Feb/6/17

early  acute  
management  in  
spinal  cord  
injury  
Hasan  Sjahrir  
Department  of  Neurology  
Sumatera  Utara  University  
Medan  
 
hBp://neurologiusu.id  
hasansjahrir  

•  2–4% of trauma patients have cervical spine

injuries (CSIs), of which roughly 20% have
spinal cord injury (SCI),
•  10% have multi-level injuries, and
•  10% have pure ligamentous injuries

•  The most common levels of injury on

admission are :
•  C4, C5 (the most common), and C6,
•  T12.

•  sundstrøm t et al. journal of neurotrauma 31:531–540 (march 15, 2014)

hasansjahrir •  chin et al. http://emedicine.medscape.com 2016

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Assessment for spinal injury

On arrival at the scene of the incident, use a
prioritising sequence to assess people with
suspected trauma, for example <C>ABCD:
§  catastrophic haemorrhage
§  airway with in-line spinal immobilisation
§  Breathing
§  circulation
§  disability (neurological)

•  NICE guideline 2016

hasansjahrir
•  Chin LS. emedicine.medscape.com.2016

PRE HOSPITAL CARE

•  stabilize  on  the  hard  backboard  and  immobilize  the  

spine  on  the  basis  of  injury  and  pain  in  the  vertebral    
•  The  paIent  is  best  treated  iniIally  in  the  supine  
posiIon  full  in-­‐line  spinal  immobilisaIon    
•  Use  analgesics  appropriately  and  aggressively  to  
maintain  the  paIent's  comfort    
•  StabilizaIon  of  unstable  injured  moIon  segments  
plays  an  important  role  in  prevenIng  further  injury.    
•  Depending  on  the  level  of  neurologic  deficit  and  
injuries,  the  paIent  may  require  admission  to  the  ICU    
•  Rajasekaran S et al. Indian J Orthop. 2015
•  NICE guideline 2016
hasansjahrir
•  Chin LS. emedicine.medscape.com.2016

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JOURNAL OF NEUROTRAUMA 31:531–540 (March 15, 2014)
ª Mary Ann Liebert, Inc. Review
DOI: 10.1089/neu.2013.3094

Prehospital Use of Cervical Collars in Trauma Patients:

A Critical Review

Terje Sundstrøm,1–3 Helge Asbjørnsen,4,5 Samer Habiba,3 Geir Arne Sunde,4–6 and Knut Wester 2,3

It  has  been  argued  that  

• Abstract
collars  
The cervical cause  
collar has more  
been routinely harm  
used for than  
trauma patients for more than 30 years and is a hallmark of state-of-the-art
prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are
good,  
largely and  
missing, and there tare
hat   we  effects
uncertain should  
on mortality, neurological injury, and spinal stability. Even more con-
cerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause
more simply   stop  
harm than good, and thatuwe
sing  
shouldthem  
simply stop using them. In this critical review, we discuss the pros and cons of
collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a

•  effec5ve  strategy  for  

safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

prehospital  spinal  
Key words: cervical collar; cervical injury; cervical spine; prehospital; trauma

immobiliza5on  that  does  not  

include  rou5ne  use  of  collars.  
Introduction Improving prehospital management has a substantial effect on
15
society as a whole and is a high-priority research area. In this
C ervical collars are considered important measures in
modern prehospital trauma care. The recommended practice
of routine application of collars in trauma patients has largely been
review, we argue that it is time to reconsider the unjustified dogma
of collar use in prehospital trauma care.
unchanged for more than 30 years.1 It is featured as a prioritized
Methods
procedure in the Advanced Trauma Life Support (ATLS) guide-
hasansjahrir
lines from the American CollegeJOURNAL OF (ACS)
of Surgeons NEUROTRAUMA
1
and the 31:531–540
We performed (March
a literature search 15, 2014)
in the Medline database using a
Prehospital Trauma Life Support (PHTLS) guidelines from the combination of relevant medical subject headings (MeSHs) and text
National Association of Emergency Medical Technicians words: (‘‘cervical vertebrae’’[MeSH] or ‘‘neck’’[MeSH] or cervi-
(NAEMT).2 These guidelines dominate the field of prehospital cal[text word]) and (‘‘braces’’[MeSH] or collar*[text words] or
‘‘immobilization’’[MeSH]) and (‘‘wounds and injuries’’[MeSH] or
trauma care, and ATLS and PHTLS are implemented in 50–60
‘‘emergency medical services’’[MeSH]). This search was limited to
countries.1,2 The use of collars is, in fact, regarded as so important human studies in English available by April 2013. All authors con-
that it is highlighted in the well-known ABCs of major trauma as a tributed to the search strategy development. We found 1018 publi-
first measure, together with establishment of free airways.1 cations, of which 88 titles were considered relevant by one or two
Collars were introduced to prevent secondary injury to the spinal independent authors (T.S. and K.W.). Borderline titles were in-
3–5
cord by immobilizing a potentially unstable spine. Many years cluded. These publications underwent full review by the author
have passed since, and this practice has evolved into a hallmark of group, and 50 articles were found relevant to prehospital use of

