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30/11/2016 Acute traumatic spinal cord injury UpToDate
Official reprint from UpToDate® Wolters Kluwer Health
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Acute traumatic spinal cord injury
Authors: Robert R Hansebout, MD, FRCS(C), FACS, Edward Kachur, MD, FRCS(C)
Section Editors: Michael J Aminoff, MD, DSc, Maria E Moreira, MD
Deputy Editor: Janet L Wilterdink, MD поменять
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2016. | This topic last updated: Oct 20, 2014.
INTRODUCTION — Spinal cord injury has become epidemic in modern society. Despite advances made in
the understanding of the pathogenesis and improvements in early recognition and treatment, it remains a
devastating event, often producing severe and permanent disability. With a peak incidence in young adults,
traumatic spinal cord injury remains a costly problem for society; direct medical expenses accrued over the
lifetime of one patient range from 500,000 to 2 million US dollars [1].
This topic reviews acute traumatic spinal cord injury. The anatomy and clinical localization of spinal cord
disease, other diseases affecting the spinal cord, and the chronic complications of spinal cord injury are
discussed separately. (See "Anatomy and localization of spinal cord disorders" and "Disorders affecting the
spinal cord" and "Chronic complications of spinal cord injury and disease".)
Issues regarding injury to the vertebral column and ligaments are also discussed separately. (See "Spinal
column injuries in adults: Definitions, mechanisms, and radiographs" and "Evaluation and acute management
of cervical spinal column injuries in adults" and "Evaluation of thoracic and lumbar spinal column injury".)
EPIDEMIOLOGY — Most demographic and epidemiological data related to traumatic spinal cord injury
(TSCI) in the United States have been collected by the Model Spinal Cord Injury Care Systems and are
published by the National Spinal Cord Injury Statistical Center [2]. In the United States, the incidence of TSCI
in 2010 was about 40 per million persons per year, or about 12,400 annually [3], with approximately 250,000
living survivors of TSCI in the United States in July 2005. Similar figures are reported in Canada [4]. The
incidence in the USA is higher than in most other countries.
The causes of TSCI in the United States are [3]:
● Motor vehicle accidents: 48 percent
● Falls: 16 percent
● Violence (especially gunshot wounds): 12 percent
● Sports accidents: 10 percent
● Other: 14 percent
Statistics differ somewhat in other countries. In Canada and western Europe, TSCI due to violence is rare,
while in developing countries, violence is even more common [5,6]. Soldiers deployed in armed conflicts also
have a substantial risk of TSCI [7].
Risk factors for TSCI have been identified. Prior to 2000, the most frequent victim was a young male with a
median age of 22. Since that time, the average age has increased in the United States to 37 years in 2010
[3], presumably as a reflection of the aging population. Males continue to make up 77 to 80 percent of cases
[2,3,5,6,8]. Alcohol plays a role in at least 25 percent of TSCI [1,9]. Underlying spinal disease can make some
patients more susceptible to TSCI [1,10]. These conditions include:
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● Cervical spondylosis
● Atlantoaxial instability
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● Congenital conditions, eg, tethered cord
● Osteoporosis
● Spinal arthropathies, including ankylosing spondylitis or rheumatoid arthritis (see "Clinical manifestations
of ankylosing spondylitis in adults", section on 'Neurologic manifestations' and "Cervical subluxation in
rheumatoid arthritis").
PATHOPHYSIOLOGY — Most spinal cord injuries are produced in association with injury to the vertebral
column. These can include any one or more of the following [1]:
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● Fracture of one or more of the bony elements прокси
● Dislocation at one or more joints
● Tearing of ligament(s)
● Disruption and/or herniation of the intervertebral disc
The injury reflects the force and direction of the traumatic event and subsequent fall, which produces
pathologic flexion, rotation, extension, and/or compression of the spine, as well as the anatomic vulnerability
of individual spinal elements. Most vertebral injuries in adults involve both fracture and dislocation [1]. The
type of injury has implications for the stability of the spinal column and the risk for further spinal cord injury
(table 1). (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs".)
The mechanisms surrounding injury to the spinal cord itself are often discussed in terms of primary and
secondary injury. The primary injury refers to the immediate effect of trauma which includes forces of
compression, contusion, and shear injury to the spinal cord. In the absence of cord transection or frank
hemorrhage (both relatively rare in nonpenetrating injuries), the spinal cord may appear pathologically normal
immediately after trauma. Penetrating injuries (eg, knife and gunshot injuries) usually produce a complete or
partial transection of the spinal cord. An increasingly described phenomenon, however, is a spinal cord injury
following a gunshot wound that does not enter the spinal canal [11]. Presumably, the spinal cord injury in
these cases results from kinetic energy emitted by the bullet.
