Expert Consensus on Evaluation and Treatment of Acute Thoracolumbar Spinal Cord Injury
Overview
1. This consensus covers patients with traumatic thoracic 11-lumbar 2 fracture dislocations with or without spinal cord, conus and cauda equina injury within 6 weeks of injury. Patients with thoracolumbar fracture dislocations in minors and late rehabilitation of thoracolumbar spinal cord injuries are excluded; pathologic, osteoporotic, and ankylosing spondylitis-related fracture dislocations are excluded.
Pre-hospital emergency
2. patients with suspected thoracolumbar spinal cord injury should be given effective braking of the spine, and attention should also be paid to the correct manner during patient handling, transfer, and examination; with spinal braking, they should be rapidly transferred to a nearby level II or higher hospital.
Diagnosis and evaluation
(a) Diagnosis
3. Diagnostic criteria: ① history of trauma; ② pain in the low back, pressure pain and percussion pain in the thoracolumbar segment; ③ with or without lower limb or rectal bladder nerve dysfunction; ④ signs of thoracolumbar fracture dislocation on imaging; the diagnosis can be established after all the above criteria are met.
(II) Assessment
A comprehensive assessment
4. it is recommended that a comprehensive assessment of the patient’s fracture morphology, neurological functional status, and status of the posterior ligament complex be performed through history, physical examination, and imaging.
5. fracture morphology is classified as compression fracture, burst fracture, distraction injury, and rotation injury; fractures can also be classified using AO and Denis typing.
6. types of nerve injury include: nerve root injury, spinal cord injury, as well as cauda equina injury and simple spinal cord cone injury; determine the degree of nerve injury, classified as incomplete or complete injury.
7. the status of the posterior ligament complex, which is mainly divided into no injury, incomplete injury, and complete rupture.
8. recommend that each patient suspected of having a thoracolumbar spinal cord injury should be evaluated individually with respect to history, mechanism of injury, clinical presentation, and imaging.
B Medical history
9. a detailed history should be taken to inquire about the causative factors and mechanism of injury, to understand the evolution of the neurological functional status, and to understand the course and outcome of their treatment.
C Local examination
10. should observe the presence of subcutaneous bruising and posterior convexity deformity of the thoracolumbar segment, routinely palpate each spine and spine gap to determine whether there is a void in the spine gap and increased spine spacing, and whether there is a sense of step between spines.
D Nerve function examination.
11. The type of nerve injury should be carefully evaluated to identify nerve root injury, spinal cord injury, and cauda equina injury and simple spinal cord cone injury; to determine the degree of nerve injury, incomplete injury or complete injury, etc., and to determine the sensory plane, motor plane, and nerve plane of nerve injury.
12. repeated neurological examinations are required to understand the evolution of neurological function. the frequency of repeated neurological examinations should be individualized according to the patient’s condition, but should be performed at least once a day for the first 3 days after the injury.
13. it is recommended to perform sensory and muscle strength examinations according to the ASIA criteria and to grade the neurological deficits of spinal cord injury using the AIS and/or Frankel method; anal sensation and the presence or absence of voluntary contractions of the anal sphincter must be examined to distinguish complete from incomplete spinal cord injury.
14. recommends that the clinical application of ASIA criteria be accompanied by a thorough and detailed examination of the patient, especially for muscle strength, not only limited to the key muscles.
E imaging options
15. x-ray should be routinely performed for the initial assessment of fracture site and type.
16. a full spine x-ray is recommended for patients with multiple injuries and high-energy injuries (fall injuries above 3 m or car accident injuries, etc.); a full spine x-ray is routinely recommended for trauma patients with combined delirium.
17. X-rays should observe the morphology of the fracture and the presence and extent of dislocation, measure the degree of compression of the vertebral body and the size of the retroflexion deformity, and measure and compare the widening of the spinous process and pedicle spacing.
18. routinely perform CT examinations and/or 3D reconstructions to observe the above-mentioned indicators, as well as the changes in the intervertebral space, spinous process spacing, intervertebral body and interarticular process relative relationships; observe the degree of fracture comminution in the sagittal and horizontal planes, and observe and measure the intrusion of the spinal canal.
19．For patients with multiple injuries caused by high energy and for patients with unstable systemic conditions, the application of multi-row CT rapid scan is recommended to rapidly clarify the diagnosis and reduce the diagnostic time.
20. MRI should be routinely performed when there is neurological dysfunction to observe the status of the spinal cord, conus and cauda equina; MRI should be performed when there is a suspicion of intervertebral disc and posterior ligament complex injury on X and CT examinations; 21.
21. For patients with spinal cord injury, MRI can be performed again 72 hours after the injury to help determine the prognosis of spinal cord injury.
22. MRI should be performed in patients with normal X-ray and CT scans, but who are suspected of having spinal cord injury on clinical examination.
Treatment
23. Treatment principles: early braking of the spine, reasonable transport and transfer to reduce secondary injury to the spinal cord; full release of nerve tissue compression, reasonable reconstruction of the stability of the spine, to create a suitable internal and external environment for the repair of nerve tissue, to promote functional recovery, to facilitate early recovery, to reduce the incidence of complications, so that patients can return to society as soon as possible.
(I) Drug therapy
24. high-dose MP shock therapy is not used as a routine treatment option, but may be used as a treatment option.
25. absolute contraindications to high-dose MP shock therapy include: injury duration of more than 8 h; spinal cord injury with penetrating or spinal cord continuity disruption; thoracolumbar injury without neurological deficits; relative contraindications include: presence of a history of gastrointestinal bleeding, presence of a history of peptic ulcer, presence of infectious disease or serious cardiac disorders.
26. During the use of high-dose MP shock therapy, proton pump inhibitors should be used routinely to prevent gastrointestinal bleeding; in patients with combined open injury and the presence of infection, antibiotics should be ordered simultaneously to prevent and treat infection; in patients with combined diabetes, attention should be paid to monitoring and controlling blood glucose to reduce complications of diabetes; the time window should be strictly controlled when performing shock therapy.