KEY RECOMMENDATIONS

1. Avoid hypoxemia (SaO2 <90%) and hypotension (SBP<90) for all spinal cord injuries. (Level III)
2. Maintain MAP >85 for all spinal cord injuries, with an emphasis on avoiding hypotension. (Level III)
3. Steroids are not indicated in the management of combat spinal cord injuries. (Level I)
4. Gabapentinoid medication should be considered early for the treatment of neuropathic pain in patients with spinal cord injuries. (Level II)
5. Early mechanical and chemoprophylactic measures against deep venous thrombosis (DVT) should be taken in patients with spine and spinal cord injuries. (Level II)

Patients who sustain neurologic compromise should have an invasive arterial line for continuous blood pressure monitoring with a goal MAP of 85-90 mmHg for up to seven days following the injury.15,31 The evidence supporting this goal is mixed, at best, however it is the opinion of the authors that there is a net benefit to maintaining this goal. Regardless, hypotension (SBP < 90 mmHg) and hypoxemia (SaO2 <90%) must be avoided. Acute management of pulmonary dysfunction following traumatic spinal cord injury improves early survival as complications of pulmonary injury are the leading cause of mortality in traumatic spinal cord injury (SCI), specifically in the cervical spine.32 Vasopressor therapy (in the euvolemic patient) and/or supplemental oxygen are recommended, when necessary, to achieve these goals.15 Prior to the use of vasopressors, ensure that hypovolemia is addressed through adequate resuscitation and evaluation and control of any bleeding. Vasopressor use in the hypovolemic patient may contribute to additional ischemic loss in other injured tissues.

GABAPENTINOID & NON-GABAPENTINOID MEDICATIONS

Non-gabapentinoid anticonvulsants (carbamazepine, phenytoin, clonazepam, phenobarbital, valproic acid) are not shown to improve or worsen long-term neurological outcomes from acute spinal cord injury.33 Early administration of the anticonvulsant gabapentin and pregabalin has been shown to have some improvement of motor recovery, pain intensity, and frequency of autonomic dysreflexia.34-36 Pregabalin and gabapentin are effective for neuropathic pain, depression, and sleep interference.36 Early (within 24 hours) administration of enteral gabapentin should be considered for spinal cord injury patients in combat.

OTHER INVESTIGATED THERAPIES

The use of other pharmacologic agents such as riluzole, dantrolene, baclofen, naloxone, tamoxifen, and interventions such as hyperbaric oxygen and nitrous oxide do not have sufficient evidence to make a recommendation for use in combat-related spinal cord injury.

HANDLING

While many spinal fractures require the head of bed to be flat prior to surgical correction or external bracing, the bed can usually be placed in 30 degrees reverse Trendelenberg. Logrolling and sacral off-loading can be safely performed in most cases every 2 hours to prevent skin breakdown and to perform secondary and tertiary assessments. It is incumbent upon the managing provider to better guide positioning management based upon the specific clinical scenario.

CORTICOSTEROIDS

Although the use of methylprednisolone sodium succinate (MSS) 24-hour infusion remains an option for the treatment of acute spinal cord injury within 8 hours of presentation, its utility in the setting of combat-related blunt or penetrating spinal cord injury is NOT recommended due to the lack of benefit and increased complications.15,37 The primary reasons are on differences in the mechanism of injury (large caliber high velocity projectiles), geographically different and/or austere environments, and concomitant traumatic injuries sustained in combat. The associated open or contaminated wounds of battle casualties with spine or spinal cord injuries are further complicated with steroid administration. Methylprednisolone administration is NOT recommended for any spinal cord injuries sustained in combat.

DVT PROPHYLAXIS REGIMEN

An aggressive DVT prophylaxis regimen should be established early and maintained beyond the evacuation process. Pneumatic compression devices in conjunction with chemoprophylaxis are established treatment standards. Prophylactic dosing of a subcutaneous low molecular weight heparin (LMWH -- e.g. enoxaparin) or FIXED, low-dose unfractionated heparin (UFH) should be initiated as soon as possible but definitely within 72 hours of injury or repair to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with ADJUSTED-dose UFH, this is not recommended for prophylaxis.38 Early active or passive mobilization of the patient helps to reduce DVT formation and is frequently cited in support of early surgical fixation, when appropriate. Patients who show clinical signs or symptoms of a DVT should undergo further imaging to confirm the diagnosis. If a DVT is present, treatment should be initiated with therapeutic anticoagulation if approved by the spine surgeon. If full anticoagulation is contraindicated, an IVC filter placement should be considered.