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How is acute spinal cord injury treated?

Acute spinal cord injury refers to hours or days after spinal cord injury during which continued deterioration or tissue damage may occur. Shortly after an injury, the spinal cord often does not appear to be severely damaged even though there may be immediate functional loss. The injury initiates a cascade of chemical and cellular responses that contribute to further tissue damage, including inflammation, free radicals, and swelling (edema). The spinal cord may be compressed during this period.

Compression or decreased perfusion (blood flow) of the spinal cord aggravate the injury. These causes of progressive tissue damage can and should be relieved as rapidly as possible. The goal of acute spinal cord injury care is to stabilize the spinal cord to prevent further damage, save as much tissue as possible, and prevent complications of spinal cord injury.

• Emergency management. The first objective of emergency management of spinal cord injury is to establish ABC (airway, breathing, and circulation). The spine must be immobilized to prevent further injury. The patient must be transported rapidly to the nearest medical center, preferably a Level 1 Trauma Center. If blood pressure is low, fluid and drug therapies must be given to maintain blood flow in the spinal cord. In cervical spinal cord injuries that affect breathing, ventilatory support may be necessary. A foley catheter is usually placed in the bladder to drain urine.

• Methylprednisolone therapy. The patient should receive intravenous high-dose steroid methylprednisolone (30 mg/kg bolus followed by 5.4 mg/kg/hour for 23 hours) as soon as possible. This therapy improves neurological recovery by about 20%. If the methylprednisolone is started between 3-8 hours after injury, the infusion should be extended to 48 hours. If the methylprednisolone cannot be started within 8 hours, it should not be given. Therapy beyond 8 hours does not improve functional recovery.

• Decompression of the spinal cord. If the spinal cord is compressed by bone or disc, every effort must be made to decompress the cord as soon as possible. Cervical spinal injuries can often be decompressed by traction of the spinal column to realign the vertebral bodies. However, thoracic and lumbosacral spinal fractures usually cannot be decompressed by traction alone. Surgery may be necessary to decompress the cord or spinal roots. Thoracic or lumbosacral spinal cord decompression may require opening the chest cavity or retroperitoneal space, requiring a team of surgeons. Some surgeons delay surgery for this reason, particularly patients that have so-called “complete” spinal cord injury. I believe that “complete” injuries should be treated as aggressively as incomplete spinal cord injuries.

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