Spinal cord injury

About 10% of blunt polytrauma cases have an underlying overt or occult spinal cord injury. All multiply injured patients should be managed expectantly and aggressively until injury is ruled out and normal physiological parameters are restored. The ability to assess these patients accurately is often limited by an associated head injury or by the absence of sensation below a complete cord injury. A high index of suspicion along with detailed clinical and radiological examination is required to detect any underlying injuries. The possibility of spinal shock should not be considered until hypovolaemia has been excluded. Intensive care management of acute spinal cord injury includes meticulous attention to fluid management, nutrition, thromboprophylaxis, early protective lung ventilation and measures to reduce ventilator-associated pneumonia. These measures have helped provide a steady improvement in long term survival of these patients over the last 20 years. There has been recent controversy about 'clearing' the spine in unconscious patients. Accurate clearance requires a painless examination in an alert, orientated patient with no distracting injury. Many ICU patients never fulfil these criteria and a risk benefit calculation has to be made. The consequences of converting a neurologically intact undiagnosed, unstable injury into a complete cord lesion are colossal. However, there is significant morbidity and mortality associated with treating all unconscious blunt trauma patients with universal spinal precautions. Many centres are now 'clearing' the c-spine of unconscious patients using a combination of cervical CT scans and plain radiological views. © 2005 Elsevier Ltd. All rights reserved.