ACS TQIP Spine Injury Best Practices Guidelines

Publication Date: March 20, 2022
Last Updated: March 23, 2022

KEY FACTORS OF THE INITIAL SPINE EVALUATION

Epidemiology

  • Vehicular trauma and unintentional falls are the leading mechanisms of spinal cord injury.
  • Older adults are more susceptible to spinal injuries related to their increased risk for low velocity falls and the presence of underlying arthritic and osteoporotic conditions.

Pre-Hospital Spinal Motion Restriction

  • Spinal motion restriction (SMR) can be achieved with a backboard, scoop stretcher, vacuum splint, ambulance cot, or other similar devices.
  • When SMR is indicated, apply it to the entire spine due to the risk of noncontiguous injuries.
  • Assure that a sufficient number of properly trained individuals are available to assist with patient transfers to minimize the risk for displacement of a potentially unstable spinal injury.

Table 1. Spinal motion restriction indications after blunt trauma

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Indications for Adults
  • Acutely altered level of consciousness (e.g., GCS <15, evidence of intoxication)
  • Midline neck or back pain and/or tenderness
  • Focal neurologic signs and/or symptoms (e.g., numbness or motor weakness)
  • Anatomic deformity of the spine
  • Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns,
  • emotional distress, communication barrier, etc.) or any similar injury that impairs the patient’s ability to contribute to a reliable examination

Cervical Collar Clearance

  • The cervical collar can be discontinued without additional radiographic imaging in an awake, asymptomatic, adult trauma patient presenting with all of the following: a normal neurological exam, no high-risk injury mechanism, free range of cervical motion, and no neck tenderness.
  • Removal of a cervical collar is recommended for adult blunt trauma patients who are neurological asymptomatic and have a negative helical cervical computed tomography (CT) imaging.
  • A negative helical cervical CT scan is recommended as sufficient to remove a C-collar in an adult blunt trauma patient who is obtunded/unevaluable.

Imaging

  • Plain radiographs of the cervical and thoracolumbar spine are not recommended in the initial screening of spinal trauma because of their low sensitivity.
  • Non-contrast, multidetector computerized tomography (MDCT) is the initial imaging modality of choice to evaluate the cervical and thoracolumbar spine.
  • MRI is the only modality for evaluating the internal structure of the spinal cord. Consider universal screening for blunt cerebrovascular injury for all patients with major trauma using a whole-body CT scan.

Physical Examination

  • Using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) clinical documentation tool is a best practice.
  • The neurologic level of injury is determined from the assessment of sensory and motor levels of injury.
  • Make no assumptions about the extent of the neurologic injury in the presence of a depressed level of consciousness, extremity or pelvic fractures, burns or other injuries, such as to the brachial plexus, that may affect the results of sensory or motor deficit evaluation.

CLASSIFICATION AND MANAGEMENT OF INJURY

Spine Injury Classification Systems

  • Spine trauma classification systems include specific injury characteristics, as well as the patient’s medical or neurologic status.
  • Patient scores for the classification system are used to guide decision making regarding surgery or nonsurgical management.

Spinal Cord Injury

  • To accurately assign an ASIA impairment grade, complete the assessment after the period in which spinal shock may occur.
  • After assessing sensation and motor function, the level of injury is defined as the lowest spinal segment with intact sensation and anti-gravity motor function preservation.

Nonoperative Management

  • Occipital condyle fractures without neural compression or cranio-cervical misalignment can be managed successfully with a rigid or semi-rigid cervical orthosis.
  • Select treatment for cervical fractures on an individual basis, based on fracture type and patient factors, including age.
  • A best practice for stable thoracolumbar fractures without neurologic deficits is adequate pain control
  • and early ambulation without a brace.

Penetrating Spinal Injury

  • The vast majority of penetrating spinal cord level injuries result in complete (ASIA A) injuries.
  • Few gunshot injuries of the spinal cord require surgical stabilization.
  • Steroids are not recommended for penetrating spinal injury

Concomitant Injuries Affecting Timing of Spinal Intervention

  • Clinical judgment plays an important role in determining the optimal timing of spinal surgery in polytrauma patients to achieve early spinal stabilization while assuring the patient’s hemodynamic stability.
  • Resuscitation and positioning the patient on the operating room (OR) table must be planned to manage potential complications associated with other injuries.

CARE OF THE SPINAL CORD INJURED PATIENT

Neurogenic Shock and Systemic Pressure-Directed Therapy

  • Injuries to the cervical and high thoracic spine cause vasoplegia and neurogenic shock due to a loss of sympathetic tone.
  • Avoid hypotension in patients with SCI. Weigh the decision to use mean arterial pressure (MAP) goals of 85-90 mmHg for 7 days against the limitations of data, and the risk for utilizing vasopressors, prolonged immobilization, need for invasive monitoring, and the consumption of limited critical care resources.
  • An agent with both alpha- and beta-adrenergic activity is recommended to treat both the hypotension and bradycardia associated with symptomatic denervation.

Pharmacological Management of Spinal Cord Injury

  • The use of methylprednisolone within 8 hours following SCI cannot be definitively recommended.
  • No other potential therapeutic agents have yet demonstrated efficacy for motor recovery and neuroprotection.

