declining
vital capacity can be an indicator of new or worsening atelectasis and/or
infection, which may warrant repeat chest radiographs with management of
secretionsandpotentialadjustmentofcurrentrespiratorymanagement,including
theuseofmechanicalventilation(11).Overtime,pulmonaryfunction,evaluated
by vital capacity, improves in individuals with tetraplegia. Increasing muscle
toneintheintercostalsandabdominalmusclesmaybenefitanindividualdueto
thedevelopmentofamoreeffectivecough(4).
In a study examining pulmonary complications after initial injury,67% of
personswithaT12andaboveSCIexperiencerespiratorycompromise,withthe
most common complications being atelectasis (36%), pneumonia (31%), and
ventilatory failure (22%) (47). A higher proportion of persons with higher
cervical injuries (C1–C4, 84%) develop pulmonary complications than
comparedtoeitherthelowercervicalinjurygroup(C5–C8,60%)orthethoracic
group(T1–T12, 65%) (47).Themostcommon respiratory complication inthe
higher cervical injury group, the lowercervical injury group, and the thoracic
group are pneumonia (63%), atelectasis (34%), and pleural effusion (38%),
respectively.Indeed,personswiththoracicinjuriesarealsoatsignificantriskfor
pulmonarycomplicationsgiventhatcompromiseofexpiratorymuscles,suchas
the intercostals and abdominal musculature, results in an ineffective cough,
inability to clear secretions with subsequent mucus formation, and atelectasis
(54).Intheacutehospitalizationperiod,45%ofindividualswithtetraplegiaand
36%ofthosewith paraplegiasufferedfrom pneumoniaand/or atelectasis(55).
Therefore, persons with both cervical and thoracic injuries benefit from an
aggressiveprophylacticpulmonaryhygieneprogramtoreducetheoccurrenceof
atelectasis (47). The use of a mechanical insufflation–exsufflation device or
suctioningmaybehelpfulinthepreventionandtreatmentofatelectasisaswell
asin the removal of secretions (11).Otherassistive techniques for pulmonary
hygiene include incentive spirometry, chest physiotherapy, assistive coughing
techniques,theuseofanabdominalbinder,andincentivespirometry(11).
CARDIOVASCULARCOMPLICATIONS
NumerouscardiovascularcomplicationscandevelopfromthetimeofinitialSCI
(seeChapters16and17).IndividualswithaninjurylevelofT6oraboveareat
particular risk for autonomic instability and often present with more severe
hypotension(3).Immediatelyafterinjury,50%to90%ofindividualswithacute
cervical SCI require either aggressive fluid resuscitation or the use of
vasopressorstomaintainanMAPgreaterthan85mmHg(2).One contributing
factortothishypotensionmaybethelossofvasoconstrictortoneinperipheral
arterioles,leadingtopoolingofblood(3).
Thedevelopment of bradycardiaismore common during thefirst2 weeks
afterinitialinjuryandmaybecomplicatedfurtherbyhypotensionandasystole
inupto15%ofpatients(3,56).DuringtheacutephaseofSCI,bradycardiahas
been reported in 17% to 77% of individuals with cervical SCI; although
supraventricular tachycardia or other arrhythmias may also occur (57).
Individualswiththoracicinjuryandbelowareatlowerriskforarrhythmias.For
example,bradycardiaoccurredin0%to13%ofindividualswithaninjuryinthe
thoracic region or below (57). For individuals with a cervical SCI, noxious
stimuli,such as endotrachealsuctioning, can alsoleadto bradycardicepisodes
(3).Educationofthepatient’scareteam,includingnursingstaffandrespiratory
therapist,withregardtotheriskofbradycardiaduringroutinecareisimportant
toensurecarefulmonitoringofat-riskpatients.TheConsortiumofSpinalCord
Medicine CPG suggests that atropine, aminophylline, vasopressors, and
pacemakers (external or implanted) may be needed for individuals with high
cervicalinjuriestoreducetheoccurrenceofsymptomaticbradycardiaduringthe
firstseveralweeks ofinjury (3).As thetimefrom injuryincreases,the riskof
bradycardiadecreases;bradycardic episodesare typicallyself-limitingwithin 2
to6weekspost-injury(57).Incasesofpersistentbradycardiaorlife-threatening
bradycardia,temporaryandpermanentpacemakershavebeenutilized(56).The
indications for a cardiac pacemaker may include symptoms such as
lightheadedness or altered mentation due to associated hypotension related to
bradycardia or could include severe bradycardia that is unresponsive to
pharmacological interventions that may result in asystole, necessitating
cardiopulmonaryresuscitation(56).