•  approximately  5%  of  paIents  with  spinal  injuries  

modern state-of-the-art prehospital care. Millions of trauma pa- collars in trauma patients by more than one author. These articles are
6,7

tients are currently fitted with a collar every year.8 However, as included here. Finally, we searched the reference lists of retrieved
evaluated in a Cochrane review in 2001 (updated in 2007), the articles and contacted experts in the field to identify pertinent studies.
experience  some  degree  of  neurological  worsening,  
documented evidence for our ongoing practice is rather limited:
Randomized, controlled trials (RCTs) are largely missing, and there
Articles published over the last 10–15 years were prioritized.

even  with  good  immobilizaIon  of  the  spine  

are uncertain effects on mortality, neurological injury, and spinal
stability.9 Moreover, and perhaps more concerning, there is a
Epidemiology of Cervical Spine and Spinal Cord Injuries
Several reports state that approximately 2–4% of trauma patients
growing body of evidence and opinion against the use of collars.9–14 have cervical spine injuries (CSIs),16–26 of which roughly 20%
•  the  collar  should,  in  theory,  protect  paIents  from  
secondary  spinal  cord  traumas  by  restricIng  
1
Department of Biomedicine, 2Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.
3
Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
4
Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.
5
6 inadvertent  movements  of  unstable  CSIs.  
Helicopter Emergency Medical Services, Bergen, Norway.
The Norwegian Air Ambulance Foundation, Drøbak, Norway.

•  using  a  collar  does  not  effecIvely  

531
reduce  moIon  in  
an  unstable  spine  
•  Collar  efficacy  on  moIon  control  has  never  been  
examined  in  real  trauma  paIents  
•  The  exisIng  evidence  for  using  collars  is  weak  
hasansjahr sundstrøm  T    et  al.  journal  of  neurotrauma  31:531–540  (march  15,  2014)  

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•  Assess whether the person is at high, low or no

risk for cervical spine injury using the Canadian
C-spine rule as follows:
•  the person is at high risk if they have at least
one of the following high-risk factors:
•  age 65 years or older
•  dangerous mechanism of injury (fall from a
height of greater than 1 metre or 5 steps,
diving, high-speed motor vehicle)
•  paraesthesia in the upper or lower limbs

hasansjahrir
NICE guideline 2016

the  person  is  at  low  risk  if  they  have  at  least  one  of  the  
following  low-­‐risk  factors:  
•  comfortable  in  a  si_ng  posiIon  ambulatory  at  any  Ime  
since  the  injury    
•  no  midline  cervical  spine  tenderness    
•  delayed  onset  of  neck  pain  
•  unable  to  acIvely  rotate  their  neck  45  degrees  to  the  
le`  and  right  
 
the  person  has  no  risk  if  they:    
•  have  one  of  the  above  low-­‐risk  factors  and    
•  are  able  to  acIvely  rotate  their  neck  45  degrees  to  the  
le`  and  right.  
hasansjahrir  
NICE  guideline  2016  

