Spinal Cord Injury Clinical Guidelines

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly and Lucinda hampton  

Introduction

The momentum for evidence-based healthcare has been gaining ground rapidly, motivated by clinicians, and management concerned about quality, consistency and costs of healthcare intervention. The use of Clinical Guidelines, based on standardised best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare and is considered one of the main ways that evidence-based medicine can be implemented. Clinical Practice Guidelines was defined by Field and Lohr (1990) as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".[1][2]

According to Woolf et al (2012) Clinical Guidelines have become one of the foundation of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of process and necessary procedures and the context for guideline development has changed with the emergence of Guideline Clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence. [3]

Purpose

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management and are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of research literature and clinical evidence - the main source for evidence-based care. [4]

"The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements". [5]

  • To describe appropriate care based on the best available scientific evidence and broad consensus;
  • To reduce inappropriate variation in practice;
  • To provide a more rational basis for referral;
  • To provide a focus for continuing professional education;
  • To promote efficient use of resources;
  • To act as focus for quality control, including audit;
  • To highlight shortcomings of existing literature and suggest appropriate future research. [4]

Limitations and Controversy

Clinical Guidelines can have their limitations and there is controversy surrounding some recommendations within some guidelines e.g. controversy around use of steroids or stem cell therapy in spinal cord injury management. Not every patient or situation fits neatly into a guideline. Guidelines to not always cover every eventuality and each patient's circumstance needs to be taken into consideration when a treatment is decided upon. Recommendations should be viewed as statements that inform the clinician, the patient and any other user, and not as rigid rules.

" The problems of getting people to act on evidence based guidelines are widely recognised. An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach. The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention-that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved. ... ". [6][7]

For a fuller discussion on the pros and cons of Clinical Guidelines, see the original series of articles written in the British Medical Journal followed by an updated and extended series with further recent considerations in the development of Clinical Guidelines. 

Development and Use of Clinical Guidelines Series 1:

  1. Potential Benefits, Limitations, and Harms of Clinical Guidelines [8]
  2. Developing Guidelines [9][9][9]
  3. Legal and Political Considerations of Clinical Practice Guidelines [10][10][10][10]
  4. Using Clinical Guidelines[11] [11][11]

Developing Clinical Practice Guidelines Series 2 - Updated and Extended:

  1. Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest [12]
  2. Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations [13]
  3. Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development [14]

Spinal Cord Injury Clinical Guidelines

While the evidence base for spinal cord injury managament and rehabilitation is increasing, substantial gaps still remain with an ongoing need for more research to improve both service delivery and more importantly patient outcomes. Many of the Clinical Guidelines related to spinal cord injuries treatments are focused on medical management such as avoidance of secondary injury from compressive lesions and hemodynamic instability. Overall most guidelines during each phase of manemegent recommend that all individuals with a spinal cord injury should have a lifetime of personalised care that is guided by a specialized, spinal cord injury centre.

Pre Hospital

Initial management of a suspected spinal cord injury is targeted toward basic life support and preventing further injury including maintaining airway, breathing, circulation and restricting further movement of the spine. The principle of pre-hospital management of spinal cord injury is to limit neurological deficit and prevent secondary injury and is achieved through: appropriate spinal immobilization; maintaining a high index of suspicion of spinal cord injury, identification and reversal of life threatening associated injuries; cardiovascular and ventilation support and ensure appropriate thermoregulation. Spinal immobilization is now an integral part of prehospital management and is advocated for all patients with potential spinal injury after any acute trauma. Early management of an individual with a potential spinal cord injury begins at the scene of the accident with the major concern during initial assessment that neurologic function may be impaired as a result of movement to the injured vertebrae. Many cases of poor outcome resulting from mishandling have been reported, with between 3 and 25% of spinal cord injuries thought to occur not at the time of the initial trauma but later during treatment or transport. These guidelines cover the assessment and early management of spinal column and spinal cord injury in pre-hospital settings including ambulance services, emergency departments and major trauma centres with the overriding aims to reduce death and impairment through the improvement in the quality of emergency and urgent care.[15][16][17]

Assessment

At all stages of the assessment protect the person's cervical spine with manual in‑line spinal immobilisation, and avoid moving the remainder of the spine. Assess whether the person is at high, low or no risk for cervical spine injury using the Canadian C‑Spine Rule or thoracic or lumbar injury. [15]

