Spinal Injury Anaesthesia in Trauma

Quick Answer

What are the critical anaesthetic considerations for patients with acute traumatic spinal cord injury?

Acute spinal cord injury requires immediate spinal protection, cardiovascular stabilisation, and prevention of secondary injury. Key principles:

1. Spinal protection - Maintain manual inline stabilisation (MILS) throughout; hard collar and spinal board/log roll precautions
2. Airway management - RSI with cricoid pressure + MILS; video laryngoscopy preferred; consider awake fibreoptic if difficult airway
3. Cardiovascular stabilisation - Neurogenic shock common; maintain MAP >80-90 mmHg for first 7 days (neuroprotection)
4. Avoid hypotension - Even single episode of SBP <90 doubles risk of poor neurological outcome
5. Methylprednisolone controversy - No longer recommended as standard; may consider case-by-case within 8 hours if complete injury
6. Timing of surgery - Early decompression (<24 hours) for cervical SCI may improve outcomes
7. Temperature management - Prevent hypothermia; maintain normothermia

Clinical Pearl: In acute spinal cord injury, the combination of hypotension and hypoxia is devastating. Every effort must be made to maintain MAP >80-90 mmHg and SpO2 >95% to protect the injured cord from secondary ischaemic injury. This is more important than any pharmacological neuroprotective agent.

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Clinical Overview

Epidemiology

Global and Australian context:

Mechanism by region:

Australian Indigenous considerations:

• Higher rates of transport-related SCI in remote communities
• Higher rates of assault-related injuries
• Delayed presentation and transfer issues
• Barriers to rehabilitation services

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Initial Management and Resuscitation

Primary Survey with Spinal Precautions

Spinal protection principles:

Airway with MILS:

• Assistant maintains MILS during intubation
• Do not allow head extension for laryngoscopy
• Use video laryngoscopy (better view without neck movement)
• Front of collar can be removed for intubation (maintain manual stabilisation)
• Replace collar immediately after intubation

C-spine clearance:

• Clinical clearance if: Alert, no intoxication, no distracting injury, no neck pain/tenderness, full painless range of motion
• Imaging if: Altered GCS, intoxication, distracting injury, neck pain, neurological deficit, high-risk mechanism
• CT C-spine is investigation of choice (sensitivity >99%)

Cardiovascular Management

Neurogenic shock:

• Occurs in injuries above T6
• Loss of sympathetic tone below lesion
• Unopposed vagal tone
• Hypotension + bradycardia
• Warm, dry skin (vasodilation)

Target haemodynamics:

Hypotension management:

1. Fluid resuscitation - Crystalloid 500-1000 mL boluses; avoid over-resuscitation (risk of pulmonary oedema)
2. Vasopressors - Noradrenaline first-line (alpha-agonist to restore vascular tone); phenylephrine alternative
3. Atropine - For bradycardia (0.6 mg IV, repeat to 3 mg if needed)
4. Inotropes - If cardiac dysfunction (adrenaline, dobutamine)
5. Monitoring - Arterial line for continuous BP monitoring

Neurogenic vs hypovolaemic shock:

Clinical Pearl: The combination of hypotension AND hypoxia is the most dangerous for secondary spinal cord injury. Even a single episode of SBP <90 mmHg or SpO2 <90% doubles the risk of poor neurological outcome. Prioritise haemodynamic stability above all else.

Respiratory Management

Level of injury and respiratory function:

Indications for intubation:

• GCS <9 with airway compromise
• PaO2 <60 mmHg or SpO2 <90% despite supplemental O2
• PaCO2 >50 mmHg with respiratory acidosis
• Vital capacity <15 mL/kg
• Rising respiratory rate with fatigue
• Bulbar dysfunction (swallowing impairment)

Ventilator strategy:

• Lung protective ventilation
• Avoid hypoxia at all costs
• PEEP to prevent atelectasis
• Consider tracheostomy early if prolonged ventilation expected

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Pharmacological Considerations

Methylprednisolone Controversy

Historical use:

• NASCIS I (1984): No benefit, possibly harm with high dose
• NASCIS II (1990): Supposed benefit if given within 8 hours (methylprednisolone 30 mg/kg bolus + 5.4 mg/kg/hr × 23 hrs)
• NASCIS III (1997): Extended infusion (48 hours) if started 3-8 hours post-injury

