Page 1627 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1146 PART 10: The Surgical Patient

(4) late hyperreflexia (1-12 months). Following the appearance of the deep
47
plantar reflex (DPR), reflexes tend to return in the following sequence: bul-
bocavernosus (BC), cremasteric (CM), ankle jerk (AJ), Babinski sign, and PORT
knee jerk (KJ). Return of reflexive detrusor (bladder) function usually
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takes months following injury. In terms of prognosis, the progression of
47
reflexes over several days following acute SCI may be more relevant than
the assessment of reflexes on the first day following SCI. 48
BLEEDING AND TRANSFUSION ISSUES

Traumatic injuries including spinal injuries are associated with blood
loss and even in the absence of detectable blood loss, anemia may be
observed during the acute phase of SCI. As in any trauma patient
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and dictated by the degree of multisystem (including head) trauma
in addition to the acute SCI, coagulopathies may occur. However,
coagulopathy after traumatic injuries is not well studied. Abnormalities
50
include disseminated intravascular coagulation (DIC) due to systemic
inflammation and tissue thromboplastin release (with brain trauma) or
consumptive coagulopathy—DIC due to bleeding, thrombocytopenia,
elevated INR, PTT, and hypofibrinogenemia.
The concern after acute neurological damage is maintaining perfu- FIGURE 119-11. Lateral radiograph of a patient in traction for bilateral C7-T1 facet
sion and oxygen delivery to the tissues to prevent further secondary dislocations. The pin is noted as a dense round object in the skull at the top of the film (see
injury. There is a recent concept in blunt trauma for a permissive hypo- arrow). Unfortunately, it is very difficult to follow the results of traction on plain portable
tension approach in bleeding patients, with less aggressive restoration images for lesions at the cervicothoracic junction. In this film, one can only see down to C6-7.
of intravascular blood volume, originally advocated for penetrating
injuries to limit bleeding. 50,51 In any case, permissive hypotension may be
detrimental to patients with significant neurological injuries and there- supported by the results of a recent large-scale, multicenter, prospective
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fore resuscitation should be appropriate and not limited after acute SCI. trial, the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS).
There is no evidence to define a particular target hemoglobin, platelet About 19.8% of patients undergoing surgery within <24 hours of SCI
transfusion, or INR threshold after trauma, including after SCI. In the demonstrated a ≥2 grade improvement in the ASIA Impairment Scale
acute phase, a packed red blood cell transfusion target Hb level in the 7 to (AIS) compared to 8.8% in the late (≥24 hours after injury decompression
10 g/dL range is reasonable. An analysis of the Transfusion Requirements group). After adjustment for preoperative neurological status and steroid
In Critical Care (TRICC) trial subset of multitrauma patients suggested administration by multivariate analysis, there was a 2.8 times greater
that a restrictive transfusion target of Hb 7 g/dL was not inferior to a chance of at least a 2 grade AIS improvement in patients who underwent
liberal target Hb of 10 g/dL. Fresh frozen plasma with target INR below early surgery compared to those who had late surgery. There was no sig-
52
2.0 and platelet transfusions to keep the levels at or above 50,000/mm in nificant difference in mortality or complications between the two groups.
3
the acute phase if there is active bleeding or if spinal hematomas are present Displaced fractures of the cervical spine must be reduced, possibly
is common. Hypofibrinogenemia with fibrinogen levels <100 mg/dL progressively by means of skull traction using tongs and the effects of traction
are treated with cryoprecipitate. Consumptive coagulopathy due to must be immediately verified radiologically (Figs. 119-11 and 119-12).
bleeding requires surgical control of the blood loss. Recombinant acti- Immobilization can be simple consisting of a cervical collar for the
vated factor VII (rFVIIa) has been used as an adjunctive hemostatic agent
in patients with intractable perioperative bleeding problems during spine
surgery, but there are a lack of studies evaluating rFVIIa administration
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on outcome after traumatic SCI complicated by bleeding.
NEUROSURGICAL MANAGEMENT ISSUES

A basic understanding of the neurosurgical management issues is help-
ful for the intensivist coordinating the care of the spinal-injured patient.
The baseline neurological examination to determine a neurological level
and the completeness of injury coupled with the results of CT and MRI
imaging form the basis of the neurosurgical intervention decision. The
two main goals are spinal cord decompression in patients with neuro-
logical deficit and persistent compression and to stabilize all unstable
spine lesions and reduce and stabilize all displaced lesions thus realign-
ing and stabilizing the vertebral column.
The degree of emergency is determined by the associated neurologi-
cal deficit which is an indication for surgery with a few rare exceptions.
There is both a basic scientific and clinical rationale supporting early
surgical decompression after traumatic SCI with evidence of persistent
spinal cord compression, because the degree of secondary neural injury
4
is directly related to the duration of ongoing spinal cord compression.
The spine surgery community has embraced the concept of early surgery.
4
Using a modified Delphi process, a panel of 10 experts recommended that
“surgical decompression of the injured spinal cord be considered within
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8 to 24 hours when medically feasible.” These recommendations are now FIGURE 119-12. Lateral radiograph of a patient in traction for a C5 burst fracture (see arrow).

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