ORIGINAL ARTICLE Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 2: 456-460 P-ISSN.2089-1180, E-ISSN.2302-2914 Spine : How to recognize and stabilize patient ORIGINAL ARTICLE in golden hours periods

Published by DiscoverSys CrossMark Doi: http://dx.doi.org/10.15562/bmj.v9i2.1777 Azharuddin*

ABSTRACT Volume No.: 9 An acute injury (SCI) early management is one of the most include a multi-slice CT protocol of the entire spine to delineate the challenging tasks in trauma cases. The outcome of its cases depends upon known injury and to exclude non-contiguous damages. The outcome SCI the accuracy, adequacy, and speed of first aid management, diagnosis, treatment depends on the number of that survived – the higher Issue: 2 and treatment within the “Golden Hours Periods.” Rapid and safe transport the number of surviving axons, the restoration of neurological functions of the spinal injury patient allows for early medical stabilization designed might be higher. The management of SCI begins before the patient to preserve and potentially improve the neurological outcome. The admitted to the hospital. The principles of treatments include early complications that arise from spinal instability or neurological must be reduction and fixation, combined extramedullary and intramedullary First page No.: 456 prevented immediately and involves all members of the multidisciplinary decompression, cell transplantation, early rehabilitation treatment, and team. Specialized assessment of people with new spinal cord complication prevention. The surgical treatment sometimes needed must take place immediately after an injury. The diagnosis of SCI should to evaluate, stabilize the spine, decompress the area that injured, and P-ISSN.2089-1180 include the level and severity of the damage of the spinal cord, type of managed any other injuries that may have been associated with the fracture or/and dislocation of the injured vertebrae, and the stability of accident. Once a patient was stabilized, care, and treatment focus on the spinal column. Imaging begins from plain radiograph and should supportive care and rehabilitation. E-ISSN.2302-2914 Keywords: spine injury, management, treatment, golden periods. Cite This Article: Azharuddin. 2020. Spine injury: How to recognize and stabilize patient in golden hours periods. Bali Medical Journal 9(2): 456-460. DOI:10.15562/bmj.v9i2.1777

Orthopaedic and Traumatology INTRODUCTION as a buffer of the body (fracture and/or disloca- Division, Department of , tion), which directly exerts a destructive force on Faculty of , Syiah Kuala (SCI) represents one of the most the spinal cord, damaging axons, blood vessels, and University/Dr. Zainoel Abidin 1 devastating survivable injuries a patient can suffer. cell membranes. Meanwhile, the secondary injury General Hospital, Banda Aceh, The neurological deficit severity depends on the Indonesia phase includes vascular dysfunction, inflammation, duration of spinal cord injury (SCI) and its degree oedema, ischemia, electrolyte shift, free radical of compression. The spinal cord compression with production, excitotoxicity, and delayed apoptotic paraplegia or quadriplegia as sequelae has enor- 2 cell death. Neurological deficits are present imme- mous socioeconomic and emotional consequences. diately after the initial injury; the secondary injury The global incidence of SCI was estimated from phase will cause a prolonged period of tissue 40 to 80 new cases per million populations per year. damage (Table 1).6,7 It means that every year, the spinal cord injury case 3 The most common form of acute SCI is happens between 250,000 and 500,000. Regardless of ­compressive-contusive type injury, which causes the cause of spinal cord injury, early decompression is the components of the vertebral column, which the principal goal for managing this case. The prog- consist of intervertebral discs and ligaments to shift. nosis was noted to be better when decompression is The disruptive force on the spinal cord causes direct *Correspondence to: done as early as possible in acute spinal injury. The traumatic injury and continuous compression. The Azharuddin, Orthopaedic and controversies regarding the importance and timing 4,5 first pathological change detected after an injury is Traumatology Division, Department of decompression are emphasized in recent studies. swelling of the spinal cord, which is usually associ- of Surgery, Faculty of Medicine, Syiah Kuala University/Dr. Zainoel ated with bleeding in central gray matter, causing Abidin General Hospital, Banda PATHOPHYSIOLOGY cells to experience necrotic death due to direct cell Aceh, Indonesia membrane disruption or ischemia due to vascular [email protected] Pathophysiological progress in SCI can be described disorders - Ion dysregulation and excitotoxicity. as a biphasic condition. This condition consists of Ionic homeostasis disorders that occur immedi- Received: 2020-03-17 the primary and secondary phases of spinal cord ately after SCI and also excitotoxicity have a signif- Accepted: 2020-06-30 injury (Table 1). The primary phase includes the icant contribution to the spread of cellular injury Published: 2020-08-01 initial mechanical damage that causes spinal failure after SCI. The final effect of the disruption of ionic