A secondary, progressive mechanism of cord injury usually follows, beginning within minutes and evolving
over several hours after injury [1,1215]. The processes propagating this phenomenon are complex and
incompletely understood [16,17]. Possible mechanisms include ischemia, hypoxia, inflammation, edema,
excitotoxicity, disturbances of ion homeostasis, and apoptosis [1,16,18]. The phenomenon of secondary injury
is sometimes clinically manifest by neurologic deterioration over the first 8 to 12 hours in patients who initially
present with an incomplete cord syndrome.
As a result of these secondary processes, spinal cord edema develops within hours of injury, becomes
maximal between the third and sixth day after injury, and begins to recede after the ninth day. This is gradually
replaced by a central hemorrhagic necrosis [19].
CLINICAL PRESENTATION — A patient with a cord injury typically has pain at the site of the spinal fracture.
This is not always a reliable feature to exclude traumatic spinal cord injury (TSCI). Patients with TSCI often
have associated brain and systemic injuries (eg, hemothorax, extremity fractures, intraabdominal injury) that
may limit the patient's ability to report localized pain [1,8]. These also complicate the initial evaluation and
management of patients with TSCI, and affect prognosis.
About half of TSCIs involve the cervical cord and as a result present with quadriparesis or quadriplegia [2,6].
The severity of cord syndromes are classified using the American Spinal Injury Association (ASIA) Scale
(table 2) [20]:
Complete cord injury — In a complete cord injury (ASIA grade A), there will be a rostral zone of spared
sensory levels (eg, the C5 and higher dermatomes spared in a C56 fracturedislocation), reduced sensation
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in the next caudal level, and no sensation in levels below, including none in the sacral segments, S4S5.
Similarly, there will be reduced muscle power in the level immediately below the injury, followed by complete
paralysis in more caudal myotomes. In the acute stage, reflexes are absent, there is no response to plantar
stimulation, and muscle tone is flaccid. A male with a complete TSCI may have priapism. The
bulbocavernosus reflex is usually absent. Urinary retention and bladder distension occur. (See "Anatomy and
localization of spinal cord disorders", section on 'Segmental syndrome'.)
Incomplete injury — In incomplete injuries (ASIA grades B through D), there are various degrees of motor
function in muscles controlled by levels of the spinal cord caudal to the injury. Sensation is also partially
preserved in dermatomes below the area of injury. Usually sensation is preserved to a greater extent than
motor function because the sensory tracts are located in more peripheral, less vulnerable areas of the cord.
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The bulbocavernosus reflex and anal sensation are often present. прокси
The relative incidence of incomplete versus complete spinal cord injury has increased over the last half
century [1]. This trend has been attributed to improved initial care and retrieval systems that emphasize the
importance of immobilization after injury (see 'Initial evaluation and treatment' below).
Central cord syndrome — An acute central cord syndrome, characterized by disproportionately greater
motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of
sensory loss below the level of injury, is described after relatively mild trauma in the setting of preexisting
cervical spondylosis [21,22]. (See "Cervical spondylotic myelopathy", section on 'Clinical presentation' and
"Cervical spondylotic myelopathy", section on 'Acute deterioration' and "Anatomy and localization of spinal
cord disorders", section on 'Central cord syndromes'.)
Anterior cord syndrome — Lesions affecting the anterior or ventral twothirds of the spinal cord, sparing the
dorsal columns, usually reflect injury to the anterior spinal artery. When this occurs in TSCI, it is believed that
this more often represents a direct injury to the anterior spinal cord by retropulsed disc or bone fragments
rather than primary disruption of the anterior spinal artery. (See "Anatomy and localization of spinal cord
disorders", section on 'Ventral (anterior) cord syndrome'.)
Transient paralysis and spinal shock — Immediately after a spinal cord injury, there may be a
physiological loss of all spinal cord function caudal to the level of the injury, with flaccid paralysis, anesthesia,
absent bowel and bladder control, and loss of reflex activity [23,24]. In males, especially those with a cervical
cord injury, priapism may develop. There may also be bradycardia and hypotension not due to causes other
than the spinal cord injury. This altered physiologic state may last several hours to several weeks and is
sometimes referred to as spinal shock.
We believe that this loss of function may be caused by the loss of potassium within the injured cells in the cord
and its accumulation within the extracellular space, causing reduced axonal transmission. As the potassium
levels normalize within the intracellular and extracellular spaces, this spinal shock wears off. Clinical
manifestations may normalize, but are more usually replaced by a spastic paresis reflecting more severe
morphologic injury to the spinal cord.
