Spinal cord injuryMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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529 items

☷ Legend

01Approach to the Critical Patient/attcp65

Immediate priorities

›Time-critical stabilization

›Airway compromise risk with high cervical injury

›If apneic or inadequate ventilation, intubation with in-line stabilization

›If impending respiratory failure, early intubation before transfer

›Spinal motion restriction

›Rigid collar plus long-axis support until imaging and clearance

›Neutral alignment

›Hemorrhagic shock exclusion before neurogenic shock label

›If hypotension with tachycardia, treat as hemorrhage until proven otherwise

›If hypotension with bradycardia and warm extremities, neurogenic shock pattern

›Hypoxia avoidance

›SpO2 target at least 94%

›Ventilation to normocapnia

›Hypotension avoidance

›SBP at least 90 mmHg

›MAP augmentation strategy per acute SCI guidance

Neurologic triage

›Neurologic severity snapshot

›Key time points

›Time of injury

›Time last normal neurologic function

›Rapid localization

›Highest abnormal dermatome

›Motor level

›High-risk syndromes

›Central cord syndrome

›Upper extremity weakness predominance

›Older patient with fall and hyperextension mechanism

›Anterior cord syndrome

›Motor loss with pain and temperature loss

›Dorsal column sparing pattern

›Brown-Sequard syndrome

›Ipsilateral motor and proprioception loss

›Contralateral pain and temperature loss

›Spinal shock vs neurogenic shock separation

›Spinal shock

›Transient areflexia below lesion

›Flaccid paralysis

›Neurogenic shock

›Hypotension from vasoplegia

›Bradycardia from unopposed vagal tone

Hemodynamic targets

›Perfusion goals

›MAP augmentation range

›MAP at least 75 to 80 mmHg

›Weak recommendation

›Very low quality evidence

›AO Spine and Praxis 2024 hemodynamic guideline

›MAP not higher than 90 to 95 mmHg

›Weak recommendation

›Very low quality evidence

›AO Spine and Praxis 2024 hemodynamic guideline

›Avoidance thresholds

›SBP less than 90 mmHg associated with worse outcomes in SCI cohorts

›Hypoxia and hypercapnia risk for secondary cord injury

Consultation and time goals

›Early specialty activation

›Neurosurgery or spine surgery early notification

›Any neurologic deficit

›Any cord compression concern

›Any unstable fracture or dislocation

›Trauma team coordination

›Polytrauma pathway parallel to SCI pathway

›Definitive care center transfer triggers

›Suspected cervical SCI

›Progressive neurologic deficit

›Neurogenic shock requiring vasopressors

›MRI need with surgical planning

02History/hx59

Mechanism and timeline

›Injury context

›Mechanism category

›Motor vehicle collision

›Fall

›Sports

›Diving

›Assault

›Penetrating trauma

›Force direction

›Hyperflexion

›Hyperextension

›Axial load

›Rotation

›Distraction

›Timeline

›Symptom onset immediately after injury

›Delayed neurologic symptoms

›Stepwise progression

›Prehospital course

›Hypotension episodes

›Hypoxia episodes

›Cardiac arrest

›Immobilization applied

Symptoms and function

›Neurologic symptoms

›Motor

›Weakness distribution

›Fatigability progression

›Gait inability

›Sensory

›Numbness

›Paresthesias

›Pain and temperature change

›Proprioception change

›Autonomic

›Urinary retention

›Bowel incontinence

›Priapism

›Temperature dysregulation

›Pain

›Neck pain

›Back pain

›Radicular pain

Risk modifiers and mimics

›Baseline vulnerability

›Cervical spondylosis

›Cervical spinal stenosis

›Ankylosing spondylitis

›Diffuse idiopathic skeletal hyperostosis

›Osteoporosis

›Anticoagulant and antiplatelet exposure

›Warfarin

›DOAC

›Clopidogrel

›Aspirin

›Nontraumatic cord compression mimics

›Infection

›Tumor

›Epidural hematoma

›Transverse myelitis

›Stroke

03Physical Exam/exam43

Primary survey focused findings

›High-risk signs

›Respiratory pattern

›Paradoxical abdominal breathing

›Shallow tidal volumes

›Hemodynamics

›Bradycardia with hypotension

›Warm dry skin with hypotension

›Priapism

›Suggestive of severe SCI

Neurologic exam structured

›ASIA style elements

›Motor key groups

›Upper extremity key muscles

›Lower extremity key muscles

›Sensory dermatomes

›Light touch level

›Pinprick level

›Sacral sparing

›Perianal sensation

›Voluntary anal contraction

›Reflexes

›Bulbocavernosus reflex

›Presence suggests end of spinal shock phase

›Deep tendon reflexes below lesion

›Syndromic patterns

›Central cord pattern

›Upper extremity weakness greater than lower extremity

›Anterior cord pattern

›Motor loss with pain and temperature loss

›Brown-Sequard pattern

›Hemisensory motor split

Spine and trauma exam

›Spine inspection and palpation

›Midline tenderness

›Step-off deformity

›Open wounds near spine

›Associated injury screen

›Head injury signs

›Chest wall injury signs

›Abdominal tenderness

›Long bone deformity

›Pitfalls

›Intoxication masking symptoms

›Distracting injury masking pain

›Elderly with central cord syndrome and minimal neck pain

04Differential Diagnosis/ddx25

Traumatic etiologies

›Spinal cord injury due to trauma (SNOMED CT concept)