456 Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj ORIGINAL ARTICLE

Table 1 Spinal cord injury phases6 Phase and key events ≤2 Hours ≤48 Hours ≤14 Days ≤6 Months ≥6 Months Injury phase Primary immediate Early acute Secondary Intermediate Chronic/late subacute Key process Primary mechanical Vasogenic and cytotoxic oedema, Macrophage Continued Pronged Wallerian and events injury, traumatic reactive oxygen species production and infiltration, formation of degeneration, severing of , lipid peroxidation, glutamate-mediated initiation glial scar cyst persistence grey matter excitotoxicity, continued haemorrhage, of astroglial formation of spared, haemorrhage, continued haemorrhage and necrosis, scar (reactive lesion demyelinated hemorrhagic neutrophil invasion, peak blood-brain astrocytosis), stabilization axons, potential necrosis, microglial barrier permeability, early demyelination blood-brain structural and activation, released (oligodendrocyte death), neuronal death, barrier repair functional factor (IL-1β, TNFα, axonal swelling, systemic events (systemic & resolution of plasticity of spared IL-6, and others , spinal shock, , hypoxia) oedema spinal cord tissue Therapeutic Neuroprotection Neuroprotection, immune modulation, cell- Glial scar Rehabilitation, aim based remyelination approaches, glial scar degradation neuroprostheses degeneration

Grade D ASIA means that motor scores below the injury level increase to 50% or higher than normal.8

IMAGING Imaging and examination must be carried out after initial stabilization. Spinal imaging is an essential part of the initial management of acute SCI; Plain X-rays or computed tomography form the basis of a standard trauma protocol and can identify most fractures and ligament injuries. Computed tomog- raphy is the first choice of imaging for patients with SCI and . CT-scan provides fast imag- ing with increased visualization of bone fractures. Figure 1 The primary condition that happens after Traumatic spinal cord Three-dimensional axial and CT scans can reveal injury includes acute changes result in cell death, axonal damage, the shape of the spinal canal and facet joints of the matrix remodelling, and formation of a glial scar7 vertebrae. For multiple injuries, a CT scan must be performed.8,9 homeostasis becomes the center caused by necrotic These imaging modalities cannot visualize the cell death and apoptosis after injury Figure( 1).3,6,8 spinal cord or surrounding soft tissue to the same level as MRI. Meanwhile, the potential risks and DIAGNOSIS disadvantages of MRI, including patients, must be stretched for up to 30 minutes and maybe risky Assessment of patients with suspected SCI should for trauma patients with respiratory difficulties or include the level and type of fracture or/and dislo- unstable hemodynamic.10 cation of the injured vertebra, spinal stability, the extent and severity of spinal cord injury, should MANAGEMENT be included in the diagnosis of SCI (Figure 2). The ASIA scale is one classification to assess the severity Acute management of SCI. ASIA grade A is assessed for injuries in the The number of neurological dysfunction after a absence of voluntary anal sphincter contractions spinal cord injury caused by improper management and perianal sensations. ASIA Grade B shows that is around 25%. First aid management for SCI patients some sensations are maintained, but the motor must be taken more seriously. Biomechanical score is zero below the injury level. ASIA Grade studies­ recommend the use of a rigid cervical collar C shows some motor function, but motor scores with supporting blocks on hardboard with a strap. below the injury level are less than 50% of normal. However, tissue necrosis can occur from pressure

Published by DiscoverSys | Bali Med J 2020; 9(2): 456-460 | doi: 10.15562/bmj.v9i2.1777 457 ORIGINAL ARTICLE

