Updated Guidelines Call for Early Mobilization of Spinal Injury

Discontinue use of back braces and cervical collars when possible and provide early surgical stabilization when indicated. These are a few recommendations from updated guidelines on the early treatment of spinal injuries recently released by the American College of Surgeons’ (ACS’) Trauma Quality Programs.

The 87-page document covers the initial spine evaluation, classification, and management of injury, care of the patient with an injured spinal cord, and implementation and integration of trauma center best practices guidelines.

The document was developed from evidence-based literature and expert input from leaders in the fields of neurosurgery, orthopedic surgery, and critical care. The American Congress of Rehabilitation Medicine’s Spinal Cord Injury Interdisciplinary Special Interest Group provided the group with guidance on sections regarding prevention, mobilization, and rehabilitation.

Christine Cocanour, MD, FACS, professor of clinical surgery at UC Davis Health in Sacramento, California, and chair of the ACS Committee on Trauma’s Best Practices Guidelines Committee, told Medscape Medical News, “As our committee thought about potential topics for a new best practices guideline, spine injury was a leading topic, because although it is relatively rare, it can have devastating consequences, and there are a number of management areas that remain controversial.”

Among those areas that required clarification is the topic of immobilization and whether spinal cord injuries or fractures of the spine should be immobilized. The gut reaction of many non–spinal trauma specialists is to immobilize the area involved rather than risk permanent spinal cord injury. But this may often be unnecessary and may prevent much-needed early mobilization.

In nonoperative injuries, the new ACS guidelines call for discontinuing bracing when possible in favor of early patient mobilization. If surgical stabilization is needed, it should occur early in the treatment algorithm.

“Although many trauma centers already provide early (surgical) stabilization for spine injured patients, this best practices guideline (BPG) will further encourage others to follow suit. I would suspect that this BPG will serve as a basis for the development of care pathways for spinal cord injured patients,” Cocanour said.

Kevin Rolfe, MD, an orthopedic spine surgeon at Harbor-UCLA Medical Center in Torrance, California, who was not involved in the committee’s work, said that spinal immobilization has been overused by surgeons, which is concerning.

“Bracing is so poorly understood, misapplied, and overapplied,” he said in an interview with Medscape Medical News. “It has become quite clear to me over the years that the vast majority of surgeons do not understand the benefits and limitations of bracing.”

He points to the use of large immobilizers known as Thoracic Lumbar Sacral Orthosis (TLSO) braces. The device extends from the collarbones to the pelvis.

“The TLSO does not immobilize the lumbar-sacral junction, yet I see people putting one on for this region. The same might be true for an Aspen hard cervical collar. It does not immobilize C7 and T1,” said Rolfe, who also serves as the acute care director for the Southern California Spinal Cord Injury Model System at Rancho Los Amigos National Rehabilitation Center in Los Angeles, California.

He uses the analogy of stopping a cast short of or just past a fracture. It can lead to the unintended and opposite consequences of inadequate immobilization and actually increase stress across the area being immobilized.

Rolfe also is concerned when he sees surgery and immobilization indications mixed up. “So many surgeons forget that the role of instrumenting a severe spinal cord injury is to improve early rehab. Instead, I see instrumentation plus a TLSO brace, which is just mixing up indications. There’s no point of the brace if you’re going to instrument for which the whole purpose was to facilitate rehab earlier.”

Additionally, there is no role for spinal cord motion restriction (SMR) in patients with penetrating trauma, the ACS guidelines state. The authors note that for most victims of penetrating spinal cord injury who arrive by ambulance, standard SMR precautions have been followed. These include use of backboards and cervical collars. The collars can be removed to address airway problems and bleeding. They can then be placed back on the patient for pain or to address instability. The authors note that the majority of gunshot injuries at any level of the spine do not require SMR.

 

Having written on this topic, Rolfe has an even stronger recommendation for first responders, such as emergency medical services workers. “I think prehospital spine immobilization for penetrating injury is contraindicated, not just optional, he said. “People have died from [doctors] missing a deviated trachea or tension pneumothorax under a collar, but none have an altered neurological course by having a collar on for gunshot or stab wounds.”

“I think prehospital spine immobilization for penetrating injury is contraindicated, not just optional,” he said. “People have died from [doctors] missing a deviated trachea or tension pneumothorax under a collar, but none have an altered neurological course by having a collar on for gunshot or stab wounds.”

 

If spinal surgery stabilization is indicated, the ACS guidelines call for early surgical stabilization but note that the decision on surgical timing is often based on clinical judgment. It is a balance between achieving early spinal stabilization and ensuring the patient’s hemodynamic stability.

The ACS guidelines recommend maintaining the patient’s mean arterial pressure (MAP) from 85 to 90 mm Hg for a total of 7 days after injury. This recommendation was based on evidence from two Level III cohort studies. The authors also call for initiating chemoprophylaxis as early as medically possible, typically within 72 hours of injury, to reduce the risk of venous thromboembolism, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE).

Rolfe thinks more research needs to be conducted in these areas. “I don’t think the MAP therapy guidelines and the DVT/PE chemoprophylaxis items are understood well enough,” he said. “More needs to be figured here, and more nuance is needed as regards chemical prophylaxis based, on AIS [American Spinal Injury Association Impairment Scale] grade, whether surgery was done, etc. This is not a one-size-fits-all. There may be higher risk of neurological compression from hematoma than actual death from PE.”

Gunshot wounds (GSWs) should also be considered a different category of injury that does not necessitate MAP stabilization from a neurologic perspective. “GSWs, in particular, where I have more extensive experience, do not need any MAP therapy, in my opinion. It is a waste of time and energy,” Rolfe remarked.

Cocanour agrees that more research into hemodynamic stability is needed. She would like to see “better studies on blood pressure management following spinal cord injury to determine the length of time and the level of blood pressure that must be maintained.”

Rolfe and Cocanour report no relevant financial relationships.

ACS. Best Practices Guidelines: Spine Injury, American College of Surgeons Trauma Quality Programs, March 2022. Full text

Jonathan Gelber, MD, is a practicing orthopedic surgeon and author of Tiger Woods’s Back and Tommy John’s Elbow: Injuries and Tragedies That Transformed Careers, Sports, and Society.

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