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NICE  guideline   2016  

hasansjahrir  

Assess  the  person  with  suspected  thoracic  or  

lumbosacral  spine  injury  using  these  factors:  
•  age  65  years  or  older  and  reported  pain  in  the  
thoracic  or  lumbosacral  spine  
•  dangerous  mechanism  of  injury  (fall  from  a  height  
of  greater  than  3  metres,  ejecIon  from  a  high  
speed  motor  vehicle,  horse  riding  accidents)  
•  pre-­‐exisIng  spinal  pathology,  or  known  or  at  risk  
of  osteoporosis  –  for  example  steroid  use  
•  suspected  spinal  fracture  in  another  region  of  the  
spine  abnormal  neurological  symptoms  
(paraesthesia  or  weakness  or  numbness)  
hasansjahrir
NICE guideline 2016

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•  on  examina5on:    
•  abnormal  neurological  signs  (motor  or  sensory  
deficit)    
•  new  deformity  or  bony  midline  tenderness  (on  
palpaIon)    
•  bony  midline  tenderness  (on  percussion)    
•  midline  or  spinal  pain  (on  coughing)  
•  on  mobilisa5on  (sit,  stand,  step,  assess  walking):  
•  pain  or  abnormal  neurological  symptoms  (stop  if  
this  occurs).  

hasansjahrir NICE guideline 2016

Patient Name ____________________________________

Examiner Name __________________________________ Date/Time of Exam___________________

STANDARD NEUROLOGICAL CLASSIFICATION

OF SPINAL CORD INJURY

(scoring on reverse side)

(distal phalanx of middle finger)

(little finger)

Comments:

NICE  guideline   2016  

hasansjahrir  
REV 03/06

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MUSCLE GRADING ASIA IMPAIRMENT SCALE STEPS IN CLASSIFICATION

0 total paralysis The following order is recommended in dete
MUSCLE GRADING ASIA
A =IMPAIRMENT SCALE
Complete: No motor or sensory STEPS IN C
of individuals with SCI.
1 palpable or visible contraction function is preserved in the sacral
0 total paralysis The following ord
1. Determine sensory levels for right and le
2 active movement, full range of segments S4-S5.
motion, gravity eliminated
A = Complete: No motor or sensory 2. Determine motorof individuals
levels for right and wit
left
1 palpable or visible contraction B = Incomplete:
function is Sensory but not motor
preserved in the sacral
Note: in regions where there is no myotom
3 active movement, full range of function is preserved below the is presumed to be the same as
1. Determine senthe sensor
2 active movement,motion,
full range of
against gravity segmentslevel
neurological S4-S5.
and includes the 3. Determine the single neurological level.
motion, gravity sacral segments S4-S5. This is the lowest2. Determine
segment mo
where motor a
4 eliminated
active movement, full range of
motion, against gravity and provides B = Incomplete: Sensory but not motor mal on both sides, andNote: in regio
is the most cephal
C = Incomplete: Motor function is pre- motor levels determined in steps 1 and 2.
3 active movement,some
fullresistance
range of function
served belowis
thepreserved
neurological below the is presumed to
4. Determine whether the injury is Complet
motion, against
5 gravity
active movement, full range of neurological
level, level
and more than half ofand
key includes (sacral
the sparing). 3. Determine the
motion, against gravity and provides muscles below the neurological If voluntary anal contraction = No AND
sacral segments S4-S5. This is the low
4 active movement,normal
full resistance
range of level have a muscle grade less AND any anal sensation = No, then injur
mal on both s
than 3. Otherwise injury is incomplete.
motion, against
5* gravity and
muscle able provides
to exert, in examiner’s C = Incomplete: Motor function 5.is Determine pre- ASIA Impairment
motorScalelevels(AIS)d
some resistance judgement, sufficient resistance to be D = Incomplete: Motor function is pre-
served below the neurological Is injury Complete? If YES, AIS=A Re
considered normal if identifiable served below the neurological NO
4. Determine
(For ZPP recordwhlow