Figure 2 Algorithm for spinal trauma management11 due to rigid boards during prolonged transport, position, which can be achieved by placing a rigid or a short period of rigid immobilization. The use cervical collar, handling the patient in an en bloc, of padded boards may reduce the risk of pressure and transporting in the supine position in spine necrosis.9 board or an inflatable transport mattress.12 Any significant trauma victim must be consid- In SCI, early intubation and ventilation are indi- ered to have a spinal cord injury until it can be cated for patients with high cervical injuries (C1–5), confirmed otherwise by clinical or radiological which cause disturbances in diaphragmatic breath- assessment. Suspected spinal injuries and SCI can ing, respiratory depression, and CO2 retention ­ - complicate the management of trauma patients these patients generally have quadriplegia because they require special manoeuvres.12 disorders. Emergency management by securing the Preventing secondary damage to the spinal cord airway with adequate oxygenation and circulation from the injured spinal segment, trauma patients is the first step to prevent further damage to spinal must be moved and transported in a safe and stable trauma. Polytraumatic spinal cord injuries are often

458 Published by DiscoverSys | Bali Med J 2020; 9(2): 456-460 | doi: 10.15562/bmj.v9i2.1777 ORIGINAL ARTICLE

complicated by systemic hypotension due to hemor- or late, especially in polytrauma cases. The removal rhagic and/or , which aggravates of damaged bones, discs, and ligament fragments the secondary neurological injury. Aggressive fluid to decompress swollen cords should limit second- must be applied to manage hypoten- ary damage and increase results.13 The time for sion and/or neurogenic shock that occurs during surgery usually classified as early, < 72 hours, or late the initial phase of injury. Recommended treatment > 72 hours.14 A prospective study by Cengiz et al. in targets include SBP 90-100 mm Hg with heart rate 27 patients with isolated thoracolumbar spinal cord 60-100 beats/minute, urine output >30 ml per hour, injury reported the results of the initial surgery and normothermia.9 in 12 patients (less than 8 hours) and late surgery in 15 patients (15-15 days). This study shows that PHARMACOLOGICAL THERAPY early surgery has a tendency toward shorter hospi- talizations, shorter intensive care units having Nerve protection is vital in spinal trauma, which lower complication rates, and better neurological aims to minimize and prevent the expansion of outcomes.13 secondary central cord damage by using medical The decompression operative techniques measures that inhibit apoptosis, cell death, and also used were based on the spinal level of injuries or improve nerve cell survival. High-dose methylpred- compression, the severity, and the available surgical nisolone (MP) therapy in the early stages was once expertise. The duration and severity of spinal cord considered positive for neurological restoration in compression before surgical intervention signifi- the acute phase of SCI. Intravenous MP injection of cantly affect the postoperative outcome of decom- 30 mg/kg bolus for 8 hours after SCI (first 3 hours) pression. The main goal of the surgery in spinal followed by continuous infusion of 5.4 mg/kg per cord injuries is to relieve cord compression as soon hour, for the next 23 hours showing an absolute effi- as possible and stabilize it to protect the cord. In ciency. While high-dose MP therapy is no longer the trauma setting, there is evidence to suggest that routinely used in acute SCI, it is still an optional the outcome is better when spinal decompression is therapeutic method. Methylprednisolone (MP) can done within 48 h.2,5 The need for surgery in unsta- even be used in incomplete cervical medulla lesions, ble spine injury is not in doubt. Decompression and especially in patients with cervical spondy- is as essential as stabilization in unstable spinal litis myelopathy that requires decompression. injuries, where it ensures the cord is no longer at Contraindications for the treatment of high doses risk of further injury. The neurological function of MP consist of penetrating injuries and injuries in a patient may not have improved in afterwards, due to shot to the spine, spinal cord injuries without but rehabilitation is more comfortable with a stable neurological deficits, gastrointestinal bleeding, and spine construct.2 diabetes. This treatment should not be given more than 8 hours after injury, and in older patients with CONCLUSION a higher risk of pneumonia. Erythropoietin (EPO) has glioprotective and The management of spinal trauma continues to neuroprotective properties, which reduce cellular evolve from time to time due to a better under- infiltration, medullary cavitation, and neuronal standing regarding the mechanism of injury and its cell death. The use of human EPO after a spinal biomechanics effect, disease pathophysiology, and cord injury is carried out by injecting a dose of improvement for both operative and non-operative 5,000 units/kg, either a single intraperitoneal injec- treatment. However, there are still some contro- tion or a daily injection for seven days which has versial areas regarding management strategies for shown to have a beneficial effect on neurological the treatment of spinal trauma, including the use recovery; even no definitive conclusions have been of corticosteroids such as methylprednisolone drawn because the number of patient subgroups is sodium succinate, the optimal time for surgical insufficient. Clinical trials of minocycline, naloxone, intervention, type and timing of anticoagulation and tirilazad also show limited therapeutic effects as prophylaxis, the role of magnetic resonance imag- nerve protection in patients with SCI. Mannitol can ing, and type and time of rehabilitation. A tailored also alleviate secondary spinal cord oedema. and multidisciplinary approach must be applied for better results in the management of spinal trauma. SURGICAL MANAGEMENT ACKNOWLEDGEMENTS The time for surgical stabilization in spinal cord injury continues to be controversial, whether early None.