Current evidence:

• No Class I evidence supporting benefit [3]
• Increased complications: pneumonia, sepsis, GI bleeding, hyperglycaemia [4]
• Most major trauma organisations no longer recommend routine use [5,6]
• Cochrane review: No significant benefit; harm likely [7]

Current recommendations:

If considering use (case-by-case basis):

• Within 8 hours of injury
• Complete injury (no motor function below lesion)
• No contraindications (infection, uncontrolled diabetes, GI bleeding risk)
• Dose: 30 mg/kg IV over 15 minutes, then 5.4 mg/kg/hr × 23 hours
• Monitor for hyperglycaemia, infection, GI bleeding

Other Pharmacological Considerations

Dexamethasone:

• No proven benefit in acute traumatic SCI
• May be used for spinal cord compression from tumour/infection
• Not recommended in traumatic SCI

GM-1 ganglioside (Sygen):

• No proven benefit
• Not recommended

Naloxone:

• No proven benefit
• Not recommended

Thyrotropin-releasing hormone (TRH):

• No proven benefit
• Not recommended

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Surgical Timing

Early vs Late Surgery

Cervical SCI:

Surgical Spine 24 trial:

• Multicentre RCT
• Early surgery (<24 hours) vs late (>24 hours)
• Improved outcomes with early decompression in cervical SCI
• Must be haemodynamically stable for surgery

Practical considerations:

• Polytrauma may delay spinal surgery (life-threatening injuries first)
• Haemodynamic stability required (MAP >80 mmHg)
• Early surgery contraindicated if: Unstable patient, thoracic/abdominal injuries requiring surgery, coagulopathy, severe hypothermia

Surgical Approach

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Anaesthetic Management

Preoperative Assessment

Essential information:

Investigations:

• CT spine (complete imaging - may have multiple non-contiguous injuries)
• MRI spine (assess cord compression, oedema, haemorrhage)
• CT head (if head injury suspected)
• Chest X-ray (if respiratory compromise)
• Labs: FBC, coags, crossmatch, electrolytes, glucose, lactate

Airway Management

Principles:

• Maintain MILS at all times
• RSI with cricoid pressure for trauma
• Avoid neck extension
• Video laryngoscopy preferred (better view with neutral head)

Technique:

1. Preoxygenation - 3 minutes or 8 vital capacity breaths
2. Positioning - MILS (assistant holds head neutral)
3. Induction - Propofol/ketamine/etomidate + opioid
4. Paralysis - Rocuronium (1.2 mg/kg for RSI) - NO SUCCINYLCHOLINE after 24-72 hours
5. Intubation - Video laryngoscopy; bougie if needed
6. Cricoid pressure - Maintain throughout until tube confirmed
7. Confirmation - EtCO2, auscultation, chest rise
8. Post-intubation - Replace hard collar; secure tube with collar in place

Difficult airway considerations:

• Cervical collar restricts mouth opening
• MILS limits head positioning
• Direct laryngoscopy difficult
• Video laryngoscopy (C-MAC, McGrath) recommended
• Awake fibreoptic if anticipated difficult airway (rare in acute trauma)
• Surgical airway backup

Intraoperative Management

Monitoring:

Anaesthetic technique:

Haemodynamic management:

Specific surgical considerations:

Blood products:

• Crossmatch 4 units PRBC
• Consider FFP, platelets if massive transfusion
• Cell salvage useful (autologous blood)
• Tranexamic acid 1 g IV (consider if significant bleeding)

Prone Positioning

Complications:

Positioning technique:

1. Adequate anaesthesia depth
2. Log roll with entire team (5-6 people)
3. Maintain MILS during turn
4. Secure airway tubing
5. Check all lines/drains
6. Pad all pressure points (face, chest, iliac crests, knees, ankles)
7. Arms positioned carefully ( prayer position or arm boards)
8. Final check: eyes, airway, lines, position

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Postoperative Management

Immediate Priorities

Extubation considerations:

Safe extubation criteria:

• Awake, following commands
• Adequate respiratory strength (head lift, hand grip)
• SpO2 >95% on FiO2 0.4
• No airway obstruction (neck swelling, haematoma)
• Haemodynamically stable
• Temperature >36°C

If high-risk:

