Spinal Injuries - Treatment

Once completely cut or degenerated, nerve endings do not recover, and functional impairments become permanent. The compressed nerve tissue can regain its function. Restoration of movement and sensitivity in the first week after injury indicates a favorable prognosis. Dysfunction that persists for more than 6 months after injury is likely to become permanent.

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Emergency care for spinal injury

Once the airway, breathing, and circulation have been stabilized, the primary goal is to prevent secondary injury to the spine or spinal cord. In unstable injuries, flexion or extension of the spine may cause contusion or rupture of the spinal cord. Therefore, careless movement of the patient may cause paraplegia, tetraplegia, or even death. A patient with suspected spinal injury should be moved as a single unit and transported on a rigid flat board or other hard surface, with additional stabilization of his position using pads without excessive pressure on body parts. A fixing collar should be used to immobilize the cervical spine. Patients with thoracic or lumbar spine injuries can be carried prone or supine. In case of cervical spinal cord injuries that may impede breathing, the patient is carried in a supine position, carefully monitoring the patency of the airway, avoiding chest compressions. It is advisable to refer such patients to a trauma center.

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Spinal Cord Injury Injury Scale

Level	Violations
A = full	Motor and sensory functions are lost, including the level of the sacral segments S
B = incomplete	Motor function is lost, sensory function is preserved below the level of injury, including the sacral S segments
C = incomplete	Motor function is preserved below the level of injury, and in > 1 control muscle groups below the level of injury the strength is < 3 points
D = incomplete	Motor function is preserved below the level of injury and at least in / control muscle groups below the level of injury the strength is equal to 3 points
E = norm	Motor and sensory functions are not impaired.

Medical care is aimed at preventing hypoxia and arterial hypotension, each of which can increase stress injury to the spinal cord. In case of damage to the first cervical segments, intubation and respiratory support are usually necessary. During intubation, the cervical spine is fixed.

Administration of high-dose glucocorticoids, begun 8 hours after injury, may improve outcome. Methylprednisolone 30 mg/kg is given intravenously over 1 hour, followed by 5.4 mg/kg/hour for the next 23 hours. Treatment of spinal injuries includes rest, analgesics, and muscle relaxants, with or without surgical intervention, until swelling and pain resolve. Additional general treatment measures for trauma are discussed in the appropriate sections.

Unstable injuries are immobilized until bone and soft tissue healing allows adequate alignment; surgical alignment and internal fixation are sometimes indicated. In complete injuries, the goal of surgical stabilization is to ensure early mobilization. Restoration of satisfactory neurologic status below the level of injury is unlikely. In contrast, patients with incomplete spinal cord injuries may experience significant improvement in neurologic function after decompression. The optimal timing of surgery for incomplete spinal cord injuries remains a matter of debate. Early surgery (eg, within 24 hours) may have a better outcome and allow for earlier mobilization and rehabilitation.

Nursing care includes prevention of genitourinary and pulmonary infections and pressure ulcers [eg, turning the patient every 2 hours (using a Stryker frame if necessary)]. Prophylaxis against deep vein thrombosis is also necessary. In immobile patients, the need for placement of a vena cava filter should be considered.

Late period treatment measures

In some patients, spasticity can be effectively controlled with medication. For spasticity associated with spinal cord injury, oral baclofen 5 mg 3-4 times daily (maximum 80 mg during the first 24 hours) and tizanidine 4 mg 3-4 times daily (maximum 36 mg during the first 24 hours) are commonly used. In patients in whom oral administration is ineffective, intrathecal baclofen 50-100 mg once daily may be considered.

Rehabilitation is necessary for patients to make the most complete recovery possible. Rehabilitation is best done in groups, combining physical therapy, skills training, and education on how to meet social and emotional needs. The rehabilitation group is best coordinated by a physician with experience in exercise therapy and physical therapy (physiotherapist). The team typically includes nurses, social workers, dietitians, psychologists, physical and occupational therapists, recreational therapists, and vocational counselors.

Physical therapy focuses on exercises to restore muscle strength and adapt to the use of assistive devices (walkers, wheelchairs, etc.) needed to improve mobility. Skills are taught to control muscle spasticity, autonomic dysreflexia, and neurological pain. Rehabilitation therapy is aimed at restoring fine motor skills. Bladder and bowel control programs teach toileting techniques, which may require intermittent bladder catheterization. Bowel habits often need to be developed using fixed-time laxatives.

Vocational rehabilitation involves assessing both fine and gross motor skills and the patient's cognitive abilities to determine the likelihood of adequate employment. It also identifies the need for assistive devices and the degree of modification of a potential workplace. Recreational therapists use similar approaches to identify and facilitate patient activities, such as hobbies, sports, and other activities.

The goal of emotional support (psychotherapy) is to combat depersonalization and the almost inevitable depression of a person who has lost control over his or her own body. Emotional support is essential to the success of all other components of rehabilitation and should be accompanied by maximum efforts to educate the patient and involve his or her family and friends.

Research into the treatment of spinal cord injury is aimed at stimulating the regeneration of nerve tissue. These include injections of autologous, incubated macrophages; epidural administration of BA-210, an experimental drug that may have both neuroprotective and nerve-growth-promoting effects; and HP-184 for the treatment of chronic spinal cord injury.