OPINION STATEMENT: Most treatment options for acute traumatic spinal cord injury (SCI) are directed at minimizing progression of the initial injury and preventing secondary injury. Failure to adhere to certain guiding principles can be detrimental to the long-term neurologic and functional outcome of these patients. Therapy for the hyperacute phase of traumatic SCI focuses on stabilizing vital signs and follows the Advanced Trauma Life Support (ATLS) algorithm for ensuring stability of airway, breathing and circulation, and disability (neurologic evaluation)-with spinal stabilization-and exposure. Spinal stabilization, with cervical collars and long backboards, is used to prevent movement of a potentially unstable spinal column injury to prevent further injury to the spinal cord and nerve roots, especially during prehospital transport. Surgery to stabilize the spine is undertaken after life-threatening injuries (hemorrhage, evacuation of intracranial hemorrhage, acute vascular compromise) are addressed. Intensive care unit (ICU) admission is to be considered for all patients with high SCI or hemodynamic instability, as well as those with other injuries that independently warrant ICU admission. Avoidance of hypotension and hypoxia may minimize secondary neurologic injury. Elevating the mean arterial pressure above 85 mmHg for 7 days should be considered, to allow for spinal cord perfusion. The use of intravenous steroids (methylprednisolone) is controversial. Early tracheostomy in patients with lesions above C5 may reduce the number of ventilator days and the incidence of ventilator-associated pneumonia. Select patients may benefit from the placement of a diaphragmatic pacer. Aggressive measures, including CoughAssist and Intermittent Positive Pressure Breaths (IPPB), should be used to maintain lung recruitment and aid in the mobilization of secretions. Some patients with high SCI who are dependent on mechanical ventilation can eventually be liberated from the ventilator with consistent efforts from both the patient and the caregiver, along with some patience. Intermittent catheterization by the patient or a caregiver may be associated with a lower incidence of urinary tract infections, compared with an in-dwelling urinary catheter. Early mobilization of patients and a multidisciplinary approach (including respiratory therapists, nutritional experts, physical therapists, and occupational therapists) can streamline care and may improve long-term outcomes. A number of investigational drugs and therapies offer hope of neurologic recovery for some patients.

Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

This study evaluated the impact of a 4-wk mandatory neurology-physical medicine and rehabilitation advanced-core clerkship for fourth-year medical students. The combined clerkship encouraged an interdisciplinary and function-based approach to the management of common neurologic, musculoskeletal, and pain complaints. Seventy-three fourth-year medical students participated in the rotation over 1 yr. A survey assessing knowledge and skill set topics was conducted before and after the clerkship. Qualitative feedback regarding the rotation was provided by the students and analyzed. Significant gaps in knowledge and skill sets were identified before the clerkship and successfully addressed by combined teaching modalities. These data demonstrate that an integrated neurology-physical medicine and rehabilitation clerkship can improve students’ confidence in multiple domains. Integrating physical medicine and rehabilitation into core clerkships at other medical schools may provide an avenue to address curriculum gaps.