›Cervical spinal cord injury (ICD-10 S14.10)

›Thoracic spinal cord injury (ICD-10 S24.10)

›Lumbar spinal cord injury (ICD-10 S34.10)

›Spinal fracture with canal compromise

›Burst fracture

›Fracture dislocation

›Odontoid fracture

›Spinal epidural hematoma

›Anticoagulation risk

›Progressive deficit pattern

›Spinal cord concussion

›Transient neurologic deficits with full recovery

Nontraumatic mimics in trauma context

›Acute ischemic stroke

›Hemiparesis without sensory level

›Peripheral nerve injury

›Plexopathy pattern

›Mononeuropathy pattern

›Acute inflammatory myelopathy

›Subacute progression

›Systemic inflammatory signs

›Cauda equina syndrome

›Saddle anesthesia

›Bladder dysfunction

›Lower motor neuron pattern

05Laboratory Tests/lt31

Baseline trauma labs

›Baseline evaluation

›Complete blood count for anemia or occult hemorrhage

›Hemoglobin trend for bleeding

›Leukocytosis nonspecific stress response

›Electrolytes and renal function

›Sodium mmol/l

›Potassium mmol/l

›Creatinine trend for contrast planning

›Coagulation profile for bleeding risk

›INR for warfarin exposure

›aPTT for heparin exposure

›Type and screen for anticipated transfusion

›High-energy mechanism

›Polytrauma

›Trauma perfusion markers

›Venous or arterial blood gas

›pH

›PaCO2 mmHg

›PaO2 mmHg

›Lactate mmol/l

›Lactate mmol/l interpretation

›Elevated lactate suggests shock physiology

›Isolated neurogenic shock may have lower lactate than hemorrhage

Targeted adjuncts

›Rhabdomyolysis risk labs

›Creatine kinase for prolonged immobilization or crush

›Rising trend triggers renal protection strategy

›Urinalysis for myoglobinuria

›Heme positive with few red cells

›Infection screening when atypical

›Blood cultures for fever or sepsis concern

›C-reactive protein for inflammatory context

06Diagnostic Tests/dt55

Scoring Systems

›Clinical decision rules for cervical imaging

›Canadian C-spine rule

›Sensitivity range 90% to 100% across studies

›Specificity range 1% to 77% across studies

›Systematic review summary

›NEXUS

›Sensitivity range 83% to 100% across studies

›Specificity range 13% to 46% across studies

›Systematic review summary

›Neurologic impairment grading

›ASIA impairment scale

›AIS A complete injury

›AIS B sensory incomplete

›AIS C motor incomplete with strength less than 3 in most key muscles

›AIS D motor incomplete with strength at least 3 in most key muscles

›AIS E normal

MRI

›Cord and soft tissue assessment

›MRI role

›Cord edema and hemorrhage characterization

›Ligamentous injury detection

›Disc herniation assessment

›Epidural hematoma assessment

›Timing for surgical planning

›MRI prior to surgery when feasible for decision support

›Weak recommendation

›Very low quality evidence

›AO Spine 2017 MRI guideline

›Contraindications and limitations

›Unstable patient with ongoing resuscitation

›Non-MRI compatible devices

›Limited availability delaying decompression

›Bony injury detection

›Initial imaging modality

›Multidetector CT initial imaging of cervical and thoracolumbar spine in trauma evaluation

›ACS TQIP spine injury best practices

›Technique considerations

›Thin slice acquisition for cervical spine

›Multiplanar reconstructions

›Interpretation pearls

›Not adequate alone for cord injury without bony injury

›Central cord syndrome may have normal CT

›Radiation considerations

›Pediatric dose minimization

›Avoid repeat imaging when prior CT available

Ultrasound (or US)

›Point-of-care ultrasound integration

›Shock differentiation

›Cardiac views for pericardial effusion and contractility

›IVC assessment as volume status adjunct

›Lung views for pneumothorax

›FAST exam in unstable trauma

›Free intraperitoneal fluid screen

›Hemopericardium screen

›Limitations

›Not a spinal imaging modality for cord evaluation

›Does not exclude hemorrhage in early or small volume bleeding

07Disposition/dispo22

Level of care

›Admission criteria

›Any objective neurologic deficit

›ICU or high-acuity monitored bed

›Neurogenic shock

›ICU with vasopressor capability

›High cervical injury or respiratory compromise risk

›ICU with ventilator readiness

›Unstable spine injury

›Spine surgery bed pathway

›Transfer criteria

›Need for emergent decompression or stabilization

›MRI for surgical planning not available locally

›Persistent MAP augmentation needs

›Time goals for definitive care

›Surgery within 24 hours when medically feasible

›Recommended by updated acute SCI guideline 2024

›Decompression prior to 24 hours associated with improved neurologic outcomes in STASCIS cohort