A transient paralysis with complete recovery is most often described in younger patients with athletic injuries.
These patients should undergo evaluation for underlying spinal disease before returning to play.
INITIAL EVALUATION AND TREATMENT
In the field — The primary assessment of a patient with trauma in the field follows the ABCD prioritization
scheme: Airway, Breathing, Circulation, Disability (neurologic status). If the patient has a head injury, is
unconscious or confused, or complains of spinal pain, weakness, and/or loss of sensation, then a traumatic
spinal injury should be assumed. Extreme care should be taken to allow as little movement of the spine as
possible to prevent more cord injury. Techniques to minimize spine movement include the use of logroll
movements and a backboard for transfer and placement of a rigid cervical collar [25]. This topic is discussed
in detail separately. (See "Prehospital care of the adult trauma patient".)
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In the emergency department — Management in the emergency department continues to prioritize
assessment and stabilization following the ABCD scheme. Lifethreatening priorities related to other injuries,
such as systemic bleeding, breathing difficulties, or a pneumothorax, can take precedence over the spinal
cord injury. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial
evaluation and management of blunt thoracic trauma in adults".)
● Vital signs including heart rate, blood pressure, respiratory status, and temperature require ongoing
monitoring. Capnography can provide a useful method of monitoring respiratory status in the emergency
department. (See "Carbon dioxide monitoring (capnography)".) поменять
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● The patient with a high cervical cord injury may breathe poorly and may require airway suction or
intubation. Respiratory mechanical support may be needed; about onethird of patients with cervical
injuries require intubation within the first 24 hours [26]. Rapidsequence intubation with inline spinal
immobilization is the preferred method when an airway is urgently required. If time is not an issue,
intubation over a flexible fiberoptic laryngoscope may be a safer, effective option. (See "Rapid sequence
intubation for adults outside the operating room".)
● Hypoxia in the face of cord injury can adversely affect neurologic outcome. Arterial oxygenation should be
monitored and supplemented as needed.
● Hypotension may occur due to blood loss from other injuries or due to blood pooling in the extremities
lacking sympathetic tone because of the disruption of the autonomic nervous system (neurogenic shock).
Prolonged hypoperfusion may adversely affect prognosis. Elevation of the legs, the headdependent
position, blood replacement, and/or vasoactive agents may be required.
● Until spinal injury has been ruled out (see 'Imaging' below), immobilization of the neck and body must be
maintained using cervical collar, straps, tape, and blocks. Athletic headgear should be left on.
● A neurologic examination should be completed as soon as possible to determine the level and severity of
the injury, both of which impact prognosis and treatment. (See "Anatomy and localization of spinal cord
disorders", section on 'Clinical localization'.) An evaluation of mental status and cranial nerve function
should be included, as many patients with TSCI have also suffered a head injury.
● The patient must be checked for bladder distension by palpation or ultrasound. A urinary catheter should
be inserted as soon as possible, if not done previously, to avoid harm due to bladder distension.
IMAGING — In many centers, a full set of cervical spine films are required on all trauma patients before a
cervical collar can be removed. Data from the National Emergency XRadiography Utilization Study (NEXUS)
allow this requirement to be modified [27]. Patients without neurologic deficits, who are alert and not confused,
who are not intoxicated, and who have no neck or midline pain or tenderness or other injury that is distracting
to the patient are unlikely to have a cervical spine injury. In the NEXUS study, these five criteria had a 99.8
percent negative predictive value for cervical spine injury (sensitivity 99 percent; specificity 12.9 percent) [27].
Similar results have been reported in other large series [28].
Patients who are not clinically evaluable for SCI because of obtundation or confusion should be assumed to
have a SCI until proven otherwise. In one metaanalysis of studies looking at such patients, the incidence of
spine injury was 7.5 percent; 42 percent of these had unstable injuries [29].
Plain xrays — Plain xrays provide a rapid assessment of alignment, fractures, and soft tissue swelling and
are, in general, the first method of assessment of traumatic spinal cord injury (TSCI). A complete set of
cervical xrays includes anteroposterior, lateral, and openmouth odontoid views. Oblique views may be
necessary if one suspects a lateral mass or facet injury or damage. All cervical vertebrae and the top of T1
must be visualized. In muscular males with a neck injury, pulling the shoulders down by pulling down on the
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wrists in a straight line and downward towards the feet may better allow visualization of the lower cervical
vertebrae. A swimmer's view should be performed if the lower cervical levels and the top of T1 are not
adequately visualized. While there are reports of missed cervical spine injury with plain films, it is rare to miss
significant injuries with adequate performance and interpretation of plain films of the occiput through the top of
T1 [30,31].
