Assessment and management of acute spinal cord injury: From point of injury to rehabilitation

Abstract

Context: Spinal cord injury (SCI) is a devastating condition that can lead to significant neurological impairment and reduced quality of life. Despite advancements in our understanding of the pathophysiology and secondary injury mechanisms involved in SCI, there are currently very few effective treatments for this condition. The field, however, is rapidly changing as new treatments are developed and key discoveries are made.

Methods: In this review, we outline the pathophysiology, management, and long-term rehabilitation of individuals with traumatic SCI. We also provide an in-depth overview of emerging therapies along the spectrum of the translational pipeline.

Evidence synthesis: The concept of "time is spine" refers to the concept which emphasizes the importance of early transfer to specialized centers, early decompressive surgery, and early delivery of other treatments (e.g. blood pressure augmentation, methylprednisolone) to affect long-term outcomes. Another important evolution in management has been the recognition and prevention of the chronic complications of SCI including respiratory compromise, bladder dysfunction, Charcot joints, and pressure sores through directed interventions along with early integration of physical rehabilitation and mobilization. There have also been significant advances in neuroprotective and neuroregenerative strategies for SCI, many of which are actively in clinical trial including riluzole, Cethrin, stem cell transplantation, and the use of functional electrical stimulation.

Conclusion: Pharmacologic treatments, cell-based therapies, and other technology-driven interventions will likely play a combinatorial role in the evolving management of SCI as the field continues to evolve.

Keywords: Neuroprotection; Pathophysiology; Regeneration; Rehabilitation; Spinal cord injury; Stem cell; Surgical decompression; Treatment.

Figures

Figure 1.

Post-traumatic syringomyelia following T6–7 thoracic spinal cord injury. (A) Sagittal T2-weighted magnetic resonance image demonstrating evidence of an extensive syrinx (white arrowhead) within the cervical and thoracic cord extending as high as the cervico-medullary junction (black arrowhead). (B) Corresponding axial cut at the C3 level highlighting the ventral-dorsal and medial-lateral size of the syrinx

Figure 2.

Primary and secondary injuries of spinal cord injury. An initial primary physical insult initiates a rapid cascade of secondary biochemical injuries extending over the immediate, early acute and subacute phases. Figure adapted from Wilson et al..

Figure 3.

Overarching management goals at each stage following spinal cord injury. Each target must be considered within the broader care of an individual, coexisting polytrauma, and local resources. Time windows are a suggestion, however, the ‘Time is Spine’ concept should be emphasized as earlier initiation of treatments/prophylactic measures, when safe, may have beneficial effects