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CHAPTER 119: Spinal Injuries 1137

hyperglycemia per se is the cause or whether other factors associated with CHAPTER Spinal Injuries
hyperglycemia such as preexisting diseases, severity of illness, or treat-
ment of TBI, has not been determined. Hypoglycemia is also harmful to
the brain. Early evidence supporting the benefits of tight glycemic control 119 John M. Oropello
in critically ill patients is being challenged. 236-241 Although very tight Nirav Mistry
235
glucose control between 80 and 120 mg/dL has not been proven beneficial Jamie S. Ullman
in the ICU, the optimal levels of glycemic control remain to be established
in critically ill patients in general, as well as in the neurotrauma patient. 242 KEY POINTS
■ THYROID FUNCTION • After acute spinal cord injury (SCI), the primary injury sets limits

As in any critical illness, moderate to severe TBI is associated with (that are not always initially obvious) on the potential extent of
the sick euthyroid syndrome—a nonthyroidal illness characterized by recovery and the degree of secondary injury determines the extent
normal thyroidal function but abnormal thyroid function tests (TFTs) of the potential recovery actually achieved.
including low T and T and increased reverse T levels. Usually thyroid- • Acute SCI patients, particularly those with cervical level and
3
4
3
stimulating hormone (TSH) levels are normal or mildly elevated. These severe SCI, are at risk for respiratory arrest, hypoxemia, and
laboratory abnormalities may lead to confusion and are of no known cardiovascular instability.
clinical significance, and treatment does not appear to be beneficial or • The prevention of secondary injury or “neuroprotection” consists
possibly detrimental. Therefore, TFTs are usually deferred in the ICU of spine immobilization, timely surgical intervention, and early
setting unless clinical signs strongly suggest a thyroid disorder. 49 recognition and treatment of hemodynamic instability, respiratory
failure, and hypoxemia.
• Hemodynamic instability is common after acute SCI and may be
KEY REFERENCES
multifactorial, including due to hypovolemia secondary to blood
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- loss, systemic inflammation from trauma or infection (vasodila-
agement of severe traumatic brain injury. I. Blood pressure and tion, decreased intravascular volume), neurogenic (vasodilation,
oxygenation. J Neurotrauma. 2007;24(suppl 1):S7-S13. inappropriate bradycardia), arrhythmias, myocardial stunning,
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- pneumothorax, or cardiac tamponade from associated trauma.
agement of severe traumatic brain injury. V. Deep vein thrombosis • The term “neurogenic shock” refers to hypotension due to vasodi-
prophylaxis. J Neurotrauma. 2007;24(suppl 1):S32-S36. lation that may be accompanied by absolute (HR <60) or relative
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the manage- bradycardia caused by the loss of outflow from the sympathetic
ment of severe traumatic brain injury. VI. Indications for intracra- autonomic component of the spinal cord arising from the high
nial pressure monitoring. J Neurotrauma. 2007;24(suppl 1):S37-S44. thoracic and cervical regions, T1-T6 level and above.
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- • The term “spinal shock” refers to the loss of sensation accompanied
agement of severe traumatic brain injury. VII. Intracranial pressure by motor paralysis and depression of spinal reflexes caudal to the
monitoring technology. J Neurotrauma. 2007;24(suppl 1):S45-S54. level of acute SCI.
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the • Among trauma patients, the risk of VTE is likely the highest after
acute spinal cord injury and LMWH should be started as soon as
management of severe traumatic brain injury. VIII. Intracranial safely possible after primary hemostasis is achieved; until that time
pressure thresholds. J Neurotrauma. 2007;24(suppl 1):S55-S58. intermittent pneumatic compression (IPC) devices should be used.
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- • Pulmonary embolism (PE) is the third leading cause of death
agement of severe traumatic brain injury. IX. Cerebral perfusion after acute SCI and after any sudden hemodynamic compromise,
thresholds. J Neurotrauma. 2007;24(suppl 1):S59-S64. unexplained dyspnea, or hypoxemia, PE must be considered.
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- • Patients with high cervical injury and prolonged ventilatory
agement of severe traumatic brain injury. X. Brain oxygen moni- failure with tracheostomy are at a higher risk of malnutrition.
84
toring and thresholds. J Neurotrauma. 2007;24(suppl 1):S65-S70. The enteral route is preferred to preserve gut integrity. The current
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the man- literature does not support the maintenance of strict normoglycemia
agement of severe traumatic brain injury. XIII. Antiseizure pro- in these critically ill patients.
phylaxis. J Neurotrauma. 2007;24(suppl 1):S83-S86. • Following spinal decompression and/or stabilization, and resolution of
• Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the potentially life-threatening cardiac and respiratory events, the goal is for
management of severe traumatic brain injury. XV. Steroids. rehabilitation specialists to become involved early in the management.
J Neurotrauma. 2007;24(suppl 1):S91-S95.
• Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-
pressure monitoring in traumatic brain injury. N Engl J Med. BACKGROUND
2012;327(26):2471-2481. Acute trauma to the spine may involve the neuronal (spinal cord and nerve
• Joseph B, Friese RS, Sadoun M, et al. The BIG (brain injury guide- roots) and/or skeletal and ligamentous structures of the vertebral column
lines) project: defining the management of traumatic brain injury by that normally protect the spinal cord. Vertebral fractures or dislocations
acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965-969. can occur without damage to the spinal cord; however, acute traumatic
• Karamanos E, Teixeira PG, Sivrikoz E, et al. Intracranial pressure spinal cord injury (SCI) often involves injury to the vertebral column. The
versus cerebral perfusion pressure as a marker of outcomes in severe manifestations of SCI may be immediate or delayed. The key to insuring
head injury: a prospective evaluation. Am J Surg. 2014;208(3):363-371. the best outcome is rapid diagnosis and prevention of secondary injuries
that can further worsen ischemic neurological damage. This includes
rapid recognition and treatment of unstable fractures, fracture fragments,
REFERENCES hematomas, or other lesions that can cause impingement or laceration of
the spinal cord and critical care management that emphasizes maintenance
Complete references available online at www.mhprofessional.com/hall of homeostasis and the detection of new or initially unrecognized injuries.

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