In addition to heart rate abnormalities, orthostatic hypotension (OH) can
developinindividualswithSCI,ascharacterizedbylightheadedness,dizziness,
or even syncopal episodes during postural changes (58). Using orthostatic
maneuvers,OHwasdiagnosedin74%ofindividualswithSCI,ofwhich 59%
were symptomatic during initial physical therapy following SCI (58).
Nonpharmacological treatment strategies include the use of compression
stockings or elastic wraps to reduce venous pooling, abdominal binders,
intravascular volume expansion through fluids, and gradual adjustment to an
uprightposition(2,3,58).Forindividualswithmoresevereorthostasis,potential
pharmacological management includes midodrine and Florinef (discussed
furtherinChapter17).
Immediately following SCI, sympathetic stimulation followed by reflexive
parasympatheticactivitysecondarytoreleaseofnorepinephrinefromsuprarenal
glands triggers a response characterized by severe hypertension followed by
bradycardia(59). This initialhypertensive phase is replaced quickly by spinal
shock (59). After spinal shock resolves, individuals with injury levels T6 and
abovemaybeatriskfor thedevelopmentof autonomicdysreflexia(AD) (60).
Elevationofsystolicbloodpressuregreaterthan20to40mmHgabovepatient’s
baseline may be suggestive of AD (60). Asudden increase inblood pressure,
headache, relative bradycardia (although tachycardia is often present), skin
flushingabovethelevelofinjury,and/orprofusesweatingaresomesymptoms
orsignsofAD(60).Routinemonitoringofvitalsignsofanindividualwhomay
beatriskforADisimportant.Lesscommonly,ADhasbeennotedinindividuals
with injuries as low as T8 (60). While AD typically develops after 1 month
postinjury, 5.7% of individuals who are at risk for AD experience episodes
withinthefirstmonthofinjury(61,62).Onecaseseriesreportedtheoccurrence
ofADasearlyas7dayspostinjurysecondarytobladderoverdistension(63).
(SeeChapters16 and17 for greater detailsregardingthepathophysiology and
managementstrategies.)
THROMBOEMBOLISMPREVENTION
Acute SCI significantly elevates the risk of venous thromboembolic (VTE)
disorderssuch aspulmonaryembolism(PE)and deepveinthrombosis (DVT).
PE has its highest incidence within the first month of injury and is the third
leadingcauseofmortalityafterinitialSCI(64,65).DVTcandevelopasearlyas
72hourspostinjury(66).TheincidenceforDVTpeakswithinthefirst2weeks
of injury, and individuals remain at increased risk for the first 12 weeks
(2,66,67). Early prevention and detection are critical in reducing potential
morbidityand mortality associatedwithVTE disorders. Individualswith acute
SCIarepredisposedtoVTEduetothepresenceofallcomponentsofVirchow’s
Triad: venous stasis, endothelial injury, and a hypercoaguable state (68). The
presence of acute SCI placesa trauma patient in the highest-riskcategory for
DVT(69).TheincidenceofVTEinacuteSCIrangesfrom47%to100%when
using contrast venography, the gold standard for thrombus detection (70–72).
More commonly in the clinical setting, duplex ultrasound is preferred for the
detection of DVT secondary to its noninvasive nature. Risk factorsassociated
with development of VTE after SCI include older age, complete neurological
injury, simultaneous lower extremity fractures, and absent or delayed
thromboprophylaxis(67).
Thromboprophylaxisisrecommendedassoonasisfeasibleinallindividuals
withacute SCI. Mechanical methods, suchaspneumaticcompression devices,
may offer some protection against thrombus formation if utilized on a
continuousbasis,andshouldbeinitiatedassoonaspossibleintheacutesetting
(67). The Consortium for Spinal Cord Medicine CPG recommends lowmolecular-weightheparin(LMWH)tobeinitiatedasachemoprophylaxisonce
thereisnosignofactivebleedinginacuteSCI(67,73).WhileLMWHhasbeen
recommendedover unfractionatedheparin(UH) becauseofsignificantly fewer
reported cases of PE and DVT associated with LMWH, more recently, the
comparativeefficacybetween thesetwo drugsinpreventingthromboembolism
has been called into question (74,75). Recent OASpine Guidelines (2017)
recommend(weakrecommendation)thateitherUHorLMWHcouldbeusedfor
acutechemoprophylaxis(76).Aboxwarningexistsregardingtheriskofspinal
orepiduralhematomaformationinpatientswhoreceiveLMWH(77).
