Management

Issues

 

Neurogenic shock

Blood pressure augmentation

Steroids

Surgical decompression

Anticoagulation

Cell based therapy

Chronic medical problems

Rehabilitation

 

Neurogenic Shock

 

Cause

 

Sympathetic tracts disrupted

- unopposed parasympathetic vagal tone

- loss of vasomotor tone with marked vasodilatation

 

Guly et al Resuscitation 2008

- 19% incidence in cervical cord injury

- 7% incidence in thoraco-lumbar cord injury

 

Diagnosis

 

Hypotensive (SPB < 90) + bradycardia (HR < 80) + warm periphery 

 

Management

 

Fluid resuscitation

Atropine (0.6 mg push) - for bradycardia

Inotropic support / noradrenaline - vasoconstriction and bradycardia

 

Pharyngeal suction & intubation stimulate vagus nerve

- may produce bradycardia & cardiac arrest

 

Blood pressure Augmentation

 

Issue

 

Hypoperfusion may contribute to ongoing post injury cord ischaemia

 

Guidance

 

Mean arterial BP should be maintained between 85–90 mmHg for the first 7 days following an acute SCI

- ICU admission

- vasopressors as needed

 

Results

 

Hawryluk et al J Neurotrauma 2015

- 74 patients in ICU with SCI

- higher average MAP values correlated with improved recovery in the first 2-3 days after SCI

- MAP values below 85 mm Hg correlated with a decrease in strength over the first 5-7 days after injury.

 

Steroids

 

Results

 

Bracken Cochrane Database Syst Review 2012

- review of 8 randomized control trials

- shown that methylprednisolone infusion if given within 8 hours, improves motor recovery

- give for 24 - 48 hours

 

Liu et al Neurology 2019

- meta-analysis of high dose methylprednisolone

- 3 RCTs and 13 observational studies

- no evidence of improvement in neurological function

- increased risk of gastrointestinal hemorrhage and respiratory infection

 

Fehlings et al Global Spine J 2017

- systematic review

- methylprednisone administered within 8 hours improved mean motor scores

- no evidence of increased complications

 

Dosing

 

Methylprednisolone

- 30 mg/kg bolus

- 5.4 mg/kg/hr for 24 - 48 hours

 

Contra-indications

- > 8 hours after presentation

- penetrating spinal injury

- infection

- diabetes

- < 13 years old

- pregnancy

 

Medications under study

 

Riluzole

 

Sodium channel blocker

- encouraging results in animal models

- currently under investigation in patients

 

Minocycline

 

Tetracycline antibiotic that penetrates CSF

- downs grades inflammation

 

Casha et al Brain 2012

- RCT of 7 days minocyline infusion in 52 patients

- tendency towards improved outcomes with minocycline

- no signification results

 

Surgical Decompression

 

Timing

 

Controversy in the literature regarding timing

- generally accepted that early surgery improves outcomes

 

Fehlings et al PLoS One 2012

- STASCIS study (landmark paper)

- Prospective cohort sutdy (n=80) comparing early (<24h) vs late surgery

- Early surgery 19.8% of patients improved 2 grades (or more) compared to late on 8.8%

 

Qiu et al Int J Surg 2021

- systematic review of 16 studies and 3977 SCI patients

- improved outcomes with surgery < 24 hours

 

Yousefifard et al Arch Acad Emerg Med 2022

- systematic review of ultra-early (< 12 hours) decompression

- improved outcomes

- especially for cervical injuries and ASIA A

 

Outcomes

 

Aarabi et al Neurosurg 2017

- major predictor of outcome 

- intramedullary lesion length (IMLL) on MRI

 

Spinal cord injury MRI

 

Anticoagulation

 

Fehlings et al Global Spine J 2017

- recommend starting anticoagulation within 72 hours

 

Arnold et al Global Spine J

- systematic review of 9 articles

- reduced rates of DVT with low molecular weight heparin

- reduced rates of DVT with commencing within 72 hours of SCI

 

Cell based therapies

 

Yousefifard et al Neuroscience 2016

- meta-analysis of neural stem / progenitor cells (NSPC) injections in animal models

- evidence of improved functional recovery

- better in acute phase of injury

 

Shinozaki et al Cells 2021 Review Article

- mechanisms of stem cell therapy in spinal cord injury

 

Chronic medical issues

 

Respiratory

C1-3 level - need portable ventilation

C4 level - need CPAP at night C4/5/6 level - phrenic nerve defunctioned, diaphragm paralysis Low cervical level - paralysis intercostals
Gastrointestinal

Paralytic ileus

- first 48 hours

- nasogastric tube

Constipation

- chronic problem

Gastric ulceration

- can be masked

- consider ranitidine

 
Urinary

Intermittent catheterisation

Urinary tract infections Renal calculi  
Skin Turn patient every 2 hours

Pressure sores

- buttock, greater trochanter, sacrum

   
Joints Daily passive ROM Foot and wrist drop splints

Spasms

- baclofen, dantrolene

 
Autonomic dysreflexia

Spinal cord injury above T6

- unmodulated sympathetic reflexes

- widespread vasoconstriction

Initiated by

- distended bowel / bladder

- pressure sores

- medical procedures

Hypertensive crisis with bradycardia

- SBP can reach > 300mmHg

- cerebral edema, stroke

- cardiac arrest

- seizures

Decompress bladder / bowel

Nitrate patches

Nifedipine

 

Rehabilitation

 

Physiotherapy

 

Goals

- range of motion

- strength training

- transfer exercises

- locomotor training

 

Lam et al Top Spinal Cord Inj Rehab 2007

- systematic review

- evidence for body weight supported treadmill training

- evidence for the use of braces

 

Functional electrical stimulation

 

de Freitas Top Spinal Cord Inj Rehab 2018

- systematic review of 5 controlled studies

- two demonstrated improvement in voluntary strength in partially paralyzed muscles

- three found no improvement

 

Exoskeletons

 

Miller et al Med Devices 2016

- systematic review of 14 studies and 111 patients

- 4% incidence of fall while training

- 3% incidence of fracture while training

- improves ambulation