injuries poisoning
Spinal Trauma
Treatment of Spinal Trauma
Immobilization Maintenance of oxygenation and spinal cord perfusion Supportive care Surgical stabilization when appropriate Long-term symptomatic care and rehabilitation Guidelines for the management of acute cervical spine and spinal cord injuries are available from the American Association of Neurological Surgeons and the Congress of Neurological Surgeons ( Treatment references ). An important goal is to prevent secondary injury to the spine or spinal cord. In unstable injuries, flexion or extension of the spine can contuse or transect the cord. Thus, when injured people are moved, inappropriate handling can precipitate paraplegia, quadriplegia, or even death due to spinal injury. Patients who may have a spinal injury should have the spine immobilized immediately; the neck is held straight manually (inline stabilization) during Tracheal Intubation . As soon as possible, the spine is fully immobilized on a firm, flat, padded backboard or similar surface to stabilize the position without excessive pressure. A rigid collar should be used to immobilize the cervical spine. Patients with thoracic or lumbar spine injuries can be carried prone or supine. Those with cervical cord damage that could induce respiratory difficulties should be carried supine, with attention to maintaining a patent airway and avoiding chest constriction. Transfer to a trauma center is desirable. 85 to 90 mm Hg for 5 to 7 days to improve spinal cord perfusion and to reduce hypotensive episodes that may adversely affect recovery ( Treatment references ). MAP targets can be achieved using volume expansion with crystalloids and/or colloids, vasopressors, or a combination. Injuries above T6–T7, because they compromise sympathetic output to the thoracic cardiopulmonary nerves, are treated with vasopressors that have chronotropic and inotropic effects such as Large doses of corticosteroids, started within 8 hours after spinal cord injury, have long been used in attempts to improve the outcome in blunt injuries, but multiple randomized clinical trials in adults have not only failed to demonstrate any added clinical benefit but have also documented increased risk of wound infection, Pulmonary Embolism (PE) , Injuries are treated with rest, analgesics, and muscle-relaxers with or without surgery until swelling and local pain have subsided. Additional Evaluation and Treatment is provided as necessary. Unstable injuries are immobilized until bone and soft tissues have healed in proper alignment; surgery with fusion and internal fixation is sometimes needed. Patients with incomplete cord injuries can have significant neurologic improvement after decompression. In contrast, in complete injury, return of useful neurologic function below the level of the injury is unlikely. Thus, surgery aims to stabilize the spine to allow early mobilization. Relief of compression caused by bone fragments, epidural hematoma, or acute malalignment may be needed. Many surgeons recommend bedside manual reduction even before MRI (or operation) for translation-rotational or distraction injury of the cervical spine causing active cord compression. However, in general, patients with clear neurologic deficits from spinal trauma should undergo MRI evaluation to define the soft tissue injury and rule out any active compressive pathology prior to any surgical intervention. Early surgery allows for earlier mobilization and rehabilitation. Recent retrospective and prospective studies suggest that the optimal timing of decompression surgery for incomplete cord injuries is within 24 hours of injury. For complete injuries, surgery is sometimes done in the first few days, but it is not clear that this timing affects outcome. The only randomized controlled trial so far to investigate the timing of surgery for spinal cord injury analyzed incomplete and complete cord injuries together. That study found better neurologic outcome at 6 months if decompression surgery was done within 24 hours of injury rather than later ( Treatment references ). Other invasive treatments still under investigation include lumbar drain placement for cerebrospinal fluid (CSF) diversion for spinal cord injury and surgical duroplasty during decompression surgery. Both techniques aim to decrease increased intrathecal CSF pressure (and the resulting secondary injury) caused by spinal cord contusion and edema. Nursing care includes preventing urinary and pulmonary infections and pressure ulcers—eg, by turning the immobile patient every 2 hours (on a prone-positioning bed when necessary). Prevention is required. A removable inferior vena cava filter could be considered in immobile patients who have contraindications to anticoagulation. Medications can effectively control spasticity in some patients.Baclofen5 mg orally 3 times a day (maximum, 80 mg during a 24-hour period) andtizanidine4 mg orally 3 times a day (maximum, 36 mg during a 24-hour period) are typically used for spasticity occurring after spinal cord injury. Intrathecalbaclofen50 to 100 mcg once a day may be considered in patients in whom oral medications are ineffective. Spinal cord injury is needed to help people recover as fully as possible. Rehabilitation, best provided through a team approach, combines physical therapies, skill-building activities, and counseling to meet social and emotional needs. The rehabilitation team is best directed by a physician with training and expertise in rehabilitation (physiatrist); it usually includes nurses, social workers, nutritionists, psychologists, physical and occupational therapists, recreational therapists, and vocational counselors. Physical therapy focuses on exercises for muscle strengthening, passive stretch exercises to prevent contractures, and appropriate use of assistive devices such as braces, a walker, or a wheelchair that may be needed to improve mobility. Strategies for controlling spasticity, Spinal Cord Autonomic Dysreflexia , and neurogenic pain are taught. Occupational therapy focuses on redeveloping fine motor skills. Bladder and bowel management programs teach toileting techniques, which may require intermittent Bladder Catheterization . A bowel regimen, involving timed stimulation with laxatives, is often needed. Vocational rehabilitation involves assessing both fine and gross motor skills, as well as cognitive capabilities, to determine the likelihood for meaningful employment. The vocational specialist then helps identify possible work sites and determines need for assistive equipment and workplace modifications. Recreation therapists use a similar approach in identifying and facilitating participation in hobbies, athletics, and other activities. Emotional care aims to combat the depersonalization and the almost unavoidable depression that occur after losing control of the body. Emotional care is fundamental to the success of all other components of rehabilitation and must be accompanied by efforts to educate the patient and encourage active involvement of family and friends. Treatments to promote nerve regeneration and minimize scar tissue formation in the injured cord are under study. Such treatments include implantation of a polymer scaffold at the level of cord injury as well as injections of autologous, incubated macrophages; human-derived embryonic stem cell oligodendrocytes; neural stem cells; and trophic factors. Stem cell research is being done; many animal studies have shown promising results and there have been several phase I and II human clinical trials. Implantation of an epidural stimulator is another treatment modality under investigation to improve voluntary movement after spinal cord injury. During epidural stimulation, electrical pulses are delivered to the surface of the spinal cord below the injury. 1.Walters BC, Hadley MN, Hurlbert RJ, et al: Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 Updates.Neurosurgery60(CN_suppl_1):82–91. doi: 10.1227/01.neu.0000430319.32247.7f 2.Hawryluk G, Whetstone W, Saigal R, et al: Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: Analysis of high frequency physiologic data.J Neurotrauma32(24):1958–1967, 2015. doi: 10.1089/neu.2014.3778 3.Vale FL, Burns J, Jackson AB, et al: Combined medical and surgical treatment after acute spinal cord injury: Results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management.J Neurosurg87(2):239–246, 1997. doi: 10.3171/jns.1997.87.2.0239 4.Fehlings MG, Wilson JR, Tetreault LA, et al: A clinical practice guideline for the management of patients with acute spinal cord injury: Recommendations on the use ofmethylprednisolonesodium succinate.Global Spine J7(3 Suppl):203S-211S, 2017. doi: 10.1177/2192568217703085 5.Fehlings MG, Vaccaro A, Wilson JR, et al: Early versus delayed decompression for traumatic cervical spinal cord injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).PLoS One7(2):e32037, 2012. doi:10.1371/journal.pone.0032037 