Prevention of secondary and tertiary injury

Spinal injuries broadly encompass two distinct clinical entities, firstly those patients with spinal column injury but no neurological abnormality, and secondly those patients with varying degrees of neurological abnormality as a result of spinal column injury, vascular accident, or other cord pathology.

In the critical care setting those patients with injuries of the spinal column but no neurological abnormalities must be treated with the utmost caution in order to avoid inadvertently producing a spinal cord lesion. The patients most at risk are those who have suffered multiple trauma where imaging and examination of the spine has been cursory due to other clinically obvious and life-threatening injuries. All patients in these circumstances must be treated as though they have a spinal injury until proven otherwise (Burney i etal 1993).

The management of spinal column injury is based on straightforward orthopedic principles. If the injury is unstable, it should be immobilized and, if and when the patient is fit for surgery, internal fixation should be considered. The advantages of early fixation are that patient handling becomes much easier and that delayed fixation (2-6 weeks after injury) is technically harder and carries significantly greater morbidity.

If the spinal column injury is shown to be causing spinal cord compression or there is deteriorating neurological function, a decompressing procedure should be considered, even in the presence of complete neurological loss.

Immobilization requires keeping the spine straight in both the coronal and sagittal planes. There are well-recognized handling techniques designed to minimize any movement of the spine whilst allowing the patient to be moved or turned. However, these must be performed by staff trained in these techniques to minimize any risk to the patient.

There are also several specialized beds available for the management of spinal-injured patients. These beds are designed to make turning safer and easier in order to avoid the development of pressure sores. Low-air-loss beds and fluidized beds should not be used unless the spine has been stabilized surgically or externally.

The pathology of an injured spinal cord involves a complex of processes which includes edema formation, intracord hemorrhage, and release of inflammatory mediators, with alterations in vascular autoregulation in the area of the injury. A significant aspect of the care of spinal-cord-injured patients with other trauma or critical illness should be the avoidance of physiological states where blood flow and oxygen delivery to the cord are compromised, potentially aggravating the injury and increasing the degree of neurological deficit. Invasive cardiovascular monitoring or esophageal Doppler monitoring may be needed to maximize oxygen delivery.

Many techniques have been tried based on pathological and biochemical findings in the spinal cord lesion, but, even though several have been found to be successful experimentally, few have translated into clinical practice.

The National Acute Spinal Cord Injury Study II was one of the first to show an improved outcome in terms of neurological function at 6 months with the use of methylprednisolone given within 8 h of injury. The dose regimen is 30 mg/kg body weight as a bolus followed by an infusion of 5.4 mg/kg body weight per hour for 23 h

(Bracken eUL 1.9.90). A recent study by the same group has shown that patients started on methylprednisolone 3 to 8 h after injury should be maintained at 5.4 mg/kg body weight for 47 h (BrĀ§cke.D..et...al 1997). However, there is a significant increase in the incidence of pneumonia.

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