Go back


    Spinal Cord Injuries

    Cardinal Presentations / Presenting Problems, Critical Care / Resuscitation, Neurological, Orthopedic, Respiratory, Trauma

    Last Reviewed on May 31, 2023
    Read Disclaimer
    By Julian Marsden,Alexander Forrester

    First 5 Minutes

    Airway Management.

    • Early intubation for [1] [2]:
      • Injuries above C5 (diaphragm at risk)
      • Quadriplegia
      • Respiratory distress
      • Decreased LOC

    Assess for complete vs. incomplete spinal cord injury (SCI).

    For trauma patients with multiple injuries, spinal immobilization is adequate until other life-threatening conditions addressed [3].


    Complete Spinal Cord Injury

    • Signs/Symptoms:
      • Complete bilateral loss of innervation below level of injury [3].
      • No sensory or motor function is preserved in the sacral segments S4-5 [4].
    • Mechanism [5]:
      • Trauma
      • Vertebral disc herniation
      • Transverse myelitis
      • Neoplasm / abscess

    Incomplete Spinal Cord Syndromes 

    Diagnostic Process

    Clinical Examination [1] [2]:

    • Trauma assessment.
    • Neurological assessment with focus on:
      • Highest level of motor and sensory function.
      • Complete vs. incomplete patterns of SCI.
      • Sacral nerve involvement, perineal sensation, anal tone, bulbocavernosus reflex (BCR).
      • Identify presence of cord syndromes (as above).

    Spinal Immobilization precautions [1] [9].


    Neurogenic Shock [1] [11]:

    • Hypotension (SBP ≤ 100 mm Hg) not attributed to other injuries.
    • Bradycardia (HR ≤ 80/min) with hypotension not attributed to other injuries.
    • Judicious volume resuscitation (if needed) to avoid pulmonary or spinal cord edema.

    Spinal Shock [3]:

    • Refers only to neurological state.
    • Loss of sacral reflexes and bulbocavernosus reflex (BCR).

    Recommended Treatment

    • Airway and ventilation support as required [3] [1].
    • Assess and treat shock [1].
    • Treat neurogenic shock, including bradycardia [3][1].
      • Restore intravascular perfusion.
      • Administer vasopressor (recommendations)[12]:
        • Norepinephrine (first line) 0.05-1 mcg/kg/min.
        • Epinephrine 0.05-0.5 mcg/kg/min.
      • Administer vasopressin to augment effects of other vasopressors (if required) at dose 0.03-0.04 units/min[12].
      • Do not use phenylephrine, can result in reflex bradycardia[12].
    • Maintain mean arterial pressure > 85 mmHg (Reverse Trendelenburg position recommended) [3].
    • NPO if surgical intervention required.
    • Place indwelling urinary catheter unless contraindicated [1].
    • Place patient on pressure reducing mattress[1].
    • Log-roll (with spinal precautions) every 2 hours to avoid pressure sores [3][1].
    • Assess areas at risk of pressure sores or skin breakdown [1].

    Criteria For Hospital Admission

    • All suspected SCI patients should be admitted by the hospitals spinal service.

    Criteria For Transfer To Another Facility

    • Transfer SCI patients to regional trauma center with neurosurgical service as soon as possible.
    • Patient to be transported with full cervical and spinal immobilization protocols, consult with EMS transport team.

    Criteria For Close Observation And/or Consult

    • Consult Neurosurgery (or orthopedic spine service) for all suspected SCI patients.

    Criteria For Safe Discharge Home

    • Discharge to be done by admitting service.

    Quality Of Evidence?


    The majority of literature focuses on long-term management and treatment. Managing SCI patients in the acute setting mainly focuses on life-saving measures and supportive care until the patient can be seen by specialist services.


    Recommendations for vasopressor dosing comes from one source following a substantial internet and literature search.


    Related Information


    Reference List

    1. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine 2008, 31(4): 403-479. doi:10.1043/1079-0268-31.4.408.

    2. Nickson.Spinal Cord Syndromes. Life in the Fastlane 2020. https://litfl.com/spinal-cord-syndromes/.

    3. Eckert & Martin. Trauma: Spinal Cord Injury. The Surgical Clinics of North America 2017, 97(5): 1031-1045. Accessed 05 07, 2023. doi:10.1016/j.suc.2017.06.008

    4. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). American Spinal Injury Association 2019. https://www.asia-spinalinjury.org/wp-content/uploads/2019/10/ASIA-ISCOS-Worksheet_10.2019_PRINT-Page-1-2.pdf.

    5. Bennett et al. Spinal Cord Injuries. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560721/

    6. Ameer et al. Central Cord Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441932/

    7. Knipe et al. Artery of Adamkiewicz. Reference article, Radiopaedia.org (Accessed on 10 May 2023) https://doi.org/10.53347/rID-26389

    8. Shams & Arain. Brown Sequard Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538135/

    9. Stiell et al. The Canadian C-spine Rule for Radiography in Alert and Stable Trauma Patients. Journal of the American Medical Association 2001, 286(15): 1841-1848. doi:10.1001/jama.286.15.1841.

    10. Specialist Trauma Advisory Network (STAN). STAN Clinical Practice Guidelines Spine 2023. http://www.phsa.ca/health-professionals/clinical-resources/stan-clinical-practice-guidelines/spine

    11. Taylor et al. Presentation of Neurogenic Shock Within the Emergency Department. Emergency Medicine Journal 2017, 34(3): 157-162. doi:10.1136/emermed-2016-205780.

    12. Shah et al. Vasopressor and Inotrope Usage in Shock, Department of Surgical Education, Orlando Regional Medical Center. Surgical Critical Care Website 2019.


    COMMENTS (0)

    Add public comment…