Neurologic signs and symptoms of cervical spine injury in the setting of normal plain xrays warrant further
imaging studies.
Patients who have pain in the thoracic or lumbar areas, especially with an appropriate neurologic deficit, also
require lateral, anteroposterior, and sometimes oblique plain xrays of either the thoracic spine, lumbar region,
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or both. Such spinal injuries, especially with a neurologic deficit, require further imaging. прокси
Computed tomography — Helical computed tomographic scanning (CT) with coronal and sagittal
reconstructions may replace plain films for screening assessment in centers in which it is readily available [32].
Prospective case series report a higher sensitivity for detecting spinal fracture when compared with plain x
rays; this is particularly true for cervical spine fracture [31,3337]. This study can also be done without moving
the patient out of the supine position. When head CT is required to rule out head injury, it may be most cost
and time efficient to use CT as the initial imaging study of the neck as well.
All abnormalities on screening plain films or CT are followed up with a more detailed CT scan of the area in
question, with fine, 2 mm cuts as needed. Areas not well visualized on plain films should be further imaged as
well. This test is very sensitive for defining bone fractures in the spine. Because CT is more sensitive than
plain films, patients who are suspected to have a spinal injury and have normal plain films should also
undergo CT. CT also has advantages over plain films in assessing the patency of the spinal canal. CT also
provides some assessment of the paravertebral soft tissues and perhaps of the spinal cord as well, but is
inferior in that regard to magnetic resonance imaging (MRI).
Myelography — When MRI is available, myelography is rarely if ever used, but remains an alternative in
combination with CT when MRI cannot be performed and spinal canal compromise is suspected.
Magnetic resonance imaging — The indications for MRI in the evaluation of acute TSCI have not been
defined [38,39].
The chief advantage of MRI is that it provides a detailed image of the spinal cord as well as spinal ligaments,
intervertebral discs, and paraspinal soft tissues that is superior to CT and is more sensitive for detecting
epidural hematoma [38,4043]. CT, however, is better than MRI in assessing bony structures. In the absence
of a cord transection or intramedullary hemorrhage, MRI is not perfectly sensitive to cord damage in the
earliest stages of TSCI. MRI has other disadvantages: it is contraindicated in the setting of a cardiac
pacemaker and metallic foreign bodies, life support equipment may be incompatible with the performance of
MRI, and the patient is enclosed during the study, which can pose some risk for monitoring vital signs and for
maintaining an airway. In some centers, MRI is not always available because of resource and personnel
issues.
Nonetheless, if the patient's clinical status permits, MRI can provide valuable information that complements
CT regarding the extent and mechanism of spinal cord injury, which can influence treatment and prognosis
[38,44,45]. MRI is also indicated in patients with negative CT scan who are suspected to have TSCI, in order
to detect occult ligamentous or disc injury or epidural hematoma [46]. In a systematic review of reported case
series, 5.8 percent of individuals with negative CT scan who went on to have an MRI were found to have a
traumatic spine injury [47]. While it has been suggested that nonalert patients require MRI in addition to CT to
exclude TSCI, one case series suggests that if obtunded patients are observed to have grossly normal motor
movement in all extremities, CT scan is sufficient in this population [48].
Spinal cord injury without radiographic abnormality — A category of TSCI called spinal cord injury
without radiographic abnormality (SCIWORA) originated prior to the use of MRI and referred to patients with a
myelopathy without evidence of traumatic vertebral injury on plain xrays or CT. Because MRI provides
superior imaging of the spinal cord, it can detect injuries to the cord that exist despite the apparent absence of
bony abnormalities [49]. Nevertheless, a number of patients with SCIWORA also have no detectable lesion on
MRI [50].
A common explanation for this phenomenon is transient ligamentous deformation with spontaneous reduction.
This is more often described in children who have weak paraspinal muscles, elastic spinal ligaments, and lax
soft tissues, which fail to protect the spinal cord from force, but has also been described in adults. (See
"Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Epidemiology' and
"Evaluation and acute management of cervical spinal column injuries in adults", section on 'Evaluation for
ligamentous injury and SCIWORA'.) поменять
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Other possible mechanisms for SCIWORA include radiographically occult intervertebral disc herniation,
epidural or intramedullary hemorrhage, fibrocartilaginous emboli from an intervertebral disc that has ruptured
into the radicular artery, and traumatic aortic dissection with spinal cord infarction. MRI is invaluable for the
diagnosis of these conditions.
