For some time, many centers administered methylprednisolone in high dosage (bolus of 30 mg/kg followed by 5.4 mg/kg every hour), beginning within 8 h of the injury and continued for 23 h. This measure, according to the multicenter National Acute Spinal Cord Study (Bracken et al, 1990) resulted in a slight improvement in both motor and sensory function. The therapeutic value of this measure has since been questioned after reanalysis of the data (Nesathurai; Hurlbert) and other studies and it is no longer considered essential; in fact many centers now eschew its use. Hypotension, a greater risk for poor outcome, is treated with infusions of normal saline and may require the transient use of pressor agents. The use of hypothermia with cooling blankets or the infusion of cooled saline has undergone periods of popularity to protect spinal tissue but has not been validated.
Imaging examinations are undertaken to determine the alignment of vertebrae and pedicles, fracture of the pedicle or vertebral body, compression of the spinal cord or cauda equina as a consequence of malalignment, or bone debris in the spinal canal, and the presence of tissue damage within the cord. CT is favored to show bony injury and displacement and MRI is suited to displaying the cord injury but if neither is available, myelography with CT scanning is an alternative. Instability of the spinal elements can often be inferred from dislocations or from certain fractures of the pedicles, pars articularis, or transverse processes, but gentle flexion and extension of the injured areas must sometimes be undertaken and plain films obtained in each position to determine if there is instability of the spinal column.
If a cervical spinal cord injury is associated with vertebral dislocation, traction on the neck may be necessary to secure proper alignment and maintain immobilization. Depending on the nature of the injury, this can be accomplished by use of a halo brace, which provides the rigid external fixation of the cervical spine. This type of fixation is usually continued for 4 to 6 weeks, after which a rigid collar may be substituted. However, modern techniques of internal fixation and realignment of the spinal column (“instrumentation”) have been move often used is possible because they liberate the patient from an external and uncomfortable device. Concerning the early surgical management of spinal cord injury, there have traditionally been two perspectives. One, advocated reduction and alignment of the dislocated vertebrae by traction and immobilization until skeletal fixation is obtained, and then rehabilitation. The other approach, represented by Munro and later by Collins and Chehrazi, proposed early surgical decompression, correction of bony displacements, and removal of herniated disc tissue and intraand extramedullary hemorrhage; often the spine is fixed at the same time by a bone graft or other form of stabilization. These procedures are detailed in the review by Ropper and Ropper. The issue of acute decompressive surgery remains contentious to the present day. The MRI has altered these empirical approaches by allowing the early demonstration of hematomas and other sources of compression that may be amenable to surgery. With clinical evidence of a complete spinal cord lesion, most surgeons do not favor early surgery.