5 active movement,inhibiting factorsof

full range were not present level,
level, andand more
at least than
half of half of key
key mus- (sacral
each side sparing
with some
cles below the neurological level Is injury
motion, against
NTgravity and
not testable. provides
Patient unable to reliably muscles below the neurological motor incomplete? If Ifvoluntary NO, AIS=B a
have a muscle grade of 3
exert effort or muscle unavailable for test-
normal resistance level
or more.have a muscle grade less YES
AND any ana
(Yes=voluntary ana
ing due to factors such as immobilization, function more than
than 3. Otherwise
level on a giveninj
sid
pain on effort or contracture. E = Normal: Motor and sensory func-
5* muscle able to exert, in examiner’s 5.of the
Determine
tion are normal. Are at least half key musclesAS
be
judgement, sufficient resistance to be D = Incomplete: Motor function is pre- (single) neurologicalIslevel
injury
graded Com
3 or
considered normal if identifiable servedSYNDROMES
CLINICAL below the neurological NO YES
NO
inhibiting factors were not present level, and at least half of key mus- AIS=C
(OPTIONAL) AIS=D
cles below the neurological level Is injury
NT not testable. Patient unable to reliably Central Cord If sensation and motormotor
function incom
is norm
have a muscle grade of 3 Note: AIS E is used in follow up testing w
exert effort or muscle unavailable for test- Brown-Sequard
documented SCI has recovered normal fu
or more.
Anterior Cord YES
ing due to factors such as immobilization, Conus Medullaris
no deficits are found, the individual is ne
hasansjahrir   ASIA Impairment Scale does not apply.
pain on effort or contracture. E = Normal:
Cauda EquinaMotor and sensory func-
tion are normal. Are at least
(single) neur
NO
CLINICAL SYNDROMES
(OPTIONAL) AIS

Central Cord If sensation a

Pain  management  in  pre-­‐hospital  and  hospital   se_ngs  
Brown-Sequard
Note: AIS E is
documented S
Anterior Cord no deficits are
•  Offer  medicaIons  to  control  pain  in  tConus
he  acute   phase  
Medullaris ASIA Impairm
Cauda Equina
a`er  spinal  injury.  
•  For  people  with  spinal  injury  use  intravenous  
morphine  5  mg  as  the  first-­‐line  analgesic  and  adjust  
the  dose  as  needed  to  achieve  adequate  pain  relief.  
•  If  intravenous  access  has  not  been  established,  
consider  the  intranasal  route  for  atomised  delivery  
of  diamorphine  or  ketamine.  
•  Consider  ketamine  in  analgesic  doses  as  a  second-­‐
line  agent.(1-­‐4.5  mg/  kg  IV  or  6.5-­‐13  mg/kg  IM)  
NICE  guideline  2016  
hasansjahrir  

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Suspected  spinal  cord  or  cervical  column  injury    

•  Perform  MRI  for  children  (under  16s)  if  there  is  a  
strong  suspicion  of:  
•  cervical  spinal  cord  injury  as  indicated  by  the  
Canadian  C-­‐spine  rule  and  by  clinical  assessment  
or  
•  cervical  spinal  column  injury  as  indicated  by  
clinical  assessment  or  abnormal  neurological  
signs  or  symptoms,  or  both.  
•  Consider  plain  X-­‐rays  in  children  (under  16s)  who  do  
not  fulfil  the  criteria  for  MRI  in  recommendaIon  but  
clinical  suspicion  remains  a`er  repeated  clinical  
assessment.  
hasansjahrir   NICE  guideline  2016  

Perform  CT  in  adults  (16  or  over)  if:  

•  imaging  for  cervical  spine  injury  is  indicated  by  the  
Canadian  C-­‐spine  rule  or  
•  there  is  a  strong  suspicion  of  thoracic  or  
lumbosacral  spine  injury  associated  with  abnormal  
neurological  signs  or  symptoms.  
•  If,  a`er  CT,  there  is  a  neurological  abnormality  
which  could  be  aBributable  to  spinal  cord  injury,  
perform  MRI.  
NICE  guideline  2016  

hasansjahrir  

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Suspected  thoracic  or  lumbosacral  column  injury  only  

(children  and  adults)  
•  Perform  an  X-­‐ray  as  the  first-­‐line  invesIgaIon  for  
people  with  suspected  spinal  column  injury  without  
abnormal  neurological  signs  or  symptoms  in  the  
thoracic  or  lumbosacral  regions  (T1–L3).  
•  Perform  CT  if  the  X-­‐ray  is  abnormal  or  there  are  
clinical  signs  or  symptoms  of  a  spinal  column  injury.  
•  If  a  new  spinal  column  fracture  is  confirmed,  image  
the  rest  of  the  spinal  column.  

