ACS releases revised mobility guidelines for spinal injury patients

Although the post-traumatic spinal cord injury represents only a small fraction of all fractures and the rate of incidence ranges from 4-23%, the long-term impacts can be debilitating and incur expenses to the individual and government.

There is a looming danger for such patients that the neural injury might be irreversible and multiple factors can play a role here.

American College of Surgeons has released revised guidelines for spinal injury mobilization  which are multifaceted and are detailed hereunder.

EPIDEMIOLOGY

Falling unintentionally and vehicle-based trauma are the major causes of spinal cord injury

Being osteoporotic and having arthritis make older people more prone to such injuries.

PRE-HOSPITAL SPINAL MOTION RESTRICTION

Devices like a backboard, scoop stretcher, vacuum splint, ambulance cot can help with Spinal motion restriction

Noncontiguous injuries are a possibility so apply SMR to the entire spine whenever indicated.

Ensure properly trained men help in patient transfers.

CERVICAL COLLAR CLEARANCE

For An 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, the cervical collar can be discontinued without additional radiographic imaging.

Its recommended to remove the cervical collar for adult blunt trauma patients who are neurological asymptomatic and have a negative helical cervical computed tomography (CT) imaging.

They recommend A negative helical cervical CT scan as sufficient to remove a C-collar in an adult blunt trauma patient who is obtunded or unevaluable.

IMAGING

For the cervical and thoracolumbar spine, plain radiographs have low sensitivity and thus are not recommended initially for screening.

Non-contrast, multidetector computerized tomography is the first imaging procedure of choice to evaluate the cervical and thoracolumbar spine.

MRI is the only procedure for evaluating the internal structure of the spinal cord.

universal screening for blunt cerebrovascular injury for all patients who have trauma should be considered using a whole-body CT scan.

PHYSICAL EXAMINATION

The best clinical documentation tool is International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

Sensory and motor level of injury is tested to determine the neurologic level of injury.

SPINE INJURY CLASSIFICATION SYSTEMS

The patient's neurologic status, medical status, and specific injury characteristics should come under Spine trauma classification systems.

For surgical or nonsurgical management Patient scores for the classification system are used as decision-making guides.

SPINAL CORD INJURY CLASSIFICATION

For accurately assigning an ASIA impairment grade, its recommended to complete the assessment after the possible spinal shock period.

The level of injury is defined as the lowest spinal segment with intact sensation and anti-gravity motor function preservation after assessing sensation and motor function.

NONOPERATIVE MANAGEMENT

Occipital condyle fractures without neural compression or craniocervical 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.

Steroids are not recommended for penetrating spinal injury

Few gunshot injuries of the spinal cord require surgical stabilization

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.

Planning must be done for resuscitation and positioning the patient on the operating room (OR) to manage potential complications associated with other injuries.

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.

PHARMACOLOGIC 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.

IMPLEMENTING THE ACS TQIP SPINE INJURY BEST PRACTICES 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 PRACTICES 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.

Read the complete guidelines here: https://www.facs.org/-/media/files/quality-programs/trauma/tqip/spine_injury_guidelines.ashx