What is the recommended assessment and initial management for a patient with suspected spinal cord injury?

Assessment and Initial Management of Suspected Spinal Cord Injury

Immediate Prehospital Stabilization

Apply manual in-line stabilization (MILS) immediately, secure a rigid cervical collar, and transport the patient on a rigid backboard with vacuum mattress while maintaining head-neck-chest alignment throughout. 1

• Keep the patient in place at the scene if no immediate life-threatening danger exists rather than moving them prematurely 1
• Transport directly to a Level 1 trauma center within the first hours after injury, as this reduces morbidity and mortality, enables earlier definitive surgery, shortens ICU length of stay, and improves neurological outcomes 1, 2
• Assume all patients with significant mechanism of injury have an unstable spine until proven otherwise 3

Hemodynamic Management (Critical for Preventing Secondary Injury)

Maintain systolic blood pressure >110 mmHg before definitive injury assessment to reduce mortality, then target mean arterial pressure ≥70 mmHg continuously for the first 7 days post-injury. 1, 2

• Admission hypotension (SBP <110 mmHg) independently predicts increased mortality after spinal cord injury 1
• Cumulative time with MAP <65–70 mmHg correlates inversely with neurological improvement 1
• Use aggressive vasopressor support, especially for neurogenic shock from injuries above T6 1
• Recognize that patients typically spend approximately 25% of the first week below MAP targets, requiring vigilant monitoring 1

Airway Management

For suspected high cervical cord injury (C4 or higher), perform immediate endotracheal intubation using rapid-sequence induction with direct laryngoscopy. 1

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening while preserving posterior spinal stabilization 1, 2
• Use a gum-elastic bougie to increase first-attempt intubation success 1
• Maintain the cervical spine in neutral axis and avoid cricoid pressure (Sellick maneuver) during airway manipulation 1
• Critical safety window: Succinylcholine may be used safely only within the first 48 hours after spinal cord injury; after 48 hours it causes life-threatening hyperkalemia due to denervation hypersensitivity 1

Diagnostic Imaging Protocol

Obtain a non-contrast CT scan of the entire spine as the initial imaging study for any patient with clinical criteria indicating possible spinal cord injury. 1, 2

• CT is the gold-standard modality for detecting spinal fractures and outperforms plain radiographs 1
• CT readily identifies fractures, subluxations, and dislocations requiring immediate spinal stabilization 1
• When chest, abdomen, or pelvis CT is already performed, reconstruct thoracic and lumbar spine images from that data to provide effective evaluation while sparing additional radiation 1

Perform non-contrast MRI of the spine within 48–72 hours of injury for all patients with confirmed or suspected spinal cord injury. 1

• MRI complements CT by allowing detailed assessment of soft-tissue structures, ligamentous integrity, intervertebral discs, and the spinal cord itself 1
• MRI protocols should include T2-weighted and gradient-echo sequences to characterize cord compression by disc material, bone fragments, or hematoma 1
• MRI is mandatory for patients presenting with neurological deficits, suspected cord compression, or suspected ligamentous instability 1

Neurological Assessment

Perform standardized neurological examination using the ASIA (American Spinal Injury Association) Impairment Scale to document:

• Motor function in key muscle groups bilaterally 4
• Sensory function including light touch and pinprick in all dermatomes 4
• Sacral sparing (perianal sensation, voluntary anal contraction, great toe flexion) to distinguish complete from incomplete injuries 4
• Document Frankel grade (A through E) to establish baseline and track recovery 5

Respiratory Management

For high cervical injuries (C2–C5), perform early tracheostomy within the first 7 days to accelerate ventilator weaning and reduce ICU length of stay. 1

• For lower cervical injuries (C6–C7), defer tracheostomy until after one or more failed extubation attempts 1
• Apply comprehensive respiratory bundle including abdominal contention belt during spontaneous breathing, active physiotherapy with mechanically-assisted insufflation/exsufflation devices, and aerosol therapy combining β2-agonists and anticholinergics 1
• Identify respiratory complications immediately, as they are life-threatening in high cervical injuries 6

Prevention of Secondary Complications

Initiate aggressive secondary-prevention measures immediately after spinal stabilization: early mobilization, daily visual and tactile skin checks, and patient repositioning every 2–4 hours. 1

• Use high-level pressure-relief supports such as air-loss or dynamic mattresses to reduce pressure-ulcer risk 1
• Begin intermittent urinary catheterization as soon as daily urine output is adequate; self-intermittent urethral catheterization is the gold standard 1
• Remove indwelling urinary catheters promptly once the patient is medically stable 1, 6

Pain Management

Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic agents (e.g., ketamine), and opioids during the acute phase. 1, 2

• For chronic neuropathic pain developing later, prescribe oral gabapentinoids for duration exceeding six months 1, 2
• Add tricyclic antidepressants or selective serotonin reuptake inhibitors when monotherapy with gabapentinoids is insufficient 1

What NOT to Do: Critical Contraindications

Do NOT administer high-dose steroids for acute spinal cord injury. 1, 7

• U.S. neurosurgical societies have issued a Level 1 statement against steroid use because of methodological flaws in the NASCIS II/III trials and significant systemic adverse effects 1, 7
• No other evidence-based pathomechanistically targeted pharmacologic therapies are currently available 1

Early Rehabilitation

Begin rehabilitation immediately after spinal stabilization to maximize neurological recovery. 1, 6

• Physical exercise promotes central nervous system regeneration through up-regulation of neurotrophic factors 1, 6
• Perform stretching techniques for at least 20 minutes per body zone during each session 1, 2
• For patients with incomplete injuries, initiate gravity-assisted ambulation or body-weight-supported treadmill training 1

Common Pitfalls to Avoid

• Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates 2
• Never use succinylcholine after 48 hours post-injury, as it can cause life-threatening hyperkalemia 1
• Never allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk 2
• Never delay immobilization in suspected spinal cord injury, as this worsens neurological outcomes 1
• Never neglect early rehabilitation, as this leads to preventable complications and poorer functional outcomes 1
• Never delay surgical decompression beyond 24 hours when spinal cord injury is confirmed, as this worsens neurological outcomes 2