What is the recommended acute management for a patient with a cervical spinal cord injury presenting with unilateral lower‑limb weakness?

Treatment of Cervical Injury with Lower Limb Hemiparesis

Immediate Stabilization and Immobilization

For any patient with cervical spinal cord injury presenting with unilateral lower limb weakness, immediately immobilize the spine with a rigid cervical collar and manual in-line stabilization (MILS) to prevent worsening neurological deficit. 1, 2

• Apply the rigid cervical collar with head-neck-chest stabilization immediately upon patient contact 1, 2
• Maintain full spinal precautions (log-roll technique, flat positioning, C-spine holding) until complete spine evaluation by a surgeon 3
• Transport directly to a Level 1 trauma center within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention 2

Airway Management

If intubation is required, use rapid sequence induction with videolaryngoscopy (preferred over direct laryngoscopy) while maintaining MILS. 2

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining MILS 1, 2
• Use a gum elastic bougie or stylet as an adjunct to increase first-pass success 2, 4
• Avoid the Sellick maneuver to minimize cervical spine movement 1, 2, 4
• Critical timing consideration: Succinylcholine can be safely used only within the first 48 hours post-injury; after 48 hours, switch to rocuronium to avoid life-threatening hyperkalemia from denervation hypersensitivity 1, 2, 4

Hemodynamic Resuscitation

Maintain mean arterial pressure (MAP) at 85-90 mmHg using vasopressors combined with fluid resuscitation for at least 5-7 days post-injury to ensure adequate spinal cord perfusion and prevent secondary ischemic injury. 1, 5, 6, 3

• Use blood products rather than excessive crystalloids to avoid fluid overload 1
• Place an arterial line for continuous hemodynamic monitoring and accurate MAP measurement 1
• Avoid hypotension and hypoxia aggressively, as these worsen secondary neurological injury 5, 3

Intensive Care Unit Management

All patients with cervical spinal cord injury presenting with neurological deficits require ICU admission with continuous monitoring. 6, 3

• Perform hourly vital signs and neurological assessments 1
• Grade neurological status daily using the American Spinal Injury Association (ASIA) classification, with the first prognostic score at 72 hours post-injury 3
• Implement cardiac, hemodynamic, and respiratory monitoring 6

Imaging and Diagnostic Evaluation

Obtain computed tomography (CT) of the spine immediately, as it is superior to plain films and rarely misses fractures. 3

• Obtain magnetic resonance imaging (MRI) within 48-72 hours from time of injury to reliably assess spinal neural elements, soft tissues, and ligamentous structures 3
• High-resolution MRI evaluation is necessary to determine whether surgical intervention is indicated 7
• Maintain full spinal precautions until the spinal column has been fully evaluated by a spine surgeon 3

Surgical Consultation and Intervention

Immediate spine surgery consultation is mandatory to discuss operative versus nonoperative management. 3

Indications for surgical intervention include: 3

• Partial or progressive neurological deficit
• Spinal cord compression (particularly if focal and anterior) 6
• Instability of the spine preventing mobilization
• Correction of deformity
• Prevention of potential neurologic compromise

Early reduction of fracture-dislocation injuries is recommended. 6

• According to a 5-year retrospective study, patients presenting with acute limb weakness who underwent surgical intervention had statistically significant better outcomes (p = 0.035) compared to those managed conservatively 7
• Surgical decompression of the compressed spinal cord is recommended, particularly if compression is focal and anterior 6

Methylprednisolone Controversy

Methylprednisolone is NOT recommended for acute spinal cord injury. 8

• The 2013 AANS/CNS Guidelines downgraded methylprednisolone from Level I to Level III recommendation because primary outcome measures in NASCIS II and III trials were all negative; any positive results came from post hoc analysis rather than preplanned endpoints 8
• Professional neurosurgery societies in the United States have issued a Level 1 statement against steroid use in all spinal cord injury patients 3
• Despite decades of use as "standard of care," careful examination reveals methodological flaws in study design and data analysis that refute the original conclusions 8

Respiratory Management

For cervical injuries at C4 or higher, intubate immediately; for lower cervical injuries, evaluate respiratory mechanics on a case-by-case basis, recognizing that any spinal cord lesion above T11 will disrupt respiratory mechanics in the acute setting. 3

• Implement a comprehensive respiratory bundle including abdominal contention belt during spontaneous breathing periods, active physiotherapy with mechanically-assisted insufflation/exsufflation device (Cough-Assist), and aerosol therapy combining beta-2 mimetics and anticholinergics 2, 4
• For upper cervical injuries (C2-C5), perform early tracheostomy within 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times 2, 4, 5
• For lower cervical injuries (C6-C7), perform tracheostomy only after one or more tracheal extubation failures 4

Prevention of Secondary Complications

Implement venous thromboembolism prophylaxis immediately: 3

• IVC filters are recommended in bedbound patients
• Low-molecular weight heparins are superior to unfractionated heparin

Aggressive pressure ulcer prevention from the acute phase: 4

• Visual and tactile checks of all at-risk areas at least once daily
• Repositioning every 2-4 hours
• Early mobilization once the spine is stabilized

Bladder management: 4

• Intermittent catheterization (by patient or caregiver) is associated with lower incidence of urinary tract infections compared to indwelling catheters
• Self-intermittent urethral catheterization is the gold standard recommended by national and international neuro-urology societies
• Remove indwelling catheters as soon as the patient is medically stable

Temperature Management

Prevent hypothermia aggressively, as each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 2

• Remove all wet clothing immediately and cover the patient 2
• Increase ambient temperature in treatment area 2
• Apply forced air warming devices as first-line active warming 2
• Administer only warm intravenous fluids; never use cold IV fluids 2
• Target normothermia: core temperature 36-37°C 2

Pain Management

Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 2, 4

• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain 2, 4
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 2, 4

Early Rehabilitation

Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities. 2, 4

• Perform stretching for at least 20 minutes per zone 2, 4
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening) 2, 4
• Use proper bed and chair positioning to correct and prevent predictable deformities 2, 4
• Aggressive rehabilitation is crucial, as most neurologic recovery occurs in the first year following injury, though recovery is a several-year process 3

Common Pitfalls to Avoid

• Never delay spinal immobilization in suspected spinal cord injury cases, as this can lead to worsening neurological outcomes 4
• Never use succinylcholine after 48 hours post-injury due to risk of life-threatening hyperkalemia 1, 2, 4
• Never allow hypotension or hypoxia, as these cause secondary neurologic injury 5, 3
• Never miss occipitocervical dislocation on CT; maintain high clinical suspicion 3
• Never assume isolated spinal injury; there is high incidence of other bodily injuries (visceral, pelvic, long bone), so maintain low threshold for comprehensive trauma evaluation 3