Immobilisation

Carry out or maintain full in‑line spinal immobilisation if there is a high-risk factor for cervical spine injury or a low-risk factor for cervical spine injury but the person is unable to actively rotate their neck 45 degrees left and right. This should be maintained during transfer and on admission to the Emergency Department. [15] A combination of a semi-rigid cervical collar, unless contraindicated by a compromised airway, known spinal deformities with supportive blocks on a backboard with straps, ideally in a vacuum mattress, is effective in limiting motion of the cervical spine and is recommended. [15]

Spinal immobilization in patients with penetrating trauma is NOT recommended secondary to an increased mortality from delayed resuscitation. [17]

Pain

Assess pain regularly in people with spinal injury using a pain assessment scale suitable for the patient's age, developmental stage and cognitive function and offer medications to control pain with intravenous morphine as the first-line analgesic. [15]

Transfer

Suspected acute traumatic spinal cord injury, with or without column injury, should be transported with full in-line spinal immobilisation, to a major trauma centre irrespective of transfer time, unless the person needs an immediate lifesaving intervention. [15][17] Rapid admission to specialized care for people with spinal cord injury as soon as possible staffed by an experienced interprofessional team. [18]

Dr. William Whetstone, UCSF professor of emergency medicine, and Dr. Lisa Pascual, UCSF professor of rehabilitation, go over how and why spinal cord injuries are managed even before the patient reaches the hospital.

Acute

Acute Clinical Guidelines in Spinal Cord Injury tend to focus more on the Medical Management covering interventions when the diagnosis is made, medical stability is achieved and early complications prevented, but in some instances extends into the rehabilitation phase when an individual has ongoing needs around their medical managament and stabilisation of spinal cord injury. Optimal destination for patients with major trauma is usually a major trauma centre. In some locations or circumstances intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network. Initial care on admission to the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and restrain of spinal motion.Life threatening injuries are prioritized and stabilized prior to imaging. Treatment normally occurs in an intensive care unit, in particular injuries to the cervical or high thoracic spinal cord where autonomic function may impact on intel treatment. In order to prevent complications such as pressure areas individuals should be transferred from the spinal board used for transport as soon as possible, while still maintaining spinal immobilization through other means. [15][17]

Assessment

A baseline neurological assessment, the ASIA Impairment Scale as described by the International Standards for Neurological Classification of Spinal Cord Injury, should be completed within 72 hours on all suspected spinal column injury or spinal cord injury to document the presence of any neurologic deficits and where present the neurological level and the completeness of injury to determine the preliminary prognosis for neurological recovery. [20] Repeat neurological assessment should be completed to to detect neurological deterioration or improvement. [20]

Diagnostic Imaging

Trauma patients who are symptomatic with either neck or back pain, cervical, thoracic or lumbar spine tenderness, or have symptoms or signs of a neurological deficit associated with spinal cord injury, and trauma patients who cannot be assessed for symptoms or signs such as those who are unconscious, uncooperative or incoherent, intoxicated, or who have associated traumatic injuries that distract from their assessment require radiographic study of the spine prior to the discontinuation of spine immobilization. Urgent imaging should be performed for spinal injury, and the images should be interpreted immediately by a healthcare professional with training and skills in this area. In the unevaluable patient, high-quality CT imaging is recommended as the initial imaging modality of choice. [15][17]

In Adults (16 and Over) CT should be performed if there is a suspicion of a cervical spine injury, with a further MRI if, after CT, there is a neurological abnormality which could be attributable to spinal cord injury prior to any surgical intervention, to facilitate improved clinical decision-making and improve prediction of neurologic outcome.[21] X-ray should be performed as the first‑line investigation for suspected spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions (T1 - L3), with a follow up 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, the rest of the spinal column should be imaged. [15][17]

In Children (15 and Under) MRI should be performed if there is a strong suspicion of cervical spine injury, while plain X‑rays should be considered for who do not fulfill the criteria for MRI but clinical suspicion of a spinal column injury remains after repeated clinical assessment. [15][17]

Pharmacology Management

The use of methylprednisolone, nimodipine and naloxone is NOT recommended for neuroprotection and prevention of secondary deterioration, in the acute stage after traumatic spinal cord injury. [15][17][22] But there is moderate evidence to suggest that Methylprednisolone be offered to adult patients within 8 hours of acute spinal cord injury as a treatment option.[21]

