Pharmacologic prophylaxis when bleeding risk acceptable
Enoxaparin 30 mg subcutaneous every 12 hours
Renal adjustment if low creatinine clearance
Coordination with surgical timing
Unfractionated heparin alternative
5000 units subcutaneous every 8 hours
Supportive care
Bladder management
Urinary retention management
Indwelling catheter for acute retention
Strict urine output tracking
Bowel regimen
Constipation prevention
Polyethylene glycol 17 g PO daily
Senna 8.6 mg PO at bedtime
Temperature management
Normothermia target
Fever worsens secondary injury risk
Pressure injury prevention
Turning schedule
Pressure-relieving surfaces
Special Populations
Pregnancy
Maternal resuscitation priority
Left lateral uterine displacement if third trimester
Aortocaval compression reduction
Imaging risk balance
CT when clinically indicated for maternal stabilization
MRI without gadolinium when feasible for cord assessment
Fetal considerations
Fetal heart rate monitoring when viable gestation and maternal stabilized
Obstetric consultation early
Medication considerations
Avoid teratogenic agents when alternatives exist
Vasopressor choice based on maternal perfusion priority
Geriatric
Central cord syndrome risk higher
Hyperextension fall mechanism common
Degenerative stenosis predisposition
Anticoagulation and bleeding
Epidural hematoma risk increased
Lower threshold for MRI when deficits and CT negative
Frailty and respiratory reserve
Early airway planning
Conservative opioid dosing
Pediatrics
SCIWORA consideration
Neurologic deficit with normal radiographs or CT
MRI priority for ligament and cord injury
Immobilization fit issues
Age-appropriate collar sizing
Avoid excessive flexion from oversized collar
Weight-based dosing
Analgesics and sedatives per kg
Vasopressors per kg per minute
Nonaccidental trauma screen when appropriate
Inconsistent history
Associated injuries
Background
Epidemiology
Incidence and burden
Traumatic SCI relatively uncommon but high morbidity
High resource utilization
Long-term disability risk
Mechanism distribution
Motor vehicle collisions common
Falls increasing with aging population
Pathophysiology
Primary injury
Mechanical disruption
Contusion
Compression
Transection
Secondary injury cascade
Ischemia and hypoperfusion
Hypotension worsens cord perfusion
Inflammation and edema
Progressive swelling
Excitotoxicity and free radical injury
Neuronal death amplification
Shock physiology
Neurogenic shock mechanism
Sympathetic outflow interruption
Peripheral vasodilation
Relative or absolute bradycardia
Therapeutic Considerations
Perfusion augmentation rationale
Cord perfusion pressure dependency on MAP
Weak evidence for specific MAP targets
AO Spine and Praxis 2024 guideline indicates very low quality evidence for MAP range recommendation
Early decompression rationale
Time-dependent relief of cord compression
Improved neurologic recovery association with decompression within 24 hours
STASCIS cohort
Steroid controversy
Potential modest neurologic benefit signal in selected studies
Complication risk and weak guideline support
Shared decision approach where considered
Patient Discharge Instructions
Copy discharge instructions
Discharge eligibility limited to patients without SCI and without unstable injury
Normal strength and sensation
No bowel or bladder dysfunction
Imaging clearance plan complete
Activity and protection
Collar use instructions if prescribed
No contact sports or heavy lifting until cleared
Driving restrictions while in collar or on sedating meds
Pain control
Acetaminophen dosing schedule
NSAID avoidance if bleeding risk or anticoagulation
Return to emergency department now
New weakness
New numbness
New trouble walking
New bowel or bladder changes
New saddle anesthesia
Worsening neck or back pain with fever
Fainting or persistent dizziness
Follow-up
Spine clinic or neurosurgery follow-up timeframe
Primary care follow-up for pain and function reassessment
Physical therapy referral if indicated
References
Clinical guidelines and key sources
Hemodynamic management guideline for acute SCI
AO Spine and Praxis guideline 2024 MAP augmentation range 75 to 80 mmHg and not higher than 90 to 95 mmHg
Surgical timing guideline and evidence
Acute SCI guideline update 2024 recommendation for surgery within 24 hours when medically feasible
STASCIS study association of decompression prior to 24 hours with improved neurologic outcome
Imaging guidance
ACS TQIP spine injury best practices guideline MDCT as initial imaging modality and MRI for cord evaluation
Steroid guidance
CAEP position statement insufficient evidence for high-dose methylprednisolone as standard or guideline
AO Spine 2017 guideline methylprednisolone as optional within 8 hours with weak recommendation
Cervical imaging decision rules evidence
Systematic review summary of Canadian C-spine rule and NEXUS sensitivity and specificity ranges
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.