Traumatic spinal cord injury (TSI) represents pathologies that result from a diverse spectrum of primary insults to the central nervous system (CNS). The incidence of TSI is about 12,000 cases annually in the United States and often affects young, otherwise healthy individuals.1,2 In addition to the long-term physical disabilities and the psychosocial impairments seen in neurotrauma survivors, the economic burden of TSI is significant. The United States currently spends $5.6 billion annually on the treatment of spinal cord injuries. It is estimated that the lifetime total cost directly attributable to spinal cord injury in a 25-year-old patient may exceed $3 million.1
Advancements in our understanding of the pathophysiology of CNS injury post-trauma have led to improvements in the critical care of patients with TSI. For spinal cord–injured patients, it is crucial that a multidisciplinary approach be taken from the outset. Similar to the management of traumatic brain injury (TBI) patients, the foremost principle guiding the management of TSI patients is to minimize the secondary neural injury that inevitably follows a primary CNS insult. Appropriate and timely emergency stabilization, critical care management, and surgical interventions are essential for delaying the progression of secondary CNS injury. Toward this end, the clinician treating TSI patients must be able to assess, monitor, and treat the multitude of physiologic derangements that result from and also facilitate CNS injury. In this chapter, we review the epidemiology, pathophysiology, and critical care management of TSI patients. Because neurosurgical intervention—whether at the bedside or in the operating room—is often necessary for TSI patients, the surgical indications for pathology encountered in the emergency and critical care setting will also be reviewed.
The National Spinal Cord Injury Statistical Center (NSCISC) collects and dispenses the most comprehensive epidemiologic data on spinal cord injury in the United States. They estimate the annual incidence of spinal cord injury at 40 cases per million population, representing about 12,000 new cases each year in the United States.1,3 About 80% of these injuries occur in males. The most common causes of spinal cord injury include motor vehicle accident in 41.3%, fall in 27.3%, and violence in 15%. Cervical spinal cord injuries are the most common comprising over 50% of lesions within the NSCISC database, followed by thoracic, lumbar, and sacral lesions. Among all levels of injury, cervical lesions confer the worst prognosis, with ventilator dependency having a strong negative association with morbidity and mortality. Death in spinal cord–injured patients most commonly results from respiratory infections and septicemia associated with urinary infections and decubitus ulcers. Despite medical advancements, life expectancies for SCI patients have not improved since the 1980s.1,3
An appreciation for the pathophysiologic mechanisms at work after TSI is important for the development and implementation of effective clinical therapeutic strategies. The injury due to TSI can be understood in terms ...