NICE  guideline  2016  

hasansjahrir  

The  thoracic  spine  is  

•  funcIonally  rigid  due  to  coronally  
oriented  facet  joints,  thin  
intervertebral  discs  and  the  ribcage.    
•  Thus,  it  requires  huge  amounts  of  
energy  to  produce  fractures  and  
dislocaIons.    
•  The  narrow  spinal  canal  in  this  region  
predisposes  to  spinal  cord  damage  
resulIng  in  a  high  incidence  of  
neurological  deficit    
•  fractures  of  the  thoracolumbar  region  
are  the  most  common  injuries  of  the  
vertebral  column.     Rajasekaran  S  et  al.  Indian  J  
hasansjahrir  
Orthop.  2015  Jan-­‐Feb;  49
(1):  72–82.  

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Spinal  cord    injury  pathology  

•  injury  mechanisms  leading  to  neural  Issue  destrucIon  
•  degree  of  neural  injury  is  directly  related  to  the  
duraIon  of  spinal  cord  compression    
•  The  primary  injury  (non  modifiable)  
•  consists  of  the  iniIal  traumaIc  compressive  
force  applied  to  the  spinal  cord  causing  
laceraIon  and  or  
•  intramedullary  hematoma  formaIon  

Wilson  JR  &  Fehlings  MG.The  American  Society  for  Experimental  NeuroTherapeuIcs,  Inc.2011  

hasansjahrir  

a  cascade  of  secondary  injury:  (potenIally  modifiable).  

•  exacerbate  the  degree  of  Issue  destrucIon,  
beginning  immediately  a`er  the  primary  injury,  
include  
•   free  radical  formaIon,    
•  cellular  ionic  imbalance,    
•  cell  membrane  lipid  peroxidaIon,    
•  release  of  excitotoxic  glutamate    
•  vascular  dysfuncIon  phenomenon,  such  as  
vasospasm  and  perfusion  reperfusion  injury.  
•  inflammaIon  and  delayed  apoptoIc  cell  death    
Rajasekaran  S  et  al.  Indian  J  Orthop.  2015  Jan-­‐Feb;  49(1):  72–82.  
Wilson  JR  &  Fehlings  MG.The  American  Society  for  Experimental  NeuroTherapeuIcs,  Inc.2011  
hasansjahrir  

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Neurogenic shock management and treatment goals

•  isotonic crystalloid solution to a maximum of 2 L

is the initial treatment of choice.
•  Overzealous crystalloid administration may cause
pulmonary edema, because these patients are at
risk for the acute respiratory distress syndrome
(ARDS).
•  Head injuries and neurologic evaluation

hasansjahrir
Chin LS. emedicine.medscape.com.2016

       the  Management  of  Acute  Trauma5c  Spinal  Cord  Injury  

•  The  NaIonal  Acute  Spinal  Cord  Injury  Studies  (NASCIS)  II  
and  III,  a  Cochrane  Database  of  Systema2c  Reviews  arIcle    
and  other  published  reports,  have  verified  significant  
improvement  in  motor  funcIon  and  sensaIon  in  paIents  
with  complete  or  incomplete  spinal  cord  injuries  (SCIs)  
who  were  treated  with  high  doses  of  methylprednisolone  
within  8  hours  of  injury.  
•  the  following  steroid  protocol:    
•  methylprednisolone  30  mg/kg  bolus  over  15  minutes    
•  And  an  infusion  of  methylprednisolone  at  5.4  mg/kg/h  
for  23  hours  beginning  45  minutes  a`er  the  bolus.  
Wilson  JR  &  Fehlings  MG.The  American  Society  for  Experimental  NeuroTherapeuIcs,  Inc.2011  
Chin  LS.  emedicine.medscape.com.2016   hasansjahrir  
 

