Initial treatment for spinal cord injury

First aid after the accident: how is a spinal cord injury diagnosed and how is acute care provided?

According to statistics from the working group on spinal cord injury of the DGUV, BG Klinikum Hamburg, 45% of all spinal cord injuries are caused by accidents. Traffic accidents are the most common cause, followed by sports accidents.

As these are often serious accidents, the priority in acute care is to check and secure vital parameters, i.e. stabilize the breathing and the cardiovascular system.

If the patient is conscious, a medical history can be taken. If the patient describes, for example, a strong impact on the back, paralysis or a sensory deficit, a spinal cord syndrome is suspected. Motor and sensory deficits are also assessed in a neurological examination.

If a spinal cord injury is suspected, the patient is transported to a hospital with neurological and trauma surgery capacities as quickly as possible.

How is the spine stabilized, and which measures are taken to prevent inury?  

For transport to the ambulance and further to the hospital, the spine must be stabilized to prevent further injuries to the spinal cord, such as from bone fragments.

There are special rescue stretchers for this, the so called spinal boards, on which the patient is strapped with belts. Vacuum mattresses are also used, especially if the patient has to be rescued from a confined space. These are pressed around the body while a vacuum is applied so that they become firm and immobilize and stabilize the patient.

If injury to the cervical spine or craniocerebral trauma is suspected then a cervical collar is applied, which protects the neck area.

If the imaging examination in hospital reveals an unstable vertebral fracture, an operation must be performed later to permanently stabilize the bone.

Which neurological examinations and imaging techniques are used to make a diagnosis?

The diagnosis of spinal cord injury is based on a thorough clinical neurological examination.

The motor function is tested by performing various movements in the absence of gravity, against gravity and against resistance exerted by the examiner. Various reflexes are also tested.

So-called key muscles can be assigned to a specific level of the spinal cord, allowing the level of damage to be estimated. Skin sensitivity is also tested, and specific areas can be associated with a particular level of the lesion. This enables targeted use of imaging diagnostics.

Diagnostic imaging techniques such as x-rays, CT and MRI are used to assess the injury in more detail and, if necessary, to plan a surgical procedure. Blood tests are also carried out, for instance to rule out critical blood loss as a result of the accident.

Neuro-urological examinations can be carried out to assess the amount of residual urine after urination and the urine flow volume over a certain period of time in order to assess bladder function.

Neurophysiological examinations, in which nerve cells are electrically stimulated, can be used to assess the remaining conductivity of the damaged section of the spinal cord.

What are the challenges in the acute treatment of the neurological shock phase?

The sudden loss of function of autonomic nerve cells in spinal shock causes the blood vessels in the periphery to dilate, causing a significant drop in blood pressure. If this occurs for other reasons, such as heat, the heart rate compensatorily increases, so the volume of blood pumped by the heart is hardly reduced. However, this increase in heart rate is not possible in spinal shock, as it is also mediated by the autonomic pathways. As a result, an unstable circulatory situation may arise, which must be treated with infusions and medications that increase blood pressure and heart rate.

In addition, the dilated blood vessels cause the body to lose more heat, which means that the body temperature must be monitored and the preservation of heat must be secured.

If the spinal cord damage is in the upper neck region, respiratory paralysis occurs. Artificial respiration is then vital for survival.

To prevent further damage to the spinal cord, surgery is usually necessary at an early stage to remove blood, disc tissue or bone fragments from the spinal canal and to treat unstable fractures.

As bladder and bowel function may be impaired in spinal shock, urinary diversion must be secured by means of a permanent catheter. Bowel evacuation is achieved with laxative medication and enemas.

Furthermore, symptoms such as sudden paralysis and disturbances of sensation, as well as the possible accident, can be very stressful for patients and can trigger anxiety. Psychological support is therefore important.

What measures are taken to prevent thrombosis and complications?

Acute spinal cord injury can lead to various complications, which is why the following preventive measures are necessary:

• Thrombosis prophylaxis: the lack of movement of the legs increases the risk of a blood clot in a vein of the leg which could be carried to the lungs and cause a pulmonary artery embolism. To prevent this, heparin injections are administered to thin the blood.
• Ulcer prophylaxis: the physical stress and the administration of painkillers increases the risk of a stomach or intestinal ulcer, which can lead to severe bleeding. Moreover, this may go unnoticed, particularly in the case of spinal cord injury, as the sensation of pain in the gastric and intestinal mucosa may be suppressed. Tablets that are gentle on the mucous membrane (proton pump inhibitors) are administered to prevent this.
• Positioning therapy: to prevent pressure sores and joint contractures, patients must be positioned functionally and regularly repositioned. If surgical stabilization needs to be postponed due to a life-threatening condition, careful positioning becomes especially important.
• Pain therapy: timely and adequate pain management reduces the risk of pain becoming chronic.

Which doctors & clinics specialize in the initial treatment of spinal cord injury?

At the accident site, the emergency doctor and trained rescue personnel provide rescue, initial acute care and transportation to the hospital.

At the hospital, various specialist departments are involved in the acute treatment of spinal cord injury. This mainly involves the neurology and trauma surgery departments. Intensive care units, where this patient is treated, are usually managed by anesthesiologists. In addition, psychiatric treatment may also be necessary.

Due to this interdisciplinary nature and the fact that this condition requires care by specialized nursing staff, there are clinics that specialize in this condition specifically.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field initial treatment in spinal cord injury. They are looking forward to and are ready to address your questions and treatment requests.