01Approach to the Critical Patient/attcp33

Initial stabilization

›Incomplete spinal cord syndromes stabilization priorities

›Airway and ventilation

›High cervical injury concern

›Early airway control threshold lower with progressive respiratory weakness

›Spine motion restriction

›Neutral alignment

›Avoid hypotension and hypoxia during transfers

›Hemodynamic targets

›MAP augmentation strategy

›MAP 85 to 90 mmHg for 7 days post acute SCI recommendation :contentReference[oaicite:0]{index=0}

›Time-critical consultation and transfer

›Neurosurgery or spine surgery early involvement

›Ongoing neurologic deficit or radiographic instability

Cord syndrome pattern recognition

›Incomplete cord syndrome pattern flags

›Central cord syndrome pattern

›Disproportionate upper extremity weakness

›Lower extremity relative sparing common :contentReference[oaicite:1]{index=1}

›Anterior cord syndrome pattern

›Motor weakness below lesion

›Pain and temperature loss with dorsal column sparing

›Brown-Sequard syndrome pattern

›Ipsilateral weakness and proprioception loss

›Contralateral pain and temperature loss :contentReference[oaicite:2]{index=2}

Secondary injury prevention

›Secondary injury prevention bundle

›Hypotension avoidance

02History/hx30

Mechanism and symptom timeline

›ABCs, oxygenation, ventilation targets

›Need for airway protection or impending fatigue

›Diaphragmatic weakness signs, NIF and VC when indicated

›Spinal motion restriction when traumatic mechanism or unstable exam

›Cervical collar fit and neutral positioning

›Log roll precautions and pressure injury prevention

›Hypotension avoidance, shock evaluation, resuscitation targets

›Consider neurogenic shock if hypotension with bradycardia and warm extremities

›Consider hemorrhagic shock with tachycardia, cool extremities, obvious trauma

›Baseline neuro exam before sedation or paralytics

›Document motor, sensory, reflexes, perianal findings

›Time stamp exam and repeat after interventions

›Emergent decompression triggers

›Progressive motor deficit

›Urinary retention or new incontinence

›Saddle anesthesia

›Rapidly evolving myelopathy

›Imaging pathway

›MRI spine when compressive lesion, cauda equina, conus, infection, tumor suspected

›CT spine when fracture or alignment concern, or MRI delay

›High risk specific etiologies

›Epidural abscess

›Start antibiotics after blood cultures if unstable or high suspicion

›Urgent spine consultation

›Epidural hematoma

›Reverse anticoagulation per agent

›Urgent spine consultation

03Physical Exam/exam56

Neurologic examination

›General and vital signs

›Fever

›Hypotension with bradycardia

›Respiratory compromise indicators

›Spine exam

›Midline tenderness

›Step off or deformity

›Range limitation and guarding

›Motor exam

›Strength by myotomes

›Shoulder abduction C5

›Elbow flexion C5 to C6

›Wrist extension C6

›Elbow extension C7

›Finger flexion C8

›Finger abduction T1

›Hip flexion L2

›Knee extension L3

›Ankle dorsiflexion L4

›Great toe extension L5

›Ankle plantarflexion S1

›Symmetry, proximal vs distal

›Tone, spasticity vs flaccidity

›Reflexes and UMN signs

›Hyperreflexia

›Clonus

›Babinski

04Differential Diagnosis/ddx20

Differential Diagnosis

›Compressive

›Fracture, dislocation

›Disc herniation

›Epidural hematoma

›Epidural abscess

›Tumor

›Vascular

›Anterior spinal artery infarct

›Spinal AVM

›Inflammatory demyelinating

›Transverse myelitis

›MS

›NMOSD

›MOGAD

›Mimics

›Guillain-Barre

›Brain stroke when no sensory level and cranial findings

›Metabolic posterior column disease

›B12 deficiency

›Copper deficiency

05Laboratory Tests/lt20

Baseline and resuscitation labs

›Laboratory evaluation considerations

›Trauma baseline

›CBC for hemorrhage concern

›Hemoglobin trend with ongoing instability

›Electrolytes and renal function

›Creatinine for contrast planning

›Hyperkalemia concern with crush injury

›Coagulation profile

›INR and aPTT with anticoagulant exposure

›Reversal planning linkage

›Type and screen

›High-energy trauma

›Anticipated operative pathway

Targeted labs by presentation

›Targeted labs for cord syndrome complications

›Venous blood gas

›Hypercapnia concern with hypoventilation

›Rising PCO2 threshold for ventilatory support

›Lactate

›Shock physiology marker

›Persistent elevation triggers broader hemorrhage search

06Diagnostic Tests/dt31

Scoring Systems

›Neurologic and functional scoring

›ASIA Impairment Scale documentation

›Baseline grade A to E

›Serial reassessment after resuscitation and imaging

›MAP augmentation candidacy framework

›Neurogenic shock suspicion

›Bradycardia with hypotension

Radiographs

›Initial imaging radiographs

›Cervical spine radiographs when CT unavailable

›Cross-table lateral screening

›Limited sensitivity compared with CT in trauma

›Chest radiograph

›Associated trauma screening

›Aspiration or pulmonary contusion context

MRI

›MRI spine indications

›Neurologic deficit with negative CT

›Ligamentous injury evaluation

›Central cord syndrome cord edema and hemorrhage characterization :contentReference[oaicite:9]{index=9}

›Suspected compressive lesion

›Epidural hematoma

›Surgical decompression planning

›Prognostication markers

›Cord hemorrhage vs edema

›Worse prognosis with hemorrhage in central cord syndrome :contentReference[oaicite:10]{index=10}

