Assume ASCI is present in every MWD trauma patient until proven it is not present. Maintain a high index of suspicion! 40-50% of MWDs with ASCI have concurrent injury elsewhere that may be more life-threatening.1 Focus on initial resuscitation and stabilization, but constantly consider potential neurological injuries. Excessive movement can cause a partial injury to become a permanent injury. Limit movement during the initial exam and treatment period to that which is absolutely necessary until a detailed neurological exam is performed.
Clinical findings of bruising over any part of the spine; spinal instability, misalignment, crepitus or pain along the spine; presence of head injury or altered mentation or level of consciousness; or major trauma to other body systems are early tips that ASCI may be present.
Specific neurological signs that strongly suggest ASCI include loss of conscious proprioception, loss of superficial and deep pain, and loss of function (paresis or paralysis).
It is ideal to localize the segment of the cord affected. Determine if upper motor neuron (UMN) or lower motor neuron (LMN) signs are present.
Radiographs, CT, or MRI are often necessary for definitive diagnosis in patients with fractures or dislocations to determine the site of injury. If these imaging modalities are available and the MWD can be managed without worsening possible injury, attempt imaging (See CPG 20). Heavy sedation or anesthesia will be necessary (See CPG 16).
Goals are to reduce neurological deficit and prevent further loss of neurological function (See Figure 46).
Figure 46. Clinical Management Algorithm for Acute Spinal Cord Injury in MWDs.
Indications for conservative (non-surgical) treatment include patients that are ambulatory or paraparetic, and patients that have strong voluntary movement and peripheral pain sensation.
Early definitive surgical correction is indicated in non-ambulatory patients, patients with palpably unstable or displaced injuries, patients that deteriorate with conservative therapy, patients with peripheral pain sensation but no voluntary movements, and patients requiring decompressive surgery to correct displaced or fractured spinal segments or bone fragments. Surgical management is likely not be feasible in a deployed setting.