The acute phase management of traumatic spinal cord injury (tSCI) with polytrauma: A narrative review

Abstract

Introduction: Traumatic spinal cord injury (tSCI) is frequently observed in polytrauma patients.

Research question: What is the optimal strategy to manage tSCI in the setting of polytrauma?

Material and methods: This narrative review focuses on: 1) extraspinal damage control surgery and resuscitation, 2) the perioperative protection of the injured spine during emergency surgery, 3) imaging and timing of spinal surgery in polytrauma, 4) early interventions for skin, bowel and bladder, and 5) the multidisciplinary approach to tSCI polytrauma patients.

Results: Damage control resuscitation (DCR) and damage control surgery (DCS), aim to prevent/correct post-traumatic physiological derangements to minimize bleeding until definitive hemostasis is achieved. Spinal protection during emergency surgery is of paramount importance to reduce secondary insults to the injured spine. Imaging, especially magnetic resonance imaging (MRI), is useful for decision-making regarding surgical management of the injured spine. Early decompressive surgery (within 24 h from trauma) is associated with better neurological outcomes. Early consultation with a physical medicine and rehabilitation physician is beneficial to optimize recovery. A close collaboration between different medical specialties involved in the early management of tSCI patients with polytrauma is advisable to improve outcome.

Discussion and conclusion: This narrative review aims to collate basic knowledge regarding acute phase management of tSCI patients in the context of polytrauma. More evidence and data form well-powered studies are necessary in this setting.

Keywords: Damage control surgery; Emergency surgery; Multidisciplinary approach; Polytrauma; Spinal trauma; Traumatic spinal cord injury.

Fig. 1

Key Aspects of Damage Control Resuscitation in Traumatic Spinal Cord Injury. This figure illustrates the key components of Damage Control Resuscitation as applied to traumatic spinal cord injury. CT - Body Core Temperature; BE - Base Excess; DCS - Damage Control Surgery; INR - International Normalized Ratio; iCA - Ionized Calcium; IV – Intravenous; POC - Point of Care; PLTs – Platelets; RBC - Red Blood Cell; REBOA - Resuscitative Endovascular Balloon Occlusion of the Aorta; tSCI - Traumatic Spinal Cord Injury; TXA - Tranexamic Acid.

Fig. 2

Consensus Recommendations for Spinal Protection During Emergency Surgery in the Acute Phase. This figure summarizes the consensus recommendations, issued jointly by the World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS), for maintaining spinal integrity during emergency surgical procedures within the first 24 h following trauma. Hb - Hemoglobin; IPCD - Intermittent Pneumatic Compression Device; MAP - Mean Arterial Pressure; MT - Massive Transfusion; PaCO₂ - Partial Pressure of Carbon Dioxide; PaO₂ - Partial Pressure of Oxygen; PLT - Platelet; POC - Point of Care; PT/aPTT - Prothrombin Time/Activated Partial Thromboplastin Time; RBC - Red Blood Cell; P - Plasma.

Fig. 3

Multidisciplinary Collaboration in the Management of tSCI Patients. This figure demonstrates the "time is spine" concept, highlighting how each specialty's interconnected role is crucial in the comprehensive treatment pathway for the acute management of polytrauma patients with spinal cord injuries. A multidisciplinary approach aims to optimize patient outcomes. ICU - Intensive Care Unit.