Anesthesia Considerations 

Acute Spinal Cord Injury 

 

 

American Spinal Injury (ASIA) Impairment Scale 

 

• A: Complete: no motor or sensory function is preserved in the sacral segments S4-5

• B: Sensory incomplete: sensory but not motor function is preserved below the neurologic level & includes the sacral segments (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body

• C: Motor incomplete: motor function is preserved below the neurologic level & more than half of key muscle functions below the neurologic level of injury have a muscle grade <3 (grades 0 to 2)

• D: Motor incomplete: motor function is preserved below the neurologic level & at least half (half or more) of key muscle functions below the neurologic level of injury have a muscle grade ≥3

• E: Normal: sensation & motor function are graded as normal in all segments & the patient had prior deficits

 

 

Considerations

 

• Emergency trauma patient with C/T/L-spine injury:

  • ATLS approach to identify multisystem life threatening & occult injuries

  • Potentially difficult airway (full stomach, C-spine, uncooperative) 

  • Hemodynamic instability: neurogenic +/- hypovolemic shock

  • Hypothermia, coagulopathy, acidosis

  • Intoxication

  • Additional injuries: traumatic brain injury (TBI) with ↑ intracranial pressure (ICP) in 25%

• Need to prevent secondary spinal cord injury (keep MAP > 85-90) 

• C-spine precautions & airway protection

• Potential for:

  • Diaphramatic paralysis (C3-C5)

  • Respiratory insufficiency with injury above T7

  • Neurogenic shock (hypotension & bradycardia)

  • Neurogenic pulmonary edema

  • Severe autonomic nervous system abnormalities

  • Hypothermia due to loss of thermoregulation

  • Hyperkalemic arrest with succinylcholine after 24 hrs 

 

 

Goals

 

• Avoid secondary spinal cord injury:

  • Spinal cord perfusion pressure: goal MAP > 85-90 (IV fluids, vasopressors)

  • Prevent hypoxemia, hypotension, hyperglycemia, hyperthermia

  • Immobilization during airway management & positioning

• Manage complications of acute spinal cord injuries

• Ventilatory & hemodynamic support as needed

• Neurogenic shock:

  • Fluids/vasopressors 

  • If bradycardic: atropine, external pacer, pharmacologic pacing (dopamine, isoproterenol) 

 

 

Conflicts

 

• Unstable c-spine, difficult airway +/- TBI (↑ ICP) vs potentially uncooperative patient

• Aspiration risk (RSI) vs hemodynamic instability