Venous Thromboembolism Prophylaxis

  • Initiate chemoprophylaxis as early as medically possible, typically within 72 hours of injury, to reduce the risk of venous thromboembolism (VTE).
  • Determine the duration of chemoprophylaxis on an individual patient basis considering injury severity, mobility status, bleeding risk, and other comorbidities.
  • Surveillance duplex ultrasound for VTE in asymptomatic patients is not recommended, but it can be considered in high-risk patients who cannot have chemoprophylaxis during the acute period.

Spinal Shock

  • Spinal shock is a total or near-total areflexia with the complete loss or suppression of motor function and sensation distal to the anatomical lesion.
  • Spinal shock can persist from days to weeks, and it can be prolonged due to toxic or septic syndromes.
  • The end of spinal shock for most patients is seen with the early return of the deep plantar reflex and with the bulbocavernosus, cremasteric, ankle jerk, Babinski sign, and knee jerk recovering in a progressive order.

Spinal Cord Injury-Induced Bradycardia

  • Sinus bradycardia is the most common dysrhythmia occurring during the acute phase following spinal cord injury.
  • Cardiovascular instability is often precipitated by suctioning, turning, and hypoxia.
  • Treatment of persistent bradycardia or intermittent episodes of severe bradycardia may include a beta-2 adrenergic agonist (albuterol), chronotropic agents (atropine, epinephrine, dopamine, norepinephrine), or phosphodiesterase inhibitors (aminophylline, theophylline).

Ventilator Management in High Spinal Cord Injury

  • Early tracheostomy is recommended to aid in mechanical ventilation during the acute and more chronic phases of care for patients with SCI.
  • Consider stimulation of the diaphragm in highSCI patients in order to plan long-term ventilator strategies and determine a patient’s potential to wean from the ventilator.

Placement of Tracheostomy Following Cervical Stabilization

  • Tracheostomy can be performed early after anterior cervical spinal stabilization without increasing the risk of infection or other wound complications.
  • Open and percutaneous tracheostomy are both safe techniques.

Analgesia in Spinal Cord Injury

  • Pain management is a priority in the care of the acutely injured SCI patient to relieve suffering and to prevent dysautonomia symptoms triggered by pain.
  • Implement a multimodal approach for the acute pain management of patients with SCI.

Avoidance of Associated Symptoms of Spinal Cord Injury

  • Treat acute autonomic dysreflexia by sitting the patient upright, removing tight-fitting garments, correcting the inciting stimulus, and if needed, administering quick onset, short-acting antihypertensives to reduce blood pressure.
  • Spasticity is managed with physical therapy, and in some cases, anti-spasticity medications.
  • Use clinical judgment and a validated assessment tool to assess skin breakdown risks, and prevent decubitus ulcers by avoiding known modifiable risk factors such as pressure, shear force, and moisture to the skin.

Neurogenic Bowel and Bladder Acute Care Management

  • Initiate a bowel management program for all patients with acute spinal cord injury.
  • The goal of effective bladder management is to preserve upper urinary tract structures and minimize urinary tract infections. Customize bladder management after acute spinal cord injury to the individual, weighing potential benefits and risks, such as fluid status, comorbid injuries and conditions, and personal preferences.

Mobilization and Rehabilitation for Acute Traumatic Spinal Cord Injury

  • Begin physical and occupational therapy treatment for patients with acute SCI within the first week after injury once medical readiness is determined, even if patients remain on some level of sedation, vasoactive support, or mechanical ventilation.
  • Provide holistic early education to patients and caregivers to help them monitor for adverse events, participate in their recovery, and plan for future care.
  • Discharge patients with an acute SCI to a comprehensive acute inpatient rehabilitation facility with expertise in SCI when possible.

IMPLEMENTATION AND INTEGRATION OF THE ACS TQIP SPINE INJURY BEST PRACTICES GUIDELINES

Implementing the ACS TQIP Spine Injury Best Practice Guidelines

  • The trauma medical director, trauma program manager, trauma liaisons, registrars, and staff have a leadership role in implementing the ACS TQIP Spine Injury Best Practices Guidelines, supporting care of the patient with SCI, and monitoring guideline compliance.
  • A stakeholder workgroup, receiving its directives from the trauma medical director and the trauma operations committee, implements the spine injury management BPG.
  • The workgroup reviews the ACS TQIP Spine Injury Best Practices Guidelines and completes a gap analysis related to the current spine care in the trauma center.

Integrating the ACS TQIP Spine Injury Best Practice Guidelines Into Trauma Center Performance Improvement

  • The interdisciplinary workgroup defines elements of the ACS TQIP Spine Injury Best Practices Guidelines to monitor through the trauma performance improvement processes.
  • After approval by the trauma operations committee, the approved elements are integrated into the existing Trauma Performance Improvement and Patient Safety (PIPS) Plan to monitor compliance.
  • The spine injury management BPG performance improvement elements are integrated into the current structure and processes of the PIPS plan.

Recommendation Grading

Overview

Title

Spine Injury Best Practices

Authoring Organizations

Publication Month/Year

March 20, 2022

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D013119 - Spinal Cord Injuries

Keywords

spinal cord injury, spine surgery, spine