Clearance and discharge rare pathway

›Discharge only when no SCI and no unstable injury

›Normal neurologic exam

›Imaging clearance per rule and clinician judgment

›Reliable follow-up

›Pain controlled with oral regimen

08Treatment/t125

Spinal motion and secondary injury prevention

›Secondary injury mitigation bundle

›Spinal motion restriction maintained until clearance

›Neutral alignment

›Log-roll technique for turns

›Oxygenation

›SpO2 at least 94%

›Avoid hypercapnia

›Perfusion

›Avoid hypotension

›MAP augmentation plan

Hemodynamic support

›Neurogenic shock management

›Initial approach

›Crystalloid bolus if hypovolemia possible

›Reassess perfusion response

›Early vasopressor if persistent hypotension with bradycardia pattern

›Neurogenic shock physiology

›MAP augmentation targets

›MAP at least 75 to 80 mmHg

›Weak recommendation

›Very low quality evidence

›AO Spine and Praxis 2024 hemodynamic guideline

›MAP not higher than 90 to 95 mmHg

›Weak recommendation

›Very low quality evidence

›AO Spine and Praxis 2024 hemodynamic guideline

›Vasopressor selection

›Norepinephrine preferred for mixed vasoplegia and relative bradycardia pattern

›If persistent hypotension, start norepinephrine infusion

›Initial 0.05 micrograms per kg per minute

›Titrate every 2 to 5 minutes

›Usual range 0.05 to 1 microgram per kg per minute

›If severe vasoplegia, higher doses per institutional protocol

›Central line consideration

›Phenylephrine for pure vasoplegia with preserved heart rate

›If tachyarrhythmia limits norepinephrine, switch to phenylephrine

›Initial 0.2 micrograms per kg per minute

›Titrate every 2 to 5 minutes

›Usual range 0.2 to 3 micrograms per kg per minute

›Epinephrine for refractory shock with myocardial dysfunction

›If shock refractory, epinephrine infusion

›Initial 0.02 micrograms per kg per minute

›Titrate every 2 to 5 minutes

›Usual range 0.02 to 0.5 micrograms per kg per minute

›Bradycardia treatment

›Atropine for symptomatic bradycardia

›If symptomatic bradycardia, atropine 0.5 mg IV

›Repeat every 3 to 5 minutes

›Maximum 3 mg IV

›Transcutaneous pacing for refractory instability

›If unstable bradycardia refractory, initiate pacing

›Monitoring

›Arterial line for frequent MAP titration

›Continuous ECG monitoring

›Urine output trend

Airway and ventilation

›Ventilatory support for high cervical injury

›Intubation strategy

›Video laryngoscopy with in-line stabilization if available

›Avoid excessive neck movement

›Ventilation targets

›Normocapnia

›Avoid atelectasis with adequate PEEP

›Anticipatory transfer airway

›If marginal ventilation and long transfer, intubate before transport

Decompression and stabilization

›Surgical management pathway

›Early surgery window

›Recommended surgery within 24 hours when medically feasible

›Acute SCI guideline update 2024

›Decompression prior to 24 hours associated with improved neurologic outcome in STASCIS study

›Indications

›Ongoing cord compression

›Progressive neurologic deficit

›Unstable fracture or dislocation

›Epidural hematoma with deficit

›Preoperative imaging

›MRI prior to surgery when feasible

›Weak recommendation

›Very low quality evidence

›AO Spine 2017 MRI guideline

Pharmacologic therapy

›Steroids

›Methylprednisolone high-dose

›Not a treatment standard or guideline

›CAEP position statement

›Insufficient evidence for routine use

›Treatment option within 8 hours in some guidelines

›Weak recommendation

›Moderate quality evidence

›AO Spine 2017 guideline

›Adverse effects risk

›Infection risk

›GI bleeding risk

›Hyperglycemia risk

›Analgesia and sedation

›Multimodal pain control

›Acetaminophen 1 g PO or IV every 6 hours

›Maximum 4 g per day

›Ibuprofen 400 mg PO every 6 hours if no contraindication

›Renal and bleeding risk screening

›Opioid for severe pain

›Morphine 0.05 mg per kg IV

›Repeat every 10 minutes as needed

›Hydromorphone 0.01 mg per kg IV

›Repeat every 10 minutes as needed

›Venous thromboembolism prophylaxis

›Mechanical prophylaxis

›Intermittent pneumatic compression unless contraindicated

›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

09Special Populations/sp33

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

10Background/b36

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

11Patient Discharge Instructions/pdi23

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

12References/r12

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.