Traumatic Spinal Cord Injury

Empowering Women's Health after Spinal Cord Injuries: A Timely and Practical Update

Women encompass about 20% of all the traumatic spinal cord injury (SCI) population and there is increased incidence and prevalence of women with SCIs. The most recent data estimate that approximately 40,000-45,000 women with SCI are living in the United States, increasing from previous years, with the most common cause still being motor vehicle collisions. Throughout their lifespan, women with SCI present with unique healthcare needs compare to the male population. Therefore we present a comprehensive summary to empower and equip all providers with awareness of these needs and recommendations of care.

Management of spinal trauma in pregnant patients: A systematic review of the literature

BACKGROUND

Despite the high incidence of spine trauma globally, traumatic spinal cord injury (tSCI) during pregnancy is considered a rare medical emergency. The literature on acute management of these patients is sparse compared with that of mothers with preexisting tSCI. This systematic review aims to evaluate management strategies for tSCI during pregnancy in improving neurologic, obstetric, and neonatal outcomes.

METHODS

A systematic review of PubMed/MEDLINE was performed without language restriction from inception until November 2, 2023 for patients who acquired tSCI during pregnancy. Excluded articles described postpartum trauma, trauma before pregnancy, or SCI of nontraumatic etiology such as neoplastic, vascular, hemorrhagic, or ischemic origin. Primary outcomes investigated were maternal American Spinal Injury Association (ASIA) grade, pregnancy termination, cesarean delivery, prematurity, and neonatal adverse events.

RESULTS

Data from 73 patients were extracted from 43 articles from 1955 to 2023. The mothers' median age was 24 years (interquartile range, 23-30 years), and the average gestational age at the time of injury was 21.1 ± 7.7 weeks. The thoracic spine was the most common segment affected (41.1%) and had the greatest proportion of complete tSCI (46.6%). Furthermore, ASIA score improvement was observed in 17 patients with 3 patients experiencing a 2-score improvement and 1 patient experiencing a 3-score improvement. Among these patients, 86% of ASIA B and 100% of ASIA C patients showed neurologic improvement, compared to only 17% of ASIA A patients. Surgically managed patients had a lower rate of neonatal adverse events than conservatively managed patients (11% vs. 34%).

CONCLUSION

Acute tSCI requires a coordinated effort between a multidisciplinary team with careful consideration. While maternal neurologic improvement was observed more often following a better ASIA grade on presentation, the presence of neonatal adverse events was less common in patients treated with surgery than in patients who were managed conservatively.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Trauma in Pregnancy

Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..

Spinal cord injury and pregnancy

Pregnancy in women with spinal cord injury is considered high risk because it may exacerbate many of their existing problems, including autonomic dysreflexia, spasms, decubitus ulcers, urinary tract infections and respiratory infections. Due to the relative rarity of spinal cord injury in the general obstetric population, clinicians often lack familiarity of these specific problems and the women themselves are usually more experienced in their own management than their obstetric team. However, studies have demonstrated that pregnancy outcomes are generally good with appropriate and experienced obstetric care. In this review, we examine the available literature and provide advice on pre-conception counselling and the antenatal, intrapartum and postnatal management of pregnant women with spinal cord injury.

Anesthetic management in a spinal cord-injured parturient woman with a left hip resection and secondary scoliosis: A case report

RATIONALE

Pregnancy after spinal cord injury, hip resection, leg amputation, and scoliosis is an uncommon event. Given the specific pathophysiological changes in this patient, an aesthetic management presented a particular challenge. The effects on the physiological changes associated with pregnancy, aesthetic methods, blood loss, autotransfusion from uterine contractions and thrombotic risk had to be considered.

PATIENT CONCERNS

A 25-year-old female earthquake survivor was admitted at 36.4 weeks of pregnancy for preterm labor. She had suffered from a spinal cord injury and complex trauma and had subsequently undergone left hip resection, bilateral amputations, and multiple surgical procedures during the previous 6 years. Additionally, she had developed severe scoliosis due to her weight-bearing posture.

DIAGNOSES

High amputation after earthquake injury; Scoliosis; Vulvar reconstruction; Intrauterine pregnancy (35.6 weeks) with a single live fetus with possible premature delivery.

INTERVENTIONS

We administered general anesthesia during a cesarean section for the parturient woman. Both the central venous pressure and pleth variability index were used to continuously evaluate intraoperative fluid management and blood loss.

OUTCOMES

Delivery and patient recovery were uneventful.

LESSONS

Anesthetic management of a pregnant woman with a spinal injury, scoliosis, left total leg and right below-knee amputations, and left hip resection requires considerable attention. Advances in medical technology have provided clinicians with insights into managing patients with this condition.

Amenorrhea, pregnancy, and pregnancy outcomes in women following spinal cord injury: a retrospective cross-sectional study

OBJECTIVE

To assess the prevalence of amenorrhea and pregnancy as well as pregnancy outcomes following spinal cord injury (SCI) in women.

METHODS

In this retrospective cross-sectional study, women with SCI were interviewed regarding demographic data, details about the timing and type of SCI they sustained, whether the neurologic deficit was complete or incomplete, and reproductive history. The study was initiated in September 2001 and lasted 3 years. Measures were compared for significance with the level of injury and extent of neurologic deficit using descriptive statistics, analysis of variance, and 2-tailed t tests.

RESULTS

Of 128 women, 53 (41.4%) had postinjury amenorrhea. The amenorrhea was transient in 50 of 53 women. SCI occurred at the mean (+/- SD) age of 27 +/- 9 years. In this group the lesions were at thoracic spine in 35 (66%), cervical spine in 16 (30%), and lumbar spine in 2 (4%). Neurologic deficit was complete in 31 women (58%) and incomplete in 22 (42%). The occurrence of amenorrhea was not influenced by the extent of neurologic deficit. Of 50 women who experienced transient amenorrhea, 10 (20%) became pregnant (6 livebirths, 4 elective terminations). Mean duration of amenorrhea was 7.96 +/- 10.9 months; there was no significant difference between mean duration of amenorrhea in women who got pregnant vs those who did not (6.4 +/- 3.8 months vs 15.8 +/- 30.8 months; P = .34). Pregnancy rate was significantly higher among those who sustained injury at a younger age (21.6 +/- 5.3 years vs 28.3 +/- 9.3 years; P = .033).

CONCLUSIONS

Level of injury did not influence duration of amenorrhea or occurrence of pregnancy. Women who experience transient amenorrhea after SCI may achieve successful pregnancies.