Diagnostic evaluation of this phenomenon in the obtunded patient is discussed in detail separately. (See
"Evaluation and acute management of cervical spinal column injuries in adults", section on 'Evaluation for
ligamentous injury and SCIWORA'.)
MANAGEMENT
Medical care — Patients with traumatic spinal cord injury (TSCI) require intensive medical care and
continuous monitoring of vital signs, cardiac rhythm, arterial oxygenation, and neurologic signs in the intensive
care unit [51,52]. A number of systemic as well as neurologic complications are common in the first days and
weeks after TSCI, contribute substantively to prognosis, and are potentially avoidable or ameliorated with
early intervention [52].
The management of medical issues specific to spinal cord injury is discussed here. The general medical care
of the trauma patient is reviewed elsewhere. (See "Overview of inpatient management in the adult trauma
patient".)
Cardiovascular complications — Neurogenic shock refers to hypotension, usually with bradycardia,
attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance.
Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications.
An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal
cord and thereby limiting secondary ischemic injury. Albeit with little empiric supporting data, guidelines
currently recommend maintaining mean arterial pressures of at least 85 to 90 mmHg, using intravenous fluids,
transfusion, and pharmacologic vasopressors as needed [5255]. Maintenance of blood pressure
intraoperatively is also important. (See "Initial evaluation and management of shock in adult trauma".)
Patients with multiple injuries often receive large amounts of intravenous fluids for various reasons. Excess
fluids cause further cord swelling and increased damage. Therefore, fluid administration, urinary output, and
electrolyte levels must be carefully monitored.
Bradycardia may require external pacing or administration of atropine. This complication usually occurs in
severe, high cervical (C1 through C5) lesions in the first two weeks after TSCI [56,57].
Autonomic dysreflexia is usually a later complication of TSCI, but may appear in the hospital setting, requiring
acute management [58]. This phenomenon is characterized by episodic paroxysmal hypertension with
headache, bradycardia, flushing, and sweating. (See "Chronic complications of spinal cord injury and
disease", section on 'Autonomic dysreflexia'.)
Respiratory complications — Pulmonary complications, including respiratory failure, pulmonary edema,
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pneumonia, and pulmonary embolism, are the most frequent category of complications during acute
hospitalization after TSCI and contribute substantively to early morbidity and mortality [40,52,5961]. The
incidence of these complications is highest with higher cervical lesions (up to 84 percent), but they are also
common with thoracic lesions (65 percent).
Weakness of the diaphragm and chest wall muscles leads to impaired clearance of secretions, ineffective
cough, atelectasis, and hypoventilation. (See "Respiratory physiologic changes following spinal cord injury".)
Signs of impending respiratory failure, such as increased respiratory rate, declining forced vital capacity, rising
pCO2, or falling pO2, indicate urgent intubation and ventilation with positive pressure support [40,61,62].
Rapidsequence intubation with inline spinal immobilization is the preferred method of intubation when an
airway is urgently required. If time is not an issue, intubation over a flexible fiberoptic scope may be a safer,
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effective option. (See "Rapid sequence intubation for adults outside the operating room".) Tracheostomy is прокси
performed within 7 to 10 days, unless extubation is imminent.
With a goal of preventing atelectasis and pneumonia, chest physiotherapy should be instituted as soon as
possible; patients may also need frequent airway suctioning. (See "Respiratory complications in the adult
patient with chronic spinal cord injury", section on 'Respiratory insufficiency' and "Respiratory complications in
the adult patient with chronic spinal cord injury", section on 'Pulmonary infection'.)
Venous thromboembolism and pulmonary embolism — Deep venous thrombosis (DVT) is a common
complication of TSCI, occurring in 50 to 100 percent of untreated patients, with the greatest incidence
between 72 hours and 14 days [63,64]. The level and severity of TSCI does not clearly have an impact on the
risk for DVT; all patients should receive prophylactic treatment.
Lowmolecularweight (LMW) heparin is considered the treatment of choice for patients with TSCI [52,6567].
Combining this treatment with pneumatic compression stockings may provide additional benefits, but this has
not been studied. Use of either lowdose unfractionated heparin therapy or pneumatic compression stockings
as monotherapy is considered inadequate protection [68], but combination therapy with these two approaches
may be considered an alternative to LMW heparin. Inferior vena cava filters should be inserted for patients for
whom anticoagulation is contraindicated [52]. This topic is discussed separately. (See "Prevention of venous
thromboembolic disease in surgical patients", section on 'Group specific recommendations'.)
Other medical complications
● Pain control. After spinal injuries, patients usually require pain relief. (See "Pain control in the critically ill
adult patient".)

