First-ever guidelines for spinal cord injuries.

Published: October 9, 2002
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How spinal cord injuries (SCI) are managed–especially in the critical early stages–has a profound effect on a patient’s outcome. The publication of the first comprehensive SCI, treatment guidelines is an important step in standardizing evidence-based care.

Acute spinal cord injury (SCI) causes devastating neurologic Impairment that often leads to a lifetime of Disability. Each year, there are approximately 11,000 new SCI cases in the United States. (1) About 55% of SCIs occur among people between the ages of 16 and 30. (1)

For years, healthcare professionals involved in SCI management have seen the need for universal SCI guidelines, similar to those issued in 1996 for treating severe head injuries. (2) Now, the first SCI guidelines have been published in a supplement to the March 2002 issue of Neurosurgery. (3) They were developed by The American Association of Neurological Surgeons and The Congress of Neurological Surgeons, based on an exhaustive review of SCI literature.

Titled Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries, the 22 guidelines cover such areas as preadmission management, neurological and radiographic assessment, and medical and surgical management.

The authors make clear that the guidelines are not perfect. Rather they are a work in progress and an important first step in both synthesizing clinical research and generating consistent and widely held standards of management and treatment of SCI patients.

Of note is the fact that the guidelines distinguish, in detail, the levels of evidence to support the individual recommendations. Some recommendations reflect “standards,” which are defined as practices supported by a high degree of clinical certainty. Other recommendations are considered “guidelines” and reflect practices that have a moderate degree of clinical certainty. And finally, there are “options,” which are practices that have a more unclear clinical certainty.

Although the SCI guidelines don’t make specific reference to nursing care, they offer an opportunity for you to compare them with your facility’s current multidisciplinary team management practices and methodologies and make educated recommendations for change, if necessary.

Here we highlight nine areas of the recommendations that are especially relevant to your nursing care. (3) Unless otherwise noted with the word “option,” the recommendations summarized here reflect “standards” and “guidelines” and thus are backed by a high to moderate degree of clinical certainty.

Cervical immobilization before admission

Mishandling of an SCI patient at the scene of the injury can result in further damage to the spine. It’s estimated that 3%-25% of SCIs occur after the initial trauma, either during transit or early in patient management. (3)

As many as 20% of SCIs involve multiple non-continuous vertebral levels; therefore, the entire spinal column is potentially at risk. (3) The guidelines recommend complete spine immobilization before hospital admission to limit motion until injury has been ruled out. This can prevent a potential “incomplete” SCI from becoming a “complete” one, with a lifetime of permanent paralysis.

Although there are several devices available for immobilizing the patient, the optimal device has not yet been identified. However, the long-standing practice of attempting to immobilize the C-spine with sandbags and tape alone is not recommended. Instead, the guidelines support the American College of Surgeons’ recommendation of a combination of a rigid Cervical collar with supportive blocks on a rigid backboard with straps as a safe, effective means of spine immobilization for transport.

Transporting patients with acute SCI

The guidelines recommend expeditious and careful transport of SCI patients by the most appropriate mode of transportation available to get them to the nearest medical facility with the capability for diagnosis and treatment.

While traditional rescue efforts may have focused on providing care to the SCI patient at the scene, optimal management now includes four specific goals: initial resuscitation, immobilization of the patient, extrication from the place of injury, and early transportation to a hospital with an SCI team. Unnecessary delay at the scene of the trauma can lead to longer hospitalizations and poor outcomes.

Ideally, transport would be done via helicopter with trained flight nurses from a center with an SCI team. However, the decision on transportation depends on the patient’s clinical condition, travel distance, geography, and availability of emergency air or road vehicles.

Patients with C-spine injuries have a high incidence of airway compromise and pulmonary dysfunction. Therefore, respiratory support should be available during the transport, and the transportation team should be trained to treat and monitor patients with respiratory difficulties using appropriate oxygenation, ventilation, and suction equipment.

Preferences for clinical assessment

While noting that there is insufficient evidence to support standards for neurologic examination, the guidelines do provide options based on the literature.

Emergency nurses and nurses who are members of the SCI treatment team can assess the patient for neurological and Functional outcome using two types of scales: a neurological Impairment scale and a functional outcome scale. Using those two scales together, according to the guidelines, appears to give the most accurate and meaningful description of SCIs-both in the acute care setting and in follow-up. Such assessment is necessary to define the patient’s deficits and facilitate communication among caregivers.

At present, the most used and studied neurological assessment scale for assessing injury classification at the time of admission is the American Spinal Injury Association (ASIA) Impairment Scale. (4) (See the box on page 35.) The ASIA Scale should also he used throughout the patient’s recovery. It’s important to perform serial assessments, following your facility’s protocol, because the patient’s status can change after admission. For example, vasogenic Edema can build up rapidly within the spinal cord. The nurse should immediately report assessment findings that indicate deterioration or an onset of symptoms in a patient who has previously been asymptomatic.

