Spinal Cord Injury Considerations

SCI Pathophys & Initial Care - Spine SOS!

• Primary Injury: Initial, irreversible mechanical damage.
• Secondary Injury: Delayed cascade (ischemia, inflammation, excitotoxicity); potentially modifiable.
• Spinal Shock: Temporary loss of reflexes, flaccid paralysis below injury. Bulbocavernosus reflex return signals end.
• Neurogenic Shock (Injury ≥T6): Sympathetic disruption. Triad: Hypotension, Bradycardia, Poikilothermia.

  ⭐ Neurogenic shock: hypotension with bradycardia/normal HR, unlike hypovolemic shock (tachycardia).

• Initial Care (ATLS & 📌 Spine SOS!):
  • Airway: Jaw thrust, C-spine control.
  • Breathing: Monitor C3-C5 (phrenic n.) for respiratory failure.
  • Circulation: MAP >85-90 mmHg (vasopressors; cautious fluids).
  • Disability: ASIA scale.
  • Immobilization: Rigid collar, log-roll.

SCI Airway & Induction - Neck's on the Line!

technique for cervical spine protection during intubation)

• C-Spine Protection:
  • Absolute priority: Manual In-Line Stabilization (MILS) by a trained assistant.
  • Remove rigid collars for intubation (may hinder view/access); maintain MILS.
• Airway Management Algorithm:

• Induction Agents:
  • Goal: Maintain Mean Arterial Pressure (MAP) for spinal cord perfusion.
  • Ketamine: Often preferred (maintains BP, bronchodilation).
  • Etomidate: Hemodynamically stable (consider adrenal suppression).
  • Propofol/Thiopentone: Use with caution (risk of hypotension ↓).
• Muscle Relaxants:
  • Succinylcholine (SCh):
    • Permissible only within first 24 hours post-SCI.
    • ⚠️ Strictly AVOID after 24-48 hours (risk of severe hyperkalemia $K^+$↑).
  • Rocuronium: Preferred non-depolarizing agent; Sugammadex available.

⭐ In acute SCI, succinylcholine is safe for RSI only within the first 24 hours. After 24-48 hours, it can cause life-threatening hyperkalemia due to upregulation of extrajunctional acetylcholine receptors (nAChRs).

SCI Intraop Hemodynamics - Pressure Points!

• MAP Goal: 85-90 mmHg (first 5-7 days); SBP >90 mmHg to optimize SCPP.

• Neurogenic Shock (>T6):

  • Triad: Hypotension, Bradycardia, Poikilothermia (📌 HBP).
  • Mgt: IV fluids (cautious), Norepinephrine (preferred), Atropine for significant bradycardia.

• Autonomic Dysreflexia (AD) (>T6):

  • Trigger: Stimuli below injury (surgery, bladder).
  • Sx: Severe HTN, pounding Headache, Brady/Tachycardia, profuse Sweating/Flushing (above lesion).
  • Mgt:

• Monitoring: Invasive A-line (mandatory), continuous core temperature.

• Temperature: Poikilothermia common → hypothermia risk. Active warming essential.

⭐ Crucial: Maintain MAP 85-90 mmHg for at least 7 days post-acute SCI to optimize spinal cord perfusion and limit secondary injury.

SCI Post-Op & Complications - Recovery Roadblocks

• Ventilatory Support: Prolonged ventilation, especially cervical lesions (C3-C5). Early tracheostomy may be needed. Weaning challenges.
• DVT Prophylaxis: Crucial. LMWH, sequential compression devices (SCDs), early mobilization if possible.
• Pain Management: Multimodal. Neuropathic pain (gabapentinoids, TCAs). Opioid-sparing techniques.
• Pressure Sores: Prevention is key. Regular turning (q2h), specialized surfaces, nutritional support.
• Autonomic Dysreflexia (AD): Persistent risk. Identify & manage triggers (bladder, bowel, skin).

  ⭐ AD is a medical emergency in patients with SCI at or above T6, characterized by paroxysmal hypertension.

• Spasticity: Develops later. Baclofen, tizanidine, physiotherapy.
• Heterotopic Ossification: Ectopic bone formation around joints, limiting mobility.
• Psychological Support: Essential for coping, rehabilitation, and quality of life adjustment post-SCI.

High‑Yield Points - ⚡ Biggest Takeaways

• Prioritize C-spine immobilization during intubation; AFOI or VL often preferred.
• Expect neurogenic shock (↓BP, ↓HR) with injuries above T6; treat with vasopressors.
• Succinylcholine is contraindicated 24h to 6-12 months post-SCI due to severe hyperkalemia risk.
• Autonomic dysreflexia (lesions >T6): sudden severe HTN, bradycardia; remove trigger, deepen anesthesia.
• Actively manage temperature due to poikilothermia.
• High cervical lesions (C3-C5) can cause respiratory failure.
• Judicious IV fluids to avoid pulmonary edema_