When using opiates with potential sedating properties, the need for pain control must be balanced with
the need for ongoing clinical assessment, particularly in patients with concomitant head injury. Pain is
often reduced by realignment and stabilization of the cervical fracture by surgery or external orthosis (see
'Decompression and stabilization' below).
● Pressure sores. Pressure sores are most common on the buttocks and heels and can develop quickly
(within hours) in immobilized patients [52]. Backboards should be used only to transport patients with
potentially unstable spinal injury and discontinued as soon as possible. After spinal stabilization, the
patient should be turned side to side (logrolled) every two to three hours to avoid pressure sores.
Rotating beds designed for the patient with spinal cord injury should be used in the interim, if available.
● Urinary catheterization. Initially, an indwelling urinary catheter must be used to avoid bladder distension.
Three or four days after injury, intermittent catheterization should be substituted, as this reduces the
incidence of bladder infections [52]. Urologic evaluation with regular followup is recommended for all
patients after SCI [69]. (See "Chronic complications of spinal cord injury and disease", section on 'Urinary
complications'.)
● Gastrointestinal stress ulceration. Patients with TSCIs, particularly those that affect the cervical cord, are
at high risk for stress ulceration [70]. Prophylaxis with proton pump inhibitors is recommended upon
admission for four weeks [60]. (See "Stress ulcer prophylaxis in the intensive care unit".)
● Paralytic ileus. Bowel motility may be silent for a few days to weeks after TSCI. Patients should be
monitored for bowel sounds and bowel emptying, and should not ingest food or liquid until motility is
restored [71].
● Temperature control. Patients with a cervical spinal cord injury may lack vasomotor control and cannot
sweat below the lesion. Their temperature may vary with the environment and need to be maintained.
● Functional recovery. Occupational and physiotherapy should be started as soon as possible.
Psychological counseling is also best offered to patients and relatives as early as possible.
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● Nutrition. Enteral or parenteral feeding should be provided within a few days after TSCI [52].
Glucocorticoids — Methylprednisolone is the only treatment that has been suggested in clinical trials to
improve neurologic outcomes in patients with acute, nonpenetrating TSCI. However, the evidence is limited,
and its use is debated [72].
Evidence — In animal experiments, administration of glucocorticoids after a spinal cord injury reduces
edema, prevents intracellular potassium depletion, and improves neurologic recovery [19,73]. The best results
were observed with administration within the first eight hours after injury [13]. Some authors believe that the
main effect of methylprednisolone on the spinal cord recovery was the inhibition of lipid peroxidation, and that
late administration of steroids may have little effect on lipid peroxidation and interfere with regenerative
processes [74].
Two blinded, randomized controlled trials have studied the efficacy of glucocorticoid therapy in patients with
acute TSCI:
● The National Acute Spinal Cord Injury Study (NASCIS) II compared methylprednisolone (30 mg/kg
intravenous [IV], followed by 5.4 mg/kg per hour over 23 more hours), naloxone, and placebo in 427
acute TSCI patients [74]. At one year, there was no significant difference in neurologic function among
treatment groups. However, within the subset of patients treated within eight hours, those who received
methylprednisolone had a modest improvement in motor recovery compared with those who received
placebo. Wound infections were somewhat more common in patients who received methylprednisolone.
● NASCIS III compared three treatment groups: methylprednisolone administered for 48 hours,
methylprednisolone administered for 24 hours, and tirilazad mesylate (a potent lipid peroxidation inhibitor)
administered for 48 hours in patients with acute complete or incomplete TSCI [75]. All 499 patients
received an initial IV bolus of 30 mg/kg methylprednisolone and were treated within eight hours of TSCI.
For patients treated within three hours, there was no difference in outcomes among treatment groups at
one year. For patients treated between three to eight hours, 48 hours of methylprednisolone was
associated with a greater motor but not functional recovery, compared with other treatments. Patients
who received the longer duration infusion of methylprednisolone had more severe sepsis and severe
pneumonia compared with the shorter duration of infusion; mortality was similar in all treatment groups
[76].
A metaanalysis of NASCIS II with two other small trials (one positive and one negative) concluded that
methylprednisolone administered within eight hours of spinal cord injury resulted in improved motor recovery
[77].