Following admission, and after the acute phase, nurses can assess the effect of the SCI on the patient’s ability to eat, bathe, dress, and perform other activities using a Functional outcome scale known as the Functional Independence Measure (FIM) score. (5) The FIM uses a seven-point scale to assess the severity of the Disability and the need for assistance. The scale evaluates 13 areas of function-everything from self -care to social cognition-and can be used as a measure of disability, Rehabilitation outcome, and caretaker burden. (5)

Radiographic study of the C-spine

Trauma patients who are symptomatic and those who can’t be assessed for signs and symptoms because they are unconscious or incoherent need radiographic study of the C-spine before immobilization is discontinued. There are many strategies and imaging techniques available for such assessment.

The authors of the guidelines, however, found that no single radiographic study can adequately rule out C-spine injury in all symptomatic patients. Based on published standards, they recommend a three-view spinal X-ray series (anteroposterior, lateral, and odontoid views) for these patients. This should be supplemented by computed tomography (CT) to further define areas that are suspicious or not well visualized on plain Cervical X-rays. Patients who are unable to cooperate with active Flexion/Extension X-rays because of pain or muscle spasm, for example, may be studied with MRI.

The guidelines consider normal X-rays and supplemental CTs or a negative MRI study within the first 48 hours of injury to be sufficient for clearing the C-spine. (3) They also indicate that the significance of a positive MRI study is currently unclear and requires further investigation.

In the obtunded patient with a normal three-view X-ray series and appropriate CT of the C-spine, the incidence of significant spine injury is less than 1%. (3) Depending on how the patient was injured, and on clinical judgment, the C-spine in selected patients may be considered cleared without further study.

As for the immobilization, the guidelines point out that the nurse should never remove the immobilization until the physician has cleared the C-spine and ruled out the possibility of traumatic acute SCI.

BP monitoring is crucial

The guidelines make two key recommendations regarding blood pressure management, an area that is well within nursing’s purview. First, systolic blood pressure below 90 mm Hg should be avoided if possible or corrected as soon as possible after SCI. (3) Second, mean arterial blood pressure (MAP) should be maintained at 85 to 90 mm Hg for the first seven days after acute SC, to improve spinal cord perfusion. (3) These measures are important because hypotension can contribute to Secondary Injury after acute SCI by further reducing spinal cord blood flow and perfusion.

The guidelines note that even one episode of systolic blood pressure dropping below 90 mm Hg could send the patient into shock and cause permanent damage. According to the guidelines, however, most patients with acute SCI are not routinely monitored or treated with blood pressure augmentation after injury.

The guidelines recommend that nursing staff make blood pressure monitoring a priority for acute SCI patients by setting monitor alarm parameters to alert staff to decreasing MAP and systolic blood pressure. They also recommend written guidelines for immediate therapeutic interventions to prevent even one episode of hypotension and the possibility of spinal cord Ischemia.

Pharmacologic interventions

This portion of the guidelines was considered the most controversial by the authors and editors. They advise readers to carefully review the available data and establish their own perspective on this particular component of SCI care.

It has long been hoped that a pharmacological agent might be developed that could improve neurological function and/or assist neurological recovery. The authors say that treatment with high-dose methylprednisolone sodium succinate (Solu-Medrol) within the first eight hours of injury is an option in acute SCI patients.(3) However, they stress that evidence suggesting harmful effects of this therapy is more consistent than any suggestion of clinical benefit, and providers need to take that into consideration.

While the mechanism of action of methylprednisolone is not completely understood, it’s thought to stabilize the neural cell membranes, maintain the blood-spinalcord barrier to reduce vasogenic Edema, improve spinal cord blood flow, and limit the inflammatory response.

The known side effects and potential significant complications associated with this high-dose steroid therapy include an increased risk for respiratory and gastrointestinal adverse events, such as GI hemorrhage; hyperglycemia; hypertension; hypokalemia; poor wound healing; and thrombocytopenia. The risk to patients, particularly older patients, needs to be carefully weighed before a treatment decision is made.(6)

Nurses, as members of the treating team, can discuss with patients the rationale behind this high-dose steroid therapy and its potential benefits and risks. Your facility should develop guidelines for methylprednisolone treatment based on a review of the literature.

