ACS TQIP Spine Injury Guidelines

Fractures of the spinal column represent a small proportion of all fractures from traumatic injury with an incidence ranging from 4 to 23 percent. 1,2 However, their impact on the individual and the health care system is significant because of their potential for long-term disability, the associated health care consequences, and costs. Despite improvements in the understanding of basic spinal fracture patterns, more reliable classification, and injury severity assessment systems, controversy remains in the management of these injuries. 1 The threat of irreversible neural tissue injury and the presence of multiple traumatic injuries that may include life-threatening abdominal and thoracic injuries leads to complex decision making.

Timing of surgical care for spinal injuries depends not only upon early decompression to improve or prevent further neurologic injury, but also on the need to first stabilize the patient’s hemodynamics or treat other life-threatening injuries. Operative versus nonoperative spinal column management is not always a clear decision, such as when progressive deformity or secondary neurologic deterioration is unlikely or it is unclear that surgical stabilization will contribute to an improved quality of life. Globally, the aging population is increasing and with it is the incidence of traumatic spinal injuries. The aging spine becomes increasingly vulnerable to injury as it stiffens and becomes osteoporotic.

Comorbidities and frailty present management and outcome challenges. This publication is intended to provide an evidence-based, practical guide for the evaluation and management of an adult patient with a spinal injury, including both spinal column fracture (SCF) and spinal cord injury (SCI). When evidence is poor or absent, best practices are then based upon expert opinion which has been drawn from leaders in the fields of neurosurgery and orthopaedic surgery. This Best Practices Guideline (BPG) begins with the epidemiology of spinal injury, then reviews pre-hospital spinal motion restriction, cervical collar clearance, and appropriate imaging.

It goes on to include details about completing a physical exam for evaluation of spinal cord injury and the classification systems for both spinal column injury and spinal cord injury. The indications for nonoperative and operative management are discussed for both blunt and penetrating spinal injuries. The use of mean arterial pressure (MAP)directed therapy is considered along with the limitations of its supporting data. Specific areas of management that are targeted include venous thromboembolism (VTE) prophylaxis, neurogenic and spinal shock, SCI-induced bradycardia, ventilator management in a patient with high SCI, and analgesia.

Because patients with SCI often have a prolonged hospital course, the guideline also includes information on prevention and management of acute autonomic dysreflexia, spasticity, pressure ulcers, and neurogenic bowel and bladder. The importance of early mobilization and rehabilitation is reviewed. The last two sections cover implementation of the Spine BPG into trauma center protocols and integration of this information into the trauma center’s performance improvement processes. References 1. Oner C, Rajasekaran S, Chapman JR, et al. Spine trauma: What are the current controversies? J Orthop Trauma. 2017 Sep; 31(Suppl 4): S1–S6. 2. Oliver M, Inaba K, Tang A, et al.

The changing epidemiology of spinal trauma: A 13-year review from a level I trauma centre. Injury. 2012; 43: 1296–1300. BEST PRACTICES GUIDELINES: SPINE INJURY

BEST PRACTICES GUIDELINES: SPINE INJURY

ƒ Vehicular trauma and unintentional falls are the leading mechanisms of spinal cord injury. ƒ 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.

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