WhileLMWHinitiationmaybedelayedduetoconcernsregardingbleeding,
daily reevaluation of bleeding risk should occur until LMWH can be started
(67).Changetal.recentlydemonstratedthatinitiationofchemoprophylaxiswith
either LMWH or UH within 48 hours of injury did not increase the risk of
intraspinal hematoma after traumatic SCI (78). Additionally, Green et al.
reported that LMWH was associated with significantly less bleeding than
standard heparin therapy (79). With regard to dosing, LMWH 40 mg
subcutaneous (SQ) daily administration seems equally safe and effective as
LMWH30mgSQtwice-a-daydosingforthepreventionofVTEdiseases(80)
inacuteSCI,althoughlargerandomizedcontrolledtrials(RCTs)havenotbeen
performed.
Routine prophylactic IVC filter placement is notrecommended afteracute
SCI(81). Gorman et al. suggestedthat IVCfilter placementmay increasethe
risk of DVT (82). However, IVC filter placement may be beneficial in SCI
patients with significant comorbidities such as longbone fractures, those who
develop of DVT despite the presence of chemoprophylaxis, or those with
contraindicationtoinitiationofanticoagulation(81).
Given the high incidence of VTE after SCI, early prevention and early
detection remain essential part sof management during the acute period.
TreatmentofVTEdisordersarecoveredinChapter16.
SKIN
Allindividualswith SCI are at increased risk for pressure injury development
duetoimpairedsensationand reducedmobility(83).Somerisk factorsfor the
development of pressure injuries in SCI include being underweight, smoking,
pulmonary disease, incontinence, decreased albumin, complete SCI, impaired
cognitivefunction,increasingage,renaldisease,diabetes,andlowerhematocrit
(84,85).Comprehensive preventionstrategiesshould be routinelyimplemented
as part of the acute management of SCI,includingtimely pressure injury risk
assessment, routine skin inspection, repositioning, and use of pressureredistributiondevices (86). For instance, the Braden scale is a widely utilized
risk-assessmenttoolthatassessesriskofpressureinjurydevelopmentbasedon
six factors: sensory perception, moisture, activity, mobility, nutrition, and
frictionandshear.Whileacompletevisualandtactileskinassessmentshouldbe
conducted on a daily basis, high-risk areas for pressureinjuryoccurrence that
require particular attention in SCI include the sacrum, coccyx, ischial
tuberosities, greater trochanters, ankles, knees (medial aspect), occiput, and
calcanei(87).
In the acute SCI period, the most common area of pressure injury
development is the sacrum (57%), followed by the heel (22%), due to the
predominance of supine positioning during this time period (88). Individuals
should be turned every 2 hours as medicallypermissible. In addition,patients
should be placed on a protective surface environment that prevents moisture
accumulation and temperature elevation of skin as well as provides pressure
redistribution. Pressure-redistribution beds have been shown to decrease the
occurrenceofapressureinjury(89).Withregardtotheheels,theuseofaheel
protector,suchasthePrevalonHeelProtectorBoot,thatnotonlyoff-loadsbut
alsokeeps the foot in aneutralposition, is associated withsignificantlyfewer
pressureinjuriescomparedtotheuseofpillowsforpressureredistribution(90).
Theuseofapillowbetweenthelowerextremitiesduringside-lyingmayhelpto
maintainproperpositioningandreducepressureinjurytothemedialmalleolus.
In addition to preventative mechanical techniques to decrease the risk of
developmentofpressureinjury,assessmentanddeliveryofadequatenutritional
intakebased on individual needstomeet caloric goals, protein,micronutrients
(zinc,vitamin C, vitamin A, and iron),andfluidis also important to maintain
skinintegrity(87).
InpersonswithacutetraumaticSCI,37.5%developedatleastonepressure
injuryduring acute care hospitalizationor inpatient rehabilitation (91).Factors
associatedwithincreased risk for pressure injury occurrence include complete
neurological injury, need for mechanical ventilation, and development of
pneumonia(91). Additionally,Ploumis etal. demonstrated that the experience
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