Many clinicians have raised concern about complications of high dose glucocorticoid therapy, particularly
infections, in this setting. However, in the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), a
nonrandomized prospective cohort study, patients who suffered a complication were less likely to have
received glucocorticoid therapy on presentation than those who did not receive glucocorticoids [78]. In
addition, glucocorticoid therapy was associated with better neurologic outcomes regardless of the timing of
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While administration of glucocorticoids has become a standard treatment in many centers for patients with
acute TSCI [13], other experts are unconvinced [7982]. The beneficial effect of methylprednisolone
compared with placebo is seen as linked to a post hoc subgroup analysis in one study (NASCIS II), although
the investigators assert that early versus late treatment was an a priori hypothesis [80,83]. The cutoff times of
eight hours and three hours have been seen as arbitrary. Actual gain in motor scores seen in treated patients
can be interpreted as marginal. Some clinicians also believe that the potential adverse effects of
glucocorticoid administration have been underemphasized, particularly with the longer, 48hour administration
[79]. Most of the recommendations for no use of steroids are based on metaanalyses of previous reports
rather than on carefully controlled case series. There are, however, still neurosurgeons who administer поменять
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glucocorticoids to patients with an acute TSCI in view of previous animal research, especially since so little
can be done after this devastating injury.
Society guidelines — In 2013, based upon the available evidence, the American Association of
Neurological Surgeons and Congress of Neurological Surgeons stated that the use of glucocorticoids in acute
spinal cord injury is not recommended [84]. Position statements from the Canadian Association of Emergency
Physicians, and endorsed by the American Academy of Emergency Medicine, concur that treatment with
glucocorticoids is a treatment option and not a treatment standard [8587]. A Consortium for Spinal Cord
Medicine similarly concluded that "no clinical evidence exists to definitely recommend" the use of steroid
therapy [88]. In a 2006 survey of 305 neurosurgeons in the United States, 91 percent used glucocorticoids to
treat patients with nonpenetrating TSCI within eight hours of injury [82]. In contrast, a 2008 survey of
Canadian spine surgeons found that 76 percent did not prescribe glucocorticoids even while 76 percent had
reported administering methylprednisolone five years earlier [89].
Contraindications — Methylprednisolone has been associated with increased mortality in patients with
moderate to severe traumatic brain injury, and should not be administered to patients with TSCI and
associated moderate to severe TBI. (See "Management of acute severe traumatic brain injury", section on
'Glucocorticoids'.)
There are little data regarding the use of methylprednisolone with penetrating injuries. However, retrospective
studies suggest a higher rate of complications and no evidence of benefit [9092]. Most clinicians do not use
glucocorticoids for penetrating spinal cord injury.
Similarly, the results of NASCIS II and III studies may not apply to individuals with multisystem trauma, in
whom the risk of complications is likely higher than those with isolated spinal cord injury. Patients with
multisystem trauma were not specifically excluded from these trials, but may have been somewhat under
represented [76].
Decompression and stabilization — There are currently no standards regarding the role, timing, and
method of vertebral decompression in acute spinal cord injury [18]. Options include closed reduction using
traction and open surgical procedures. Radiologic features of spinal column injuries that are associated with
instability are presented in the table and are discussed separately (table 1). (See "Evaluation and acute
management of cervical spinal column injuries in adults" and "Evaluation of thoracic and lumbar spinal column
injury".)
Closed reduction — For cervical spine fracture with subluxation, closed reduction methods are a
treatment option. Thoracic and lumbar fractures do not respond to closed treatment methods.
This technique involves use of longitudinal traction using skull tongs or a halo headpiece. An initial weight of 5
to 15 pounds is applied; this is increased in fivepound increments, taking lateral xrays after each increment
is applied. The more rostral the dislocation, the less weight is used, usually about three to five pounds per
vertebral level. While weights up to 70 pounds are sometimes used, we suggest that after 35 pounds is
applied, patients be observed for at least an hour with repeat cervical spine xrays before the weight is
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cautiously increased further. Administration of a muscle relaxant or analgesic, such as diazepam or
meperidine, may help facilitate reduction.
Closed reduction may obviate surgery and promote neurologic improvement in some cases. Early reports
raised a concern that closed reduction in the setting of associated disc disruption and/or herniation has the
potential to exacerbate neurologic injury [93,94]. However, more recent prospective case series and a
systemic literature review suggest that this is probably not an important concern [9597]. In one series of 82
patients with cervical subluxation injuries, early rapid closed reduction was achieved in 98 percent, failing in
just two patients who required open surgical reduction [95]. The average time to achieve reduction was two
hours. Disc herniation and disruption were noted in 46 percent of postprocedure MRIs, but these did not
affect neurologic outcome.
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Surgery — Goals for surgical intervention in TSCI include stabilization of the spine, as well as reduction of
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dislocations and decompression of neural elements. There are no evidencebased guidelines regarding the
indications for or timing of surgery in TSCI [98]. In general, the specific management of cervical, thoracic, and
lumbar spine and spinal cord injuries depends to a large extent on a surgeon's personal experience and
practice norms in his or her center.