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•  The  risks  of  steroid  therapy  are  increased  incidence  of  

infecIon  and  avascular  necrosis  has  been  documented.    
•  Updated  guidelines  ithe  American  AssociaIon  of  
Neurological  Surgeons  (AANS)  recommend  against  the  use  
of  steroids  early  a`er  an  acute  SCI.    
•  The  guidelines  recommend  that  methylprednisolone  
not  be  used  for  the  treatment  of  acute  SCI  within  the  
first  24-­‐48  hours  following  injury.    
•  The  previous  standard  was  revised  because  of  a  lack  of  
medical  evidence  supporIng  the  benefits  of  steroids  in  
clinical  se_ngs  and  evidence  that  high-­‐dose  steroids  are  
associated  with  harmful  adverse  effects.    
Chin  LS.  emedicine.medscape.com.2016  
hasansjahrir  

•  the  administraIon  of  monosialotetrahexosyl  

ganglioside  (GM-­‐1)  complex  following  acute  
spinal  cord  injury,  improving  neurologic  recovery  
at  a  3-­‐month  
•  The  available  medical  evidence  does  not  
support  a  significant  clinical  benefit.    
•  It  was  evaluated  as  a  treatment  adjunct  a`er  
the  administraIon  of  methylprednisolone.    

Chin LS. emedicine.medscape.com.2016

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Numerous  pharmacological  agents  thought  to  miIgate  the  

secondary  injury  have  been  extensively  studied.  These  
include    
•  the  steroids  (anIinflammatory),  gangliosides,  
naloxone  (opiate  receptor  antagonist),  calcium  
channel  blockers,  free  radical  scavengers  and  
neurotropic  agents    
•  that  evidence  of  the  drug's  efficacy  and  impact  is  weak    
•  the  use  of  high  dose  methyl  prednisolone  in  the  treatment  
of  acute  SCI  is  not  proven  as  a  standard  of  care.    
•  In  a  systemaIc  review  of  studies,  concluded  that  there  is  
no  evidence  for  the  effecIveness  of  bracing  in  paIents  
with  traumaIc  thoracolumbar  fractures.    
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Rajasekaran S et al. Indian J Orthop. 2015 Jan-Feb; 49(1): 72–82.

Early  management  in  the  emergency  department  aIer  

trauma5c  spinal  cord  injury  

•  Do  not  use  the  following  medicaIons,  aimed  at  

providing  neuroprotecIon  and  prevenIon  of  
secondary  deterioraIon,  in  the  acute  stage  a`er  
acute  traumaIc  spinal  cord  injury:  
•  Methylprednisolone,  nimodipine,  naloxone.  
•  Do  not  use  medicaIons  in  the  acute  stage  
a`er  traumaIc  spinal  cord  injury  to  prevent  
neuropathic  pain  from  developing  in  the  
chronic  stage.  
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NICE  guideline  2016  

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CommunicaIon  with  terIary  services/trauma  centre  

•  the  trauma  team  leader  should  immediately  contact  the  
spine  neurosurgical  192
or  spinal  surgeon  oWILSON
rthopaedic  
AND FEHLINGS
on  call    
•  performing  early  decompression  and  restore  stability    
•  One  systemaIc  review,  concluded  that  early  spinal  
surgery  (<24  h)  results  in  beBer  neurological  outcome  
than  delayed  surgery  (>24  h)  for  paIents  with  
incomplete  injuries  (class  2  evidence)  
•  Vaccaro  et  al.  randomized  paIents  to  either  early  
surgery  (<72  h)  or  late  surgery  (>72  h),  and  found  no  
difference  in  neurologic  recovery  or  length  of  hospital  
stay  between  these  groups.(class  2  evidence)  
FIG. 1. Preoperative T2-weighted cervical spinal magnetic resonance image demonstrating spinal cord compression at level C6-C7 with
Wilson  JR  &  Fehlings  MG.The  American   Society  
concomitant for  signal
hyperintense Experimental   NeuroTherapeuIcs,  
changes within the cord. Based on the formula from TableInc.2011  
1, the degree of spinal cord compression is (1 -
NICE  guideline  2016   [0.4/(0.8+0.7)/2])×100%=53%.
hasansjahrir  

specific approach for decompression or reduction were
excluded. Between the two approaches, there were no
significant differences in spinal fusion rates, alignment,
neurologic recovery, or long-term complications.
Practically, for questions of approach or other operative
related issues, it is up to the surgeon to combine the best
192 WILSON AND FEHLINGSavailable evidence with their own anecdotal experience to
create a treatment plan tailored to the patient and the
specifics of the clinical scenario.
Illustrative clinical case
A 20-year-old male driver was involved in a motor
vehicle rollover accident while unrestrained. His neuro-
logical examination on arrival at hospital demonstrated