• Consider extubation in ICU rather than theatre
• Have reintubation equipment ready
• Consider non-invasive ventilation post-extubation
• Extubate over airway exchange catheter

ICU admission:

• All complete cervical injuries
• High thoracic injuries with respiratory compromise
• Haemodynamically unstable patients
• Multi-trauma patients
• Postoperative ventilation planned

Complications

Blood Pressure Management (Critical First 7 Days)

Target:

• MAP >80-90 mmHg for first 7 days [9]
• This is neuroprotective for the injured cord
• May improve neurological outcomes

Technique:

• Noradrenaline infusion titrated to MAP target
• Adequate fluid resuscitation
• Treat all hypotension aggressively
• Protocol-driven management in ICU

Methylprednisolone Postoperative

If started preoperatively:

• Continue infusion 23 hours total (or 48 hours if started 3-8 hours post-injury)
• Monitor for:
  • Hyperglycaemia (insulin sliding scale)
  • Infection (pneumonia, wound infection)
  • GI bleeding (PPI prophylaxis)
  • Wound healing issues
• Most centres have stopped routine use

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Special Populations

Paediatric SCI

Unique features:

• SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) - more common
• Higher injury level for same mechanism
• Immature spine with ligamentous laxity
• Higher risk of complete injury
• Methylprednisolone NOT recommended (complications outweigh benefits)

SCIWORA:

• Neurological deficit without fracture on plain X-ray/CT
• Due to ligamentous laxity, elasticity of spine
• MRI shows cord injury
• More common in children <8 years
• Immobilise despite normal X-rays if mechanism concerning

Elderly Patients

Considerations:

• Falls most common cause
• Pre-existing spinal stenosis, spondylosis
• High comorbidity burden
• Osteoporosis (fixation challenges)
• Risk of polypharmacy interactions
• Delirium risk
• Conservative management may be appropriate for some

Pregnancy

Considerations:

• Physiological changes complicate management
• Supine hypotension syndrome (aortocaval compression)
• Difficult intubation (airway changes)
• Reduced FRC
• Fetal monitoring if viable
• Left lateral tilt positioning

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Patients

Disproportionate burden:

Access challenges:

Cultural considerations:

Practical strategies:

1. Early engagement - ALO involvement from admission
2. Retrieval - Coordinate RFDS/retrieval services efficiently
3. Family support - Accommodation near hospital; travel assistance
4. Discharge planning - Extensive planning needed for remote return
5. Rehabilitation - Cultural appropriateness of programs
6. Equipment - Ensure appropriate for home environment

Māori Health (Aotearoa New Zealand)

Epidemiology:

• Higher rates of traumatic SCI in Māori population
• Younger age at injury
• Higher proportion from transport accidents and violence

Burden of injury:

• Significant whānau impact
• Loss of workforce participation
• Accommodation challenges

Cultural considerations:

• Whānau involvement in all decisions
• Karakia and spiritual support
• Whānau ora approach to holistic rehabilitation
• Māori Health Worker involvement
• Discharge to whānau care with appropriate support

Te Tiriti obligations:

• Equity in access to spinal services
• Culturally appropriate rehabilitation
• Address disparities in injury rates
• Māori workforce development

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ANZCA Final Examination Focus

High-Yield Topics

Written examination:

Viva scenarios:

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Assessment Content

SAQ 1: Neurogenic Shock vs Hypovolaemic Shock (20 marks)

Question:

A 24-year-old man presents to ED following a high-speed motor vehicle accident. He was ejected from the vehicle. He has a GCS of 15 but complains of inability to move or feel his legs. His vital signs are:

• BP: 82/50 mmHg
• HR: 48 bpm
• SpO2: 96% on O2
• Temperature: 35.8°C

His abdomen is soft and non-tender. Chest X-ray is normal. CT spine shows a T4 burst fracture with retropulsion into canal.

a) Differentiate between neurogenic shock and hypovolaemic shock. What features in this case suggest neurogenic shock? (8 marks)

b) Outline your immediate management priorities for this patient. (8 marks)

c) What are the haemodynamic targets for the first 7 days following acute spinal cord injury, and why are these important? (4 marks)

Model Answer:

a) Shock Differentiation (8 marks):

Neurogenic shock features (4 marks):