Pain Assessment

Continue to assess pain using the same pain assessment scale that was used in the pre-hospital setting. Intravenous morphine should be utilized as the first-line analgesic with ketamine as a second-line agent.[15] Short-acting sedation should be considered to allow for periodic neurologic assessment. [20]

Surgical Management

Early decompression surgery, ≤ 24 hours after injury, should be considered as a treatment option in adults with traumatic central cord syndrome, and be offered as an option regardless of level for other spinal cord injuries but evidence is of low quality. [15]

Respiratory Management

Closely monitor for respiratory failure following spinal cord injury.Obtain baseline respiratory parameters and arterial blood gases during initial assessment and at intervals until stable. [20] Intensive Care Unit admission for all complete tetraplegia and incomplete tetraplegia injury level C5 or above. [20]

Deep Venous Thrombosis and Thromboembolism Prophylaxis

Venous Thromboembolism (VTE) prophylaxis is recommended in patients with severe motor deficits due to spinal cord injury including use of low molecular weight heparins, rotating beds, or a combination of modalities such as low dose heparin in combination with pneumatic compression stockings or electrical stimulation as a prophylactic treatment strategy. It is recommended that VTE Prophylaxis should be administered early post injury, within 72 hours, and continued for a 3-month duration. [17][23]

Skin Care and Pressure Ulcer Prevention

Ensure that occupational therapy and physiotherapy members of the interprofessional team who have combined specialized training and experience working with people with spinal cord injury and in seating and positioning perform a comprehensive pressure management assessment, in consultation with other interprofessional team members. Perform a comprehensive assessment of posture and positioning to evaluate pressure ulcer risk. Consider all surfaces in both recumbent and sitting positions that a person uses to participate in daily activities over the entire 24-hour period. [18]

Use relevant Risk Assessment Tools such as the Waterlow Scale, the Braden Scale, or the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) tool to assess pressure ulcer risk in people with spinal cord injury. Use the results of a comprehensive and systematic assessment of pressure ulcer risk factors to select and implement risk management strategies in individuals with spinal cord injury and reassess risk factors on a routine basis, as determined by the healthcare setting, institutional guidelines, and changes in the individual’s health status. Avoid prolonged immobilization whenever possible, limit the time a person is on a spinal board and employ intraoperative pressure reduction strategies. [18]

Turn and reposition individuals who require assistance at least every 2 hours, initially, while maintaining spinal precautions as required to provide pressure relief.. Adjust the repositioning schedule based on the individual’s skin response, determined by frequent skin checks. [20]

Ensure proper bed positioning by using devices and techniques that are appropriate for the type of support surface and mattress and the individual’s health status. Use pillows, cushions, and positioning aids to: Bridge contacting tissues, including bony prominences, unload bony prominences and protect pressure ulcers and vulnerable areas of skin. [18]

Use supine positioning to stretch and oppose sitting postures to maintain flexibility and skeletal alignment and reduce spasticity. Use a side-lying position at a 30° angle from supine that does not position the person directly on either hip. Use prone positioning to stretch the hips and trunk while offloading the buttock region, including the ischial tuberosities, sacrum, and coccyx. [18]

Consider a universal prevention program to protect the heels of all people with spinal cord injury while supine or reclined, especially people undergoing surgical procedures.[18]

Orthostatic Hypotension

Once medical and spinal stability develop an appropriate program for out-of-bed sitting to improve symptoms of orthostatic hypotension. Utilize non-pharmacologic interventions including lower limb compression with graduated elastic stockings and elastic wraps, abdominal binders (especially with cervical and high-level motor-complete injuries), and gradual attainment of an upright position. Use pharmacologic therapy, where required, for those with more severe orthostatic hypotension. [20]

Multidisciplinary Team

Develop protocols for multidisciplinary involvement, physiotherapy, occupational therapy, rehabilitation nurses, dietician and speech and language therapy, in the early management of individuals immediately following injury during the acute hospitalization phase. Introduce relevant physiotherapy, occupational therapy and speech and language therapy interventions that will assist the recovery of individuals with a spinal cord injury to prevent possible secondary complications including; [20]

