Operative and Nonoperative Treatment for Spinal Injuries

KEY RECOMMENDATIONS

In cases of incomplete spinal cord injury, spinal decompression should be undertaken as soon as it is safe and feasible to do so, including at Role 3 installations if appropriate support and resources are available in theater. (Level III)

Taking into account evacuation time, planned staged operations at Role 3 and 4 facilities are an acceptable option in instances where patients present with incomplete injury or worsening neurologic deficit. (Level III)

NON-OPERATIVE TREATMENT

In order to proactively guide treatment and logistical decisions, it is imperative that the deployed surgeon be intimately familiar with the operative and non-operative options in their theatre of operation. The actual materials on hand for non-operative management in the deployed setting may be variable, but generally include C-collars, other orthotic braces, and occasionally, halo devices.

For cervical fracture-dislocations, especially those associated with incomplete injury, closed reduction downrange is recommended. In patients with cervical dislocation and spinal cord injury, CT myelogram may represent an alternative advanced imaging modality prior to proceeding with closed reduction. In the civilian literature, MRI data obtained prior to reduction have not been shown to affect the outcome of the closed reduction, provided the patient is awake, neurologically intact and able to provide a reliable examination.39 Thus closed reduction of cervical fracture-dislocations, even in the absence of an MRI, may represent another area of possible intervention while in-theater.

OPERATIVE TREATMENT

The decision for operative treatment of U.S. and coalition spine fractures in theater is ultimately left to the deployed surgical team, including the spine surgeon (if available) and the Chief of Trauma. Good clinical judgment is a priority in the care of patients with spine and spinal cord injuries in a deployed setting. Surgery that can be delayed safely until the patient arrives to the Role 4 military treatment facility should be delayed. However, there may be some conditions which may benefit from immediate surgery in-theater, including but not limited to:

- incomplete spinal cord injuries
- open cerebrospinal fluid (CSF) leaks
- expected prolonged delay in transport, or
- where an urgent reduction may improve the degree of “root sparing” in a cervical spinal cord injury.

INCOMPLETE INJURIES

The management of incomplete spinal cord injuries in theater remains controversial due to the potential for higher rates of neurologic improvement with early operative intervention weighed against obvious challenges posed by an austere environment. Initial spinal cord injury or subsequent progression can occur via fracture displacement, bone fragment compression, expanding hematoma, spinal cord edema or infarction. In civilian literature, animal studies have demonstrated that immediate decompression of neural elements is associated with a reduction in neurological sequela.40-44 Several large investigations have demonstrated significant improvement in neurologic outcomes with early surgical intervention in incomplete spinal cord injuries.6,10,45,46 This information has led many major U.S. trauma centers to adopt a goal of early surgical decompression in cases of incomplete spinal cord injury. There are some data to suggest that it is not the timing of surgery alone that is the key factor, but the extent of decompression.47 However, these data must be carefully applied to the deployed setting as forward medicine presents unique challenges not experienced in high volume modern trauma centers. In one investigation examining the outcomes of 50 cases of spinal cord injury treated surgically in theater versus those undergoing delayed care at Landstuhl Regional Medical Center, Schoenfeld demonstrated no differences in neurologic recovery between groups.9 Patients who were treated with surgery in theater had significantly higher rates of postoperative complications (40% vs. 20%) and had higher rates of additional surgical procedures. Though limited by its relatively low case numbers and retrospective nature, this study may challenge the extrapolation of civilian literature to a deployed setting. Given this conflict in civilian and military literature, deployed spine surgeons should carefully weigh the potential for neurologic recovery with available forward resources in cases of incomplete spinal cord injury. Instances of incomplete neurologic deficit with easily addressed compressive pathology, neurologic progression, delayed evacuation or injuries in coalition partners not eligible for evacuation represent times when operative intervention in theater may provide clear benefit to the patient. In these cases, implants used in theater should be compatible with systems at higher levels of care in case revision surgery is required.

SPINAL INSTRUMENTATION

The decision to perform spinal stabilization in a deployed setting depends, in part, on the presence and sterility of appropriate implants, comfort level of the operative team and availability of sufficient diagnostic imaging modalities. Advocates for early instrumentation argue that stabilizing these injuries minimizes the need for spinal immobilization, improves pulmonary toilet, lowers the risk of venous thromboembolism and may improve analgesia. Yet, these advantages may not fully translate to the deployed population as over half have concomitant extremity or pelvis fracture and/or significant hemodynamic distress.48 Deployed surgeons may also consider non-instrumented decompressive procedures in cases with incomplete or progressive neurologic deficit and ongoing canal compromise. These simpler cases often place less strain on the deployed operative team and medical logistical system while requiring less operative time and exposure. This decision for early decompressive surgery with delayed stabilization requires careful direct coordination between spine surgeons at Role 3 and 4 facilities. In Schoenfeld’s retrospective review of patients who sustained operative spinal injuries in theater this approach resulted in neurologic improvement in 2 of 3 cases.9