Indications — Indications for cervical spine surgery include significant cord compression with
neurologic deficits, especially those that are progressive, that are not amenable or do not respond to closed
reduction, or an unstable vertebral fracture or dislocation (table 1) [99]. Neurologically intact patients are
treated nonoperatively unless there is instability of the vertebral column. Most penetrating injuries require
surgical exploration to ensure that there are no foreign bodies imbedded in the tissue, and also to clean the
wound to prevent infection.
Defining surgical indications for closed thoracolumbar fractures has been somewhat more challenging, in part
because of difficulties defining spinal instability in these lesions. The Denis anatomicbased classification
based on a threecolumn model of spinal stability has somewhat limited clinical utility, as it does not clearly
accommodate all fracture types [100]. The Thoracolumbar Injury Severity Score has been proposed as an
alternative and uses a scoring system of three variables: the morphology of the injury, the integrity of the
posterior ligamentous complex, and the neurologic status of the patient (table 3) [101,102]. A total score of
less than four indicates a nonoperative injury; more than four, an operative injury; and four, an injury that is
operative at the surgeon's discretion. This algorithm has good intrarater and interrater reliability [103]. The
clinical efficacy of the algorithm itself remains to be prospectively evaluated.
Timing — The timing of surgical intervention is not defined and remains somewhat controversial [52].
Animal and some clinical studies suggest that early relief of spinal cord compression (within eight hours) leads
to a better neurologic outcome [18,104108]. However, older clinical reports suggested that early surgery led
to increased medical complications and poorer neurologic outcome, perhaps as a reflection of the vulnerability
of the acutely injured cord [109111]. More contemporary studies suggest that medical complication rates are
actually lower in patients who undergo early surgery, which allows for earlier mobilization and reduced length
of intensive care unit and hospital stay [112118].
One trial randomly assigned patients with complete or incomplete cervical TSCI to "early" (within 72 hours) or
"late" (more than five days) surgery and found no significant difference in the improvement of American Spinal
Injury Association (ASIA) grade or motor scores between the two groups [119]. A systematic review analyzed
published data regarding the timing of surgical decompression and concluded that early decompression,
within 72 hours, can be performed safely, without increasing systemic complications [104]. An impact on
neurologic outcome of early versus late surgery could not be determined from the available data. It may be
that 72 hours represents too late a cutoff time to define early surgery.
A metaanalysis that included patients from nonrandomized case series compared neurologic outcomes in
1687 patients with TSCI [120]. Those who received decompressive surgery within 24 hours had a better
outcome than either those treated conservatively or with delayed surgery. An analysis of homogeneity
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suggested that the data in this analysis was not reliable for patients with complete TSCI. The subsequently
published, nonrandomized, Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), compared
outcomes in those who received surgery within 24 hours (mean 14.2 hours) after injury to those whose
surgery was performed later (mean 48.3 hours) [121]. After adjusting for glucocorticoid treatment and injury
severity, there was a 2.8 fold higher odds in improved outcomes with early surgery. Mortality and
complications were similar in both patient groups.
Most clinicians consider deteriorating neurologic function after incomplete TSCI to be an indication to perform
surgery as early as possible if there are no contraindications (eg, hemorrhagic shock, blood dyscrasias).
The role of early surgery with a complete TSCI (ASIA grade A) is debatable given the overall poor prognosis
of these patients. While many surgeons operate to stabilize the spine, most defer the surgery to a less
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immediate time frame. However, many series show that a small percentage of these patients can improve, прокси
and it is possible that potential benefits for surgical decompression in this group may be maximized by earlier
rather than later surgery [53].
In a 2010 survey of spine surgeons, the majority (>80 percent of 971 respondents) reported a preference to
decompress the spine within 24 hours of TSCI [122]. Shorter time intervals (within 6 to 12 hours) are
preferred by the majority of surgeons for certain lesions, including incomplete cervical TSCI. A 2011 report of
an expert panel concurred with this approach [108].
Technical aspects — Not all surgical cases require decompression, and not all decompression cases
require instrumentation and fusion. The technical aspects of the surgery are tailored to the individual case.
In the case of a cervical fracture with a cervical spinal cord injury, the anesthesiologist usually performs a
fiberoptic intubation, done with the patient awake to reduce any further cord injury that potentially could be
caused by a regular intubation with neck movement and extension [123]. There is a risk for regurgitation and
aspiration with the patient in a headdependent position. Anesthetists are also usually involved in the
postoperative care of patients with TSCI [124].
Investigational treatments — A number of strategies are being investigated as potential treatments of acute
TSCI [16], but are not currently recