Traumatic Spinal Injury Management

Clinical assessment

High index of suspicion in any significant trauma, especially with: Neck/back pain, Neurological deficits, Head injury, Altered mental status, High-risk mechanism. Perform careful neurological examination (motor strength, sensation level using dermatomes, reflexes, rectal tone). Palpate spine for tenderness/deformity. Maintain immobilization throughout assessment.

Investigations

• Imaging (Hospital Level):
• - X-rays: Standard AP, Lateral, and Odontoid views for cervical spine. AP/Lateral views for thoracic/lumbar spine. Can detect fractures, dislocations, instability.
• - CT Scan: More sensitive than X-ray for detecting bony injuries, especially complex fractures or visualizing cervical spine in obtunded patients. Often primary imaging modality.
• - MRI Scan: Best for evaluating spinal cord injury, ligamentous injury, disc herniation, hematomas compressing the cord.
• Neurophysiological testing (e.g., SSEP, MEP) - specialized centers.

Diagnostic criteria

Clinical suspicion based on mechanism and neurological findings, confirmed by imaging demonstrating fracture, dislocation, instability, or spinal cord lesion.

Non-pharmacological management

• Immobilization (CRITICAL First Step):
• - Maintain spinal alignment during extrication and transport.
• - Apply a rigid Cervical Collar (properly sized) for suspected neck injury.
• - Secure patient to a firm surface (e.g., long spinal board, scoop stretcher) with straps/head blocks.
• - Log-roll patient carefully if turning is necessary, maintaining spinal alignment.
• - Continue immobilization until spinal injury is definitively ruled out by clinical assessment and imaging.
• Airway Management (with C-spine control): Use jaw thrust maneuver instead of head-tilt/chin-lift. If intubation needed, maintain manual in-line stabilization.
• Breathing Support: Assess respiratory function (esp. high cervical injuries). Provide oxygen. Assist ventilation if needed.
• Circulation Support: Treat hypotension. Differentiate hypovolemic shock (tachycardia) from Neurogenic Shock (bradycardia, hypotension, warm peripheries due to loss of sympathetic tone). Neurogenic shock requires fluids and potentially vasopressors (norepinephrine) +/- atropine for bradycardia (Hospital level).
• Prevent complications: Pressure sore prevention (remove from hard board ASAP), DVT prophylaxis, bladder/bowel management (catheterization), temperature regulation.
• Decompression (Hospital/Specialist Level):
• - Non-operative: Skull traction (for cervical fractures/dislocations), Bed rest, Bracing (collars, corsets).
• - Operative: Surgical decompression (e.g., laminectomy, discectomy) and stabilization (fusion with instrumentation) for unstable fractures, cord compression, or progressive neurological deficit.

Pharmacological treatment

• Analgesia: Appropriate pain control.
• Methylprednisolone: High-dose steroids were previously used but are NO LONGER routinely recommended due to questionable benefit and increased risks (infection, GI bleed, hyperglycemia). Use only under specific protocols in specialist centers if considered at all.
• Vasopressors/Inotropes: For management of neurogenic shock (Hospital level).
• Medications for spasticity, neuropathic pain, bladder dysfunction (long-term management).

Monitoring

Frequent neurological assessment (motor, sensory levels, reflexes) to detect any deterioration. Monitor vital signs closely (watch for neurogenic shock). Monitor respiratory status. Monitor for complications (pressure sores, DVT, infection).