Published by DiscoverSys | Bali Med J 2020; 9(2): 456-460 | doi: 10.15562/bmj.v9i2.1777 459 ORIGINAL ARTICLE

DISCLOSURE 8. Feng Y, Sun T, Chen L, Xie J, Zhang Z, Huang H, et al. Clinical therapeutic guideline for neurorestoration in spinal The author reports no conflicts of interest in this cord injury (Chinese version 2016). J Neurorestoratology. 2017;Volume 5:73–83. work. 9. Yue JK, Winkler EA, Rick JW, Deng H, Partow CP, Upadhyayula PS, et al. Update on critical care for acute spinal cord injury in the setting of polytrauma. Neurosurg REFERENCES Focus. 2017;43(5):1–9. 10. Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, 1. Kim D, Ludwig S, Vaccaro A, Chang J. Atlas of spine AS, Martin AR, et al. A Clinical Practice Guideline trauma: adult and pediatric. Saunders, Elsevier; 2008. for the Management of Acute Spinal Cord Injury: 1–113 p. Introduction, Rationale, and Scope. Glob Spine J. 2017; 2. Ojo OA, Poluyi EO, Owolabi BS, Kanu OO, 7(3_supplement):84S-94S. Popoola MO. Surgical decompression for traumatic spi- 11. Maschmann C, Jeppesen E, Rubin MA, Barfod C. New nal cord injury in a tertiary center. Niger J Clin Pract. clinical guidelines on the spinal stabilisation of adult 2017;20(11):1455–60. trauma patients – consensus and evidence based. Scand J 3. Ahuja CS, Wilson JR, Nori S, Kotter MRN, Curt A, Trauma Resusc Emerg Med. 2019;27(1):1–10. Fehlings MG. Traumatic spinal cord injury. Nat Rev. 12. Scholtes F, Brook G, Martin D. Spinal cord injury and its 2017;3:1–21. treatment: current management and experimental per- 4. Shrivastava S, Sakale H, Dulani R, Singh PK, Sanrakhia M. spectives. Adv Tech Stand Neurosurg. 2012;38:29–56. Role of Decompression in Late Presentation of Cervical 13. Cengiz ŞL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing Spinal Cord Disorders. Asian Spine J. 2014;8(2):183–9. of thoracolomber spine stabilization in trauma patients; 5. Fehlings MG, Vaccaro A, Wilson JR, Singh A, Cadotte DW, impact on neurological outcome and clinical course. A Harrop JS, et al. Early versus Delayed Decompression real prospective (RCT) randomized controlled study. Arch for Traumatic Cervical Spinal Cord Injury : Results of Orthop Trauma Surg. 2008;128(9):959–66. the Surgical Timing in Acute Spinal Cord Injury Study 14. Carreon LY, Dimar JR. Early versus late stabilization of (STASCIS). PLoS One. 2012;7(2):1–8. spine injuries: A systematic review. Spine (Phila Pa 1976). 6. Rowland JW, Hawryluk GWJ, Kwon B, Fehlings MG. 2011;36(11):727–33. Current status of acute spinal cord injury pathophysi- ology and emerging therapies: Promise on the horizon. Neurosurg Focus. 2008;25(5):1–3. 7. Alizadeh A, Dyck SM, Karimi-Abdolrezaee S. Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury Mechanisms. Front Neurol. This work is licensed under a Creative Commons Attribution 2019;10(March):1–25.

460 Published by DiscoverSys | Bali Med J 2020; 9(2): 456-460 | doi: 10.15562/bmj.v9i2.1777