• Hypotension from loss of sympathetic vasomotor tone
• Bradycardia from unopposed vagal tone (cardioaccelerator fibres T1-T4 interrupted)
• Warm, dry skin (peripheral vasodilation)
• Normal or bounding pulses (wide pulse pressure)
• Preserved or brisk capillary refill
• Poor response to fluid resuscitation alone

Hypovolaemic shock features (4 marks):

• Tachycardia (primary compensatory mechanism)
• Cool, clammy skin (peripheral vasoconstriction)
• Delayed capillary refill
• Narrow pulse pressure
• Tachypnoea
• Good response to fluid resuscitation

This case suggests neurogenic shock:

• BP 82/50 with HR 48 (hypotension with relative bradycardia - classic)
• T4 injury level (above T6, above sympathetic outflow)
• Soft abdomen, normal chest X-ray (no obvious blood loss source)
• High-energy mechanism but neurogenic pattern
• Temperature 35.8°C (poikilothermia from sympathetic denervation)

b) Immediate Management (8 marks):

Airway and breathing (2 marks):

• Spinal precautions (hard collar, log roll precautions)
• High-flow oxygen; maintain SpO2 >95%
• Assess respiratory function (T4 level: some intercostal paralysis)
• Monitor for respiratory deterioration

Circulation (4 marks):

• Large-bore IV access × 2
• Fluid resuscitation: 500-1000 mL crystalloid bolus
• Arterial line for continuous BP monitoring
• Target MAP >80-90 mmHg
• Vasopressors: Noradrenaline infusion (first-line) titrated to MAP target
• Treat bradycardia: Atropine 0.6 mg IV if HR <50 or symptomatic
• Continue vasopressors to maintain target MAP

Spinal protection (1 mark):

• Maintain MILS (manual inline stabilisation)
• Strict spinal precautions
• Log roll technique for any movement

Monitoring and investigations (1 mark):

• Continuous ECG, SpO2, BP monitoring
• FBC, crossmatch 4 units, coagulation screen
• CT chest/abdomen/pelvis to rule out other injuries
• MRI spine (when stable) for cord compression assessment

c) Haemodynamic Targets (4 marks):

Targets:

• MAP >80-90 mmHg
• Avoid any episode of SBP <90 mmHg
• Maintain SpO2 >95%

Rationale:

• Spinal cord perfusion pressure = MAP - intrathecal pressure
• Injured cord extremely vulnerable to ischaemia
• Even single episode of hypotension (SBP <90) or hypoxia (SpO2 <90) doubles risk of poor neurological outcome
• Maintenance of perfusion is neuroprotective and may improve functional recovery
• Target maintained for first 7 days (critical window for secondary injury prevention)

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SAQ 2: Airway Management with Cervical Spine Injury (20 marks)

Question:

A 35-year-old man with a C5 fracture-dislocation requires urgent intubation for deteriorating respiratory function. He is currently in a hard cervical collar. There is concern about airway difficulty.

a) Describe the technique for rapid sequence induction with manual inline stabilisation (MILS). (10 marks)

b) What specific equipment and preparations are required? (4 marks)

c) What are the potential complications of intubation in the presence of cervical spine injury, and how can these be minimised? (6 marks)

Model Answer:

a) RSI with MILS Technique (10 marks):

Preparation (2 marks):

• Assistant designated for MILS (trained in technique)
• Patient supine, head neutral (no extension, flexion, rotation)
• Hard collar removed or front opened (maintain manual stabilisation)
• Standard RSI drugs drawn up; difficult airway equipment ready

Preoxygenation (1 mark):

• 3 minutes of 100% O2 or 8 vital capacity breaths
• Maintain MILS throughout

Positioning (1 mark):

• Assistant positions at head of bed
• Hands on either side of head
• Fingers on mastoid processes
• Thumbs on forehead or zygoma
• Maintain head in neutral position with no movement

Induction (1 mark):

• Propofol 2-3 mg/kg or ketamine 1-2 mg/kg (preferred if shock)
• Opioid (fentanyl 1-2 mcg/kg or alfentanil 10-20 mcg/kg)

Paralysis (1 mark):

• Rocuronium 1.2 mg/kg (RSI dose)
• Cricoid pressure applied (10N awake, 30N after loss of consciousness)

Intubation (2 marks):

