Review Question - QID 213124

The patient is presenting with a spinal cord injury from a C6 vertebral body fracture. The best treatment would be an early surgical decompression and stabilization.

Spinal cord injuries are due to direct trauma to the spinal cord with secondary injury believed to be the result of free radical production due to decreased perfusion. Several adjunct treatments for spinal cord injuries to reduce the effect of secondary injury have been utilized. Methylprednisolone has not been found to be effective in long term follow-up systematic reviews and hypothermia treatment has very weak animal and nearly no human data to support recommending. The best approach is early surgical decompression which limits the ischemic time of the cord.

Cappuccino et al. presented a case report of a professional football player that sustained a C3-4 fracture-dislocation with an ASIA A spinal cord injury that was promptly treated with systemic hypothermia. They reported that the player was surgically reduction and stabilization with a final improvement cooled to 92.5° F with a cooling catheter until post-op day 3 with final motor recovery to ASIA D. The authors concluded that it is uncertain how much hypothermia contributed to the patient's recovery, which further studies are needed to ascertain the benefit of hypothermia treatment.

Beauchamp et al. wrote a letter to the editor regarding the publication by Cappuccino et al. They stated that the claim of hypothermia benefiting the neurological recovery in the case report is questionable based on lack of scientific reporting of the initial neuro exam and past animal studies revealing minimal improvement in outcomes. They reaffirmed that future prospective studies are needed to draw definitive conclusions of the effectiveness of hypothermia treatment.

Kwon et al. reviewed the literature regarding hypothermia treatment for spinal cord injuries. Generally, the literature has evidence to support hypothermia treatment for cardiac arrest and protection against ischemic spinal cord injury during abdominal aortic aneurysm repair. Evidence to support efficacy in spinal cord injuries is limited, with conflicting data from animal studies and weak data from 40-year-old human studies. Further, hypothermia is associated with increased complications, including sepsis, pneumonia, coagulopathy, arrhythmias, and rebound hypertension. The authors concluded that recommending hypothermia treatment for spinal cord injuries is limited and further studies are needed to make further recommendations.

Figures A and B are the sagittal and axial CT slices of the cervical spine with a burst fracture at C6 and retropulsion of fragments with canal encroachment. Figures C and D are the sagittal T2 and STIR weighted MRI images of the cervical spine demonstrating the C6 vertebral body fracture with retropulsion and cord compression.

Incorrect answers:
Answer 1: Recent evidence has shown that IV steroids have limited efficacy and increased risk of complications. The current body of literature does not have conclusive evidence for the use of hypothermia treatment.
Answer 2: IV methylprednisolone has not been shown in recent literature to have any long-term benefit and is associated with increased complications, including gastrointestinal bleeding.
Answer 3: Systemic hypothermia has not been shown to be effective in human spinal cord injuries. Literature supports use in cardiac arrest and abdominal aortic aneurysm repair.
Answer 5: Regional hypothermia has not demonstrated any efficacy in human spinal cord injuries.