Our patient is a 23-year-old woman with no known medical history who presents after a rollover motor vehicle accident. During the accident, the patient had immediate loss of movement in her legs with preserved sensation. She also reports weakness in her hands but has some movement in the fingers bilaterally.
On her initial evaluation, the patient is awake, alert, and appropriate. Her neurologic examination shows intact sensation to light tough and pinprick throughout her body. She had no movement in her legs but has full strength in her biceps and deltoids. She has decreased but present movement in her bilateral wrist extensors, triceps, and grip. Her rectal tone is present as well. She has no other obvious injuries on her secondary trauma survey.
The patient has hypotension with bradycardia. Her respiratory rate and oxygen saturation are within normal limits, and she is able to communicate without difficulty. Her laboratory results and initial chest radiograph do not demonstrate any acute abnormalities.
Spine trauma and spinal cord injury are a significant problem across the world. In the United States, 12 000 new spinal cord injuries occur per year, and it is estimated that 250 000 individuals are living with this condition. This injury is principally found in men, and the average is 30 years. Cervical spine fractures account for 20% to 30% of all spine fractures with 10% to 20% resulting in spinal cord injury. Approximately 16% of injuries involve the thoracic spine, and the rest include the thoracolumbar junctional segments and the lumbar spine.1
Management of spinal injury in the intensive care unit (ICU) can improve the patient’s outcome and decrease morbidity and mortality. This chapter (1) provides guidelines for the initial stabilization and workup of patients with spine injuries, (2) presents the concepts of spine stability and the rationale for surgical management, and (3) explains management of ICU-related issues and how to avoid complications.
How should the patient initially be managed?
Although this patient has clear clinical evidence of a cervical spinal cord injury, the first step in the assessment of any trauma patient begins with the ABCs (airway, breathing, and circulation). Although this evaluation should begin in the emergency department (ED), all critical care specialists should be familiar with the initial resuscitation and should repeat the steps upon arrival to the ICU. Prior to definitive stabilization, the cervical spine should be immobilized in a rigid collar, and the patient should be maintained on a flat, firm surface.2,3
Airway and circulation are essential in this patient population as hypoxia and hypotension may worsen secondary spinal cord injury,4,5 and therefore any patient with a clear indication for intubation such as a low Glasgow Coma Scale (GCS) score, hypoxia, or failure of diaphragmatic function should be immediately intubated. The main predictors of intubation in a spine ...