Treating acute SCI patients with GM-1 Ganglioside (Sygen), a naturally occurring compound in cell membranes of mammals, is another optional therapy. (7)

Only two studies have demonstrated benefits of GM-1 ganglioside.(4)

Managing subaxial Cervical injuries

The guidelines recommend closed or open reduction of subluxations or displaced subaxial cervical spine fractures (excluding facet dislocation injuries). The neurosurgical team should evaluate closed reduction vs. external immobilization, rigid orthoses, and bed rest, based on the individual patient’s condition and prognosis.

Regardless of what system or device is used, the nurse is responsible for teaching the patient and family about the treatment and how the patient will be managed following treatment. Skilled nursing care is crucial to prevent secondary complications following the nonoperative or operative treatment.

Intensive care setting is needed for monitoring

Patients with acute SCIs are at risk of developing life-threatening cardiac or respiratory complications within one to two weeks after injury. The guidelines recommend that such patients–particularly those with severe Cervical level injuries–be managed in an ICU or similar closely monitored setting for the first seven to 14 days. They report that, unfortunately, this hasn’t been widely done in the past.

The guidelines also recommend cardiac, hemodynamic, and respiratory monitoring for early detection of cardiovascular dysfunction and respiratory insufficiency in SCI patients.

Detecting potential complications early and initiating treatment immediately can help the patient recover more quickly and start the Rehabilitation phase of his recovery. But this requires nurses who have developed the special skills and knowledge needed to provide the intense monitoring, which can improve outcomes by reducing the risk of complications and death. ICU nurses can also play an important role in developing admission/discharge protocols and aggressive, comprehensive management strategies for SCI patients.

Managing DVT and thromboembolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications following acute SCI Protocols for preventing these complications should be put in place at the time of admission and continued until the patient is no longer at risk for them. The coagulation profile of patients with cervical SCI may change rapidly.

The guidelines recommend prophylactic treatment of thrombo-embolism in patients with severe Motor deficits, using such preventive measures as adjusted-dose heparin, rotating beds, low-molecular-weight heparin, or a combination of modalities. Low-dose heparin therapy alone or oral anticoagulation alone are not recommended.

As options, the guidelines describe prophylactic treatment of DVT and PE for three months and vena cava filters for patients who don’t respond to anticoagulation or who aren’t suitable candidates for anticoagulation therapy and/or mechanical devices.

Nurses will need to teach patients to spot the signs and symptoms of DVT and PE since rapid diagnosis and treatment are essential. Patients developing DVT may have tenderness, pain, swelling, warmth, or skin discoloration at the involved area. Guideline options for diagnostic testing for DVT are duplex Doppler ultrasound, impedance plethysmography, and venography, (The classic triad of PE symptoms is acute onset of dyspnea with shortness of breath, chest pain, and hemoptysis.)

To learn more about the DVT and thromboembolism guideline–as well as the other guidelines not mentioned here–visit your library for a copy of the supplement to the March 2002 issue of Neurosurgery. If your library doesn’t have a copy, you can call (300) 638-3080 to obtain one from the publisher.

REFERENCES

(1.) The National Spinal Cord Injury Statistical Center (NSCISC). “Facts and figures at a glance – May 2001.” www.spinalcord.uab.edu/ (27 July 2002).

(2.) The Brain Trauma Foundation & the American Association of Neurological Surgeons. (2002). Guidelines for the management and prognosis of traumatic brain injury. New York: Author.

(3.) The American Association of Neurological Surgeons & The Congress of Neurological Surgeons. (2002). Guidelines for the management of acute Cervical spine and spinal cord injuries. Neurosurgery, 50(3), S1.

(4.) The American Spinal Injury Association & The International Medical Society of Paraplegia. (1996). International standards for neurological and Functional classification of spinal cord injury. Chicago: The American Spinal Injury Association.

(5.) Barker, E. (2002). Neuroscience nursing: A spectrum of care. St. Louis: Mosby.

(6.) Amar, P. A., & Levy, M. L. (1999). Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal card injury. Neurosurgery, 44(5), 1027.

(7.) Geisler, F., Coleman, W., et al. (2001). The Sygen Multicenter Acute Spinal Cord Injury Study. Spine, 26(245), S87.

RELATED ARTICLE: KEY WORDS

* spinal cord injury (SCI)

* spine immobilization

* initial resuscitation

* radiographic assessment

* methylprednisolone sodium succinate [Solu-Medrol]

* GM-1 Ganglioside (Sygen)

* subaxial cervical injury

* deep vein thrombosis (DVT)

* thromboembolism

ELLEN BARKER is the president of Neuroscience Nursing Consultants in Greenville, Del., and author of Neuroscience Nursing: A Spectrum of Care. MICHAEL SAULINO is an assistant professor in the department of Rehabilitation medicine at Thomas Jefferson University in Philadelphia and an attending Physiatrist at Magee Rehabilitation Hospital in Philadelphia.
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