07Disposition/dispo17

Admission and transfer criteria

›Disposition pathway for cord syndromes

›ICU admission indications

›MAP augmentation need

›Vasopressor infusion requirement

›Step-down admission indications

›Stable hemodynamics with persistent deficit

›Ongoing neuro checks

›Transfer indications

›No spine surgery capability

›Need for urgent decompression or stabilization

Follow-up and rehabilitation planning

›Post-acute disposition planning

›Inpatient rehabilitation early involvement

›PT and OT consultation

›Hand function focus for central cord syndrome

›Bladder management planning

›Intermittent catheterization program

›Urology involvement as needed

08Treatment/t64

Immediate life-saving interventions

›Life-saving priorities for suspected acute SCI

›Oxygenation and ventilation support

›Assisted ventilation threshold if declining respiratory mechanics

›ICU airway planning

›Hemodynamic support

›Neurogenic shock pathway

›Vasopressor infusion for MAP target

›Norepinephrine infusion

›Initiate 0.05 mcg/kg/min

›Titrate every 2 to 5 minutes to MAP target 85 to 90 mmHg :contentReference[oaicite:11]{index=11}

›Typical range 0.05 to 0.5 mcg/kg/min

›Phenylephrine infusion

›Initiate 0.5 mcg/kg/min

›Titrate every 2 to 5 minutes to MAP target

›Typical range 0.5 to 5 mcg/kg/min

›Vasopressin adjunct

›Fixed dose 0.03 units/min

›Catecholamine sparing option

›Analgesia compatible with neuro reassessment

›Acetaminophen PO or IV

›Max 4 g per day

›Opioid titration if severe pain

›Fentanyl IV 25 to 50 mcg

›Repeat every 5 to 10 minutes as needed with monitoring

›Steroid therapy decision support

›MPSS 24-hour infusion option within 8 hours adult acute SCI

›Moderate evidence and weak recommendation in guideline :contentReference[oaicite:12]{index=12}

09Special Populations/sp29

Pregnancy

›Pregnancy considerations in acute SCI

›Maternal resuscitation prioritized

›Left uterine displacement after mid-pregnancy

›Aortocaval compression mitigation

›Imaging considerations

›MRI preferred when feasible

›CT when clinically necessary

›Medication safety

›Avoid teratogenic agents

›Obstetric consultation early

Geriatric

›Geriatric considerations

›Central cord syndrome risk with cervical spondylosis

›Hyperextension ground-level fall association :contentReference[oaicite:15]{index=15}

›Delirium risk

›Minimize sedatives

›Frequent reorientation and pain control balance

›Higher complication risk

›Pressure injury prevention

›Early mobilization planning with rehab

Pediatrics

›Pediatric considerations

›SCIWORA consideration

›MRI despite normal CT in neurologic deficit

›Ligamentous injury and cord edema detection

›Weight-based dosing

›Vasopressor and analgesic dosing by kg

10Background/b27

Epidemiology

›Epidemiology overview for incomplete SCI syndromes

›Central cord syndrome common incomplete SCI subtype

›Older adults with degenerative stenosis overrepresented :contentReference[oaicite:16]{index=16}

›Brown-Sequard syndrome uncommon

›Often penetrating or lateralized injury mechanisms :contentReference[oaicite:17]{index=17}

›Anterior cord syndrome uncommon

›Vascular compromise mechanism consideration

Pathophysiology

›Pathophysiology by syndrome

›Central cord syndrome mechanism

›Central cord gray matter and corticospinal tract involvement

›Upper limb motor fibers more medial vulnerability concept

›Anterior cord syndrome mechanism

›Anterior spinal artery territory injury

›Corticospinal and spinothalamic tract involvement with dorsal column sparing

›Brown-Sequard syndrome mechanism

›Hemisection pattern

›Ipsilateral corticospinal and dorsal column disruption with contralateral spinothalamic loss :contentReference[oaicite:18]{index=18}

Therapeutic Considerations

›Therapeutic rationale

›MAP augmentation rationale

›Spinal cord perfusion support and secondary injury mitigation

›Guideline recommendation MAP 85 to 90 mmHg for 7 days :contentReference[oaicite:19]{index=19}

›Steroid therapy controversy

›MPSS within 8 hours as optional therapy with weak recommendation :contentReference[oaicite:20]{index=20}

›Complication risk consideration

›Surgical decompression and stabilization

11Patient Discharge Instructions/pdi20

Copy discharge instructions

›Discharge instructions for incomplete cord syndromes after inpatient evaluation

›Return immediately

›New weakness

›New numbness

›New bowel or bladder dysfunction

›New saddle anesthesia

›Worsening neck or back pain

›Fever with spinal pain

›Activity restrictions

›Cervical collar adherence if prescribed

›No driving with collar unless cleared

›Skin care

›Collar skin checks twice daily

›Pressure sore warning signs

›Rehab plan adherence

›PT and OT appointments

›Hand therapy focus when indicated

›Medications

›Avoid sedating meds unless prescribed

›Opioid safety and constipation prevention

12References/r11

Clinical practice guidelines and reviews

›Guideline and evidence sources

›MAP management guideline recommendation

›AOSpine clinical practice guideline summary of MAP 85 to 90 mmHg for 7 days :contentReference[oaicite:21]{index=21}

›Steroid guideline

›AOSpine guideline on MPSS within 8 hours as optional weak recommendation :contentReference[oaicite:22]{index=22}

›CAEP position statement on steroids in acute SCI

›MPSS protocol as optional therapy with weak evidence :contentReference[oaicite:23]{index=23}

›Central cord syndrome reference

›NCBI Bookshelf StatPearls central cord syndrome overview :contentReference[oaicite:24]{index=24}

›Brown-Sequard syndrome reference

›NCBI Bookshelf StatPearls Brown-Sequard syndrome overview :contentReference[oaicite:25]{index=25}

Evidence & Review

Evidence & Review