Grant Ryan A, Quon Jennifer L, Abbed Khalid M
Department of Neurosurgery, Yale University-Yale New Haven Health System, Tompkins Memorial Pavilion, 789 Howard Avenue, 4th Floor, New Haven, CT, 06519, USA,
Curr Treat Options Neurol. 2015 Feb;17(2):334. doi: 10.1007/s11940-014-0334-1.
Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.
脊髓损伤（SCI）会导致严重的发病率和死亡率。急性情况下的临床管理需要在重症监护病房进行，以便识别、预防和治疗因局部缺血、低血压、缺氧和炎症引起的继发性损伤。维持充足的灌注和氧合至关重要，平均动脉压应保持在>85 - 90 mmHg至少1周。应佩戴颈托并采取全面的脊柱保护措施（滚动翻身、平躺、固定颈椎），直到脊柱外科医生对脊柱进行全面评估。在脊髓损伤患者中，其他身体损伤的发生率很高，因此对于评估内脏、骨盆和长骨损伤应保持较低的阈值。脊柱计算机断层扫描优于普通X线片，因为前者很少漏诊骨折，不过需要注意的是，枕颈脱位仍可能漏诊。为了可靠地评估脊髓神经成分、软组织和韧带结构，建议进行磁共振成像检查，且应在受伤后48 - 72小时内完成。所有患者应每天使用美国脊髓损伤协会分类法进行分级，受伤后72小时进行首次预后评分。高位颈髓（C4或更高节段）损伤的患者应立即插管，低位颈髓损伤的患者应逐例评估。然而，在急性情况下，任何高于T11的脊髓损伤都会扰乱呼吸力学。类固醇药物的使用极具争议，美国神经外科专业协会已发布一级声明反对在所有患者中使用类固醇。因此，我们目前不主张使用类固醇。对于每例脊髓损伤患者，都必须咨询脊柱外科医生，讨论手术与非手术管理策略。手术指征包括部分或进行性神经功能缺损、脊柱不稳定无法活动、畸形矫正以及预防潜在的神经功能损害。采取措施预防深静脉血栓形成导致的肺栓塞是必要的：对于卧床患者，建议使用下腔静脉滤器，低分子量肝素优于普通肝素。大力预防压疮以及营养支持应是治疗的主要内容。最后，需要注意的是神经功能恢复是一个数年的过程。大部分恢复发生在受伤后的第一年，因此积极的康复治疗至关重要。
