Emergency management: What immediate medical procedures can I expect?

Stabilization
Once a person is injured, the first priority is to stabilize the patient's breathing, blood pressure and spinal column (in most cases using a back board and a cervical neck collar). .A patient with a suspected SCI will most likely be brought to or moved to the nearest Level 1 Trauma Center, which provides the highest level of surgical care to trauma patients, with a full range of specialists and equipment available 24 hours a day.

During the early days of hospitalization, a variety of medications may be used to control the extent of the damage to the spinal cord, alleviate pain, treat infections, and other issues related to the injury. Patients may be sedated and put into traction to prevent further damage. Some other types of traction techniques are metal bracing attached to weights or a body harness, a halo to prevent the head from moving, or a rigid neck collar.

Neuroprotection
These therapies, also called neuroprotective therapies, aim to stop or reduce the immediate responses (such as swelling) to the injury that may further spinal cord damage. Methylprednisolone is a steroid drug sometimes used in the first few hours after an injury; it is intended to reduce inflammation and improve recovery but there is no clear evidence to support this. Still, it is commonly used though it may not be appropriate in all cases.

Therapeutic hypothermia (spinal cord cooling) is a medical treatment that lowers the body temperature in order to protect the cells in the body from damage after a traumatic brain or spinal cord injury, stroke or cardiac event. Body temperature can be lowered by invasive methods, using catheters filled with saline to cool a patient's blood as it leaves the heart, thus lowering the temperature of the whole body. Non-invasive techniques use special blankets that have cold water running through them. These blankets may be combined with ice packs or cold fans in order to achieve more rapid temperature decline.

There have been media reports that cooling is beneficial. According to the American Association of Neurological Surgeons, there is currently no published data that shows that SCI patients who are treated with therapeutic hypothermia improve compared to others who are not treated using this method. The use of local therapeutic hypothermia at the time of surgery appears safe but no criteria for treatment guidelines have been established. Currently, there is not enough evidence available to recommend for or against therapeutic hypothermia with traumatic spinal cord injury.

Classifying the injury
Physicians determine the level and extent of the injury by using x-rays, MRIs, or CT scans. The patient will also undergo a thorough neurological examination. This measures sensation, muscle tone and reflexes of all limbs and the trunk. The results will be reflected in what is called an ASIA (American Spinal Injury Association Classification of Spinal Cord Injury) scale, a tool used to classify the spinal cord injury patient into various categories (ASIA A, B, C, D, or E; A is the most impaired, E the least). During an ASIA exam, the physician looks at a variety of determinants such as muscle movement, range of motion, and notes whether or not the person can feel light touch or sharp and dull sensations.

Surgical interventions
Once a patient is medically stable, he or she will meet with a surgeon to make the decision on surgical interventions. Surgery is recommended for many reasons such as removal of bone fragments, foreign objects, blood clots, herniated disks, fractured vertebrae, spinal tumors or anything that appears to be compressing the spine. Surgery to stabilize the spine helps to prevent future pain or deformity.

Surgical stabilization
Stabilization of the spinal cord is a common surgical intervention following a spinal cord injury. This procedure removes bone fragments and restores the alignment of the vertebrae thus reducing compression on the spinal cord. Stabilization can occur within the first 72 hours or it may be delayed until after the body has been medically stabilized. There is no evidence to support an advantage for either early or delayed treatment.

Spinal fusion
If the vertebrae in the spinal column appear unstable, the doctor may perform a spinal fusion. A spinal fusion may be done with metal plates, screws, wires and/or metal rods; sometimes small pieces of bone from other areas of the body (usually the hip or knee) or from a cadaver (bone bank) are used. Bone grafts help the patient's bones grow, thus serving to fuse the vertebrae. In cervical injuries the stabilization can be done through the throat (anterior) or through the neck (posterior) or both. Thoracic and lumbar injuries are usually approached through the back.

Respiratory
The lungs themselves are not usually affected by paralysis but the muscles of the chest, abdomen, and diaphragm may be. If complete paralysis occurs at level C3 or above, the phrenic nerve is no longer stimulated and the diaphragm will not function. Some individuals with lower level injuries may also need ventilator assistance for short periods of time before they can breathe on their own (called being weaned off the ventilator). Successful weaning from a ventilator is impacted by many factors: age, level of injury and time spent on the ventilator.

For more detailed information on the clinical practice guidelines on respiratory management with spinal cord injury you can request booklets from the Paralyzed Veterans of America. These booklets also provide guidelines on proper weaning from a ventilator.

People injured at the mid-thoracic level or higher may have trouble taking deep breaths and exhaling forcefully. This can lead to lung congestion and respiratory infections. Ways of preventing respiratory complications include maintaining proper posture, coughing regularly (if necessary, with assistance), following a healthy diet, drinking plenty of fluids, eliminating smoking or being around smoke, exercising, and getting vaccinated for influenza and pneumonia.