FIG. 1. Preoperative T2-weighted cervical spinal magnetic resonance image demonstrating spinal cord compression
FIG. 2. Postoperative at levelspinal
T2-weighted cervical C6-C7 with resonance image at 1-year postinjury demonstrating complete decom-
magnetic
concomitant hyperintense signal changes within the cord. Based on the formula frompression
Table 1,ofthe
thedegree of spinal
spinal cord cord compression
and restoration of normal iscervical
(1 - spinal alignment.
[0.4/(0.8+0.7)/2])×100%=53%. spinal  cord  compression  at  level  C6-­‐C7  with   PostoperaIve  T2-­‐weighted  cervical  spinal  
concomitant  hyperintense  signal  changes   magneIc  resonance  image  at  1-­‐year  
specific approach for decompression or reduction were Neurotherapeutics,tailored
create a treatment Vol. 8, No.to2,the 2011patient and the
within  the  cord.  Based  on   the  formula  fplan
rom   posInjury   demonstraIng  complete  decom-­‐  
excluded. Between the two approaches, there were no specifics of the clinical scenario.
significant differences in spinalTable  
fusion 1,  trates,
he  dalignment,
egree  of  spinal  cord  compression   pression  of  the  spinal  cord  and  restoraIon  
is  (1  complications.
neurologic recovery, or long-term -­‐  [0.4/(0.8  +  0.7)/2])  Illustrative
×  100%  =clinical
 53%.  case
hasansjahrir   of  normal  cervical  spinal  alignment.  
Practically, for questions ofASIA  
approach C  Sor CI  other operative A 20-year-old male driver wasASIA   involved in a motor
D  SCI  
related issues, it is up to the surgeon to combine the best vehicle rollover accident while unrestrained. His neuro-
available evidence with their own anecdotal experience to logical examination on arrival at hospital demonstrated

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•  In  June  2012,  the  FDA  approved  the  use  of  pregabalin  

for  the  management  of  neuropathic  pain  associated  
with  spinal  cord  injury.    
•  dosed  pregabalin  (150-­‐600  mg/d)      
•  Studies  showed  pregabalin  significantly  reduced  
neuropathic  pain,  More  paIents  taking  pregabalin  
showed  30%  and  50%  reducIons  in  pain  than  those  
taking  placebo  at  12  and  16  weeks    
•  The  precise  mechanism  of  acIon  is  unknown  but  is  a  
GABA  analog  which  binds  to  a  subunit  of  voltage-­‐
gated  calcium  channels  in  CNS.  

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Chin LS. emedicine.medscape.com.2016

Recommendations for research The guideline committee

has made the following recommendations for research.

•  Neuropathic pain relief

•  Does early treatment with a centrally acting analgesic
(for example pregabalin) reduce the frequency or
severity of neuropathic pain in people with spinal cord
injury?

hasansjahrir NICE guideline 2016

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Why  this  is  important

•  Neuropathic  pain  occurs  in  40%  of  people  with  
spinal  cord  injury.
•  It  can  be  severe  and  disabling,  and  in  people  with  
spinal  cord  injury  it  can  lead  to  further  
impairment  of  function.  
•  Having  neuropathic  pain  can  also  result  in  
increased  care  needs  and  costs  of  care
•  It  also  increases  the  risk  of  significant  depressive  
illness  and  suicide.  
•  Research  is  needed  to  address  whether  early  
treatment  of  spinal  cord  injury  with  a  centrally  
acting  analgesic  such  as  pregabalin  might  reduce  the  
frequency  or  severity  of  neuropathic  pain.
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NICE  guideline  2016

The  end  

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