  • Initiate range of motion exercises of all joints within the first week after injury and continue throughout the acute phase.
  • Strengthening Exercises.
  • Seating and Positioning.
  • Mobilization, including bed mobility, transfer training, relevant locomotion (gait or wheelchair).
  • Splinting - Upper and Lower Extremity.
  • Respiratory Interventions including percussion, vibration, suctioning, postural drainage, mobilization, training of accessory muscles, cough, and deep breathing exercises,
  • Functional and/or augmentative communication.
  • Assessment of swallowing.
  • Assessment of cognitive and/or language deficits from concomitant traumatic brain injury.
  • Nutritional Status including anthropometric measurements, dietary intake and losses, nutrition- and hydration-related blood work, ability to self-feed or dependence on others for eating and drinking and other barriers to optimal food and fluid intake
  • Educate patients and families about the rehabilitation process and encourage their participation in discharge planning discussions.
" Early intervention by multidisciplinary team members may shorten length of stay during the acute hospitalization phase through prevention of secondary complications and moving the patient more quickly toward discharge to the next level of care " [20]

Communication and Support

Communicate to patients and family members about what is happening and why including information on known injuries, details of investigations and treatment, and expected outcomes of treatment, including time to returning to usual activities and the likelihood of permanent effects on quality of life, such as pain, loss of function or psychological effects. [15]

Rehabilitation

This phase of the spinal cord injury recovery process focuses on the common issues that individuals with a spinal cord injury will encounter as they recover and is focused on person-centred outcomes of activities and participation rather than interventions aimed purely at pathology or impairments. Rehabilitation primarily focuses on preventing secondary complications, promoting neurorecovery and maximizing function following injury. Other objectives include to improve a patient’s independence in activities of daily living, to help a patient accept a new lifestyle and to facilitate community reintegration.Guidelines highlight the importance of a specialist multidisciplinary team but both timeframe and pathway for this process is not restricted and often overlaps with the into the long-term management phase. Along with the rest of the multidisciplinary team this is largely where physiotherapists play a large role in the management of individuals with Spinal Cord Injury. Organised Spinal Cord Injury care, processes of care, early timing of rehabilitation and high intensity of rehabilitation therapies are important factors that have been identified as promoting better overall outcomes for individuals with spinal cord injury. This phase can cover a range of settings including an acute spinal cord injury unit, spinal cord injury rehabilitation units, early supported discharge services and other community rehabilitation services. Clinical Practice Guidelines provides evidence-based recommendations for the optimal type and timing of rehabilitation in patients with acute spinal cord injury once they are medically stable for intensive rehabilitation with the ultimate goal being to improve outcomes and reduce morbidity in patients with spinal cord injury through improved standards of care and evidence-informed decision making on types of treatment offered. [21][24]

Timing of Rehabilitation

Rehabilitation should be offered to patients with an acute spinal cord injury when they are medically stable and can tolerate the required treatment intensity. [21][24]

Standing

All patients with a spinal cord injury should be individually assessed for the potential benefits of standing relevant to their level and type of injury and should be assessed for a standing program as soon as they are physiologically stable. Specific standing goals should be identified for the individual based on the initial assessment and on-going evaluation with suitable outcome measures used, such as measurement of bone mineral density, joint range of movement, spasticity, quality of life, bowel frequency and duration of bowel regime, complications, cardiovascular parameters, respiratory function and skin condition. [25]

Individuals should stand at least three or more times a week for thirty to sixty minutes each time. [25]

Gait Training

Gait training should include conventional overground walking, supported by body weight–supported treadmill training where feasible. [21][24]

Functional Electrical Stimulation

Functional electrical stimulation is recommended to improve hand and upper extremity function both in acute and subacute cervical spinal cord injury. [21][24]

Mental Health

Assess the following as part of the comprehensive evaluation of people with spinal cord injury: Quality of life, Pain and Depression [18]

Neuropathic Pain

All individuals with a spinal cord injury should be screened for pain on admission to rehabilitation, regularly throughout inpatient rehabilitation and at each follow up post discharge. Where pain is present an assessment should be completed to determine the type and intensity of pain.[26]

Diagnosis of neuropathic pain, including its causes, should be informed by a complete patient history, followed by a physical examination, using the International Spinal Cord Injury Pain (ISCIP) Classification System with further investigations as required. Screen for Red Flags to determine serious underlying conditions that may cause, aggravate or mimic neuropathic pain and require further investigation and prompt medical review. Similarily assess and manage psychosocial factors (yellow flags) that may contribute to pain-related distress and disability and address patient concerns, expectations and needs as part of the neuropathic pain assessment. [26]