• Video laryngoscopy (C-MAC, McGrath) - provides good view without neck movement
• Direct laryngoscopy if video unavailable
• No head extension; maintain neutral position
• MILS maintained throughout (assistant resists any movement forces)
• Bougie available for difficult views

Confirmation and securing (2 marks):

• Confirm placement (EtCO2 waveform, auscultation, chest movement)
• Cricoid pressure released
• Tube secured
• Hard collar replaced immediately
• MILS released once collar reapplied

b) Equipment and Preparations (4 marks):

Airway equipment:

• Video laryngoscope (essential)
• Multiple tube sizes (7.0, 7.5, 8.0)
• Bougie (essential rescue device)
• Supraglottic airway (LMA) as backup
• Surgical airway kit (cricothyroidotomy) - immediately available
• Difficult airway cart

Monitoring:

• Continuous SpO2, ECG, EtCO2 (essential for confirmation)
• NIBP or arterial line

Drugs:

• Induction agent (propofol, ketamine)
• Rocuronium (NO SUCCINYLCHOLINE in acute SCI)
• Vasopressors (phenylephrine, metaraminol) for hypotension
• Atropine for bradycardia

Team:

• Experienced intubator
• Assistant trained in MILS
• Additional assistant for cricoid pressure
• Entire team briefed on plan and backup strategies

c) Complications and Prevention (6 marks):

Primary complication: Secondary spinal cord injury (2 marks):

• Excessive neck movement during intubation
• Cord compression from displaced fracture
• Prevention: MILS throughout; video laryngoscopy; avoid extension

Airway complications (2 marks):

• Difficult intubation due to collar restriction
• Failed intubation
• Oesophageal intubation
• Prevention: Video laryngoscopy; bougie use; backup plans (LMA, surgical airway)

Cardiovascular complications (2 marks):

• Severe bradycardia/asystole from vagal response
• Hypotension from neurogenic shock + anaesthesia
• Prevention: Atropine 0.6 mg IV prior to intubation; vasopressors available; maintain intravascular volume

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Viva Scenario: Intraoperative Hypotension in Spinal Surgery

Scenario:

You are anaesthetising a patient with a C6 burst fracture undergoing posterior decompression and stabilisation in the prone position. Thirty minutes into the procedure, the blood pressure drops from 110/70 (MAP 83) to 70/45 (MAP 53). Heart rate is 55 bpm.

Examiner: "How would you manage this situation?"

Candidate Response:

"This is significant hypotension in a spinal cord injury patient where we must maintain MAP >80-90 mmHg to protect the injured cord. My immediate response would be:

Immediate assessment (30 seconds):

• Check the monitor - is this real? (Check trace, cuff position, arterial line if present)
• Check patient position - is there abdominal compression? (Prone position can cause IVC compression reducing venous return)
• Check for surgical causes - is there significant bleeding? (Ask surgeon)
• Check anaesthetic depth - is it too deep?

Immediate treatment:

1. Call for help - Alert surgeon and call anaesthetic colleague if available
2. Reduce anaesthetic - Turn down volatile/propofol; maintain only with opioid/remifentanil
3. Fluid bolus - 500-1000 mL crystalloid rapidly
4. Position - Check and relieve any abdominal compression in prone position; ensure adequate venous return
5. Vasopressors - Phenylephrine 100 mcg or metaraminol 0.5-1 mg IV immediately
6. If no response - Noradrenaline infusion (prepare and start)

Specific considerations for this patient:

• This is likely neurogenic shock combined with anaesthesia
• The bradycardia (55 bpm) suggests vagal predominance from high spinal injury
• I need atropine 0.6 mg IV immediately for the bradycardia
• Target MAP >80-90 mmHg - this is neuroprotective

Surgical considerations:

• Ask surgeon about bleeding
• If massive bleeding: activate massive transfusion protocol
• Consider cell salvage return
• May need to pack and hold if uncontrolled

Monitoring:

• If not already present, insert arterial line for continuous monitoring
• Check Hb if ongoing bleeding
• Check gases (lactate, base excess)

Documentation:

• Document timing and duration of hypotension
• This matters for outcomes - prolonged hypotension worsens neurological prognosis

Prevention going forward:

• Start noradrenaline infusion prophylactically
• Maintain light anaesthetic depth
• Ensure good venous return (check prone positioning)
• Continue fluid administration as needed
• Maintain MAP >80 consistently"

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