Pregabalin, Gabapentin and Amitriptyline can be used for the reduction of neuropathic pain intensity among people with a spinal cord injury as a first line treatment, while tramadol can be used as a second line treatment with Lamotrigine considered in those with incomplete SCI for the reduction of neuropathic pain intensity. [27]

Chronic

According to the British Medical Journal, chronic spinal cord injury refers to a permanent and/or progressive interruption in the conduction of impulses across the neurons and tracts of the spinal cord with the term generally used when a spinal cord injury has been present for at least 1 year. Studies that have followed up people with a spinal cord injury indicate that individuals may continue to make functional gains following interventions, up to two years post spinal cord injury, and often longer in those with an incomplete spinal cord injury across a range of functional skills. Guidelines for this phase focus on the long-term management of individuals with spinal cord injury in particular in relation to managing the prevention of secondary complications such as contracture, pressure sores etc. and is concerned with person-centred and family-centred care. Long Term Management can be very complex in nature  as a result of the wide variety of individual circumstance that each individual post spinal cord injury is faced with. Life expectancy for people with a spinal cord injury continues to increase and as a result we continue to see more individuals with a spinal cord injury with age-related diseases that affect the general population, including cardiovascular disease, infection and malignancies. Similarly multi-system impairments as a result of the spinal cord injury can lead to several complications, particularly infections, respiratory complications and pressure sores. All of these place individuals at greater risk of hospital admission every year following their injury compared with the general population. This creates a challenge for research and as a consequence, the evidence to guide recommendations here are more difficult to interpret, and often more sparse but this should not reduce the importance of this phase and the need for further research in this area in order to develop expert guidance on best practice. [18][20] 

Multidisciplinary Team Management

Provide adequate outpatient services where people with spinal cord injury who are living in the community can access an interprofessional team of clinicians with expertise in the management of individuals with spinal cord injury. Ensure that routine follow-up appointments provide preventive care to reduce secondary complications and improve quality of life. [18][20]

Skin Care and Pressure Ulcer Management

Identify potential psychosocial factors that could increase the risk of pressure ulcers in people with spinal cord injury. Identify the psychosocial impact of pressure ulcers in people with spinal cord injury and pressure ulcers. Refer individuals to appropriate resources for problem resolution, including: Vocational rehabilitation services, Peer counselling and support groups and Formal psychotherapy and/or family therapy. Provide individuals who have spinal cord injury, their families, significant others, and healthcare professionals with structured education about effective strategies for the prevention and treatment of pressure ulcers. Provide education specific to the individual after each assessment and reassessment. This education should include: Potential causes and risks of pressure ulcer development, Methods of self-monitoring and Reduction of pressure ulcer risks as part of the prevention plan. [18]

Promote self-management for spinal cord injury. Help them learn, consistently apply, and incorporate effective and appropriate pressure ulcer prevention strategies into their daily life. [18]

Reassess pressure management using a 24-hour approach every 2 years, or more often if a pressure ulcer develops or there is a significant change in health status including weight changes or functional ability or if there are changes in living situation or a deterioration in the support surface/equipment. [18]

Avoid prolonged use of full-time bed rest to treat pressure ulcers in individuals with spinal cord injury. Use bed rest, if necessary, to offload pressure completely for a specific and limited time, such as after surgical repair of pressure ulcers. Re-evaluate the suitability of the support surface for pressure ulcer prevention and treatment at least every 4 years, and sooner if the person’s medical condition changes. Reassess gross motor skills abilities and current pressure management strategies if gross motor function declines or a pressure ulcer develops. [18]

Exercise Guidelines

These exercise guidelines, appropriate for adults (aged 18-64) with chronic spinal cord injury (at least one year post-onset, neurological level of injury C3 and below), from traumatic or non-traumatic causes, including tetraplegia and paraplegia, irrespective of sex, race, ethnicity or socio-economic status. provide minimum thresholds for achieving the following benefits: [28]

  • improved cardiorespiratory fitness
  • improved muscle strength
  • improved cardiometabolic health
Spinal Cord Injury Exercise Guidelines [29]

Resources

Pre-Hospital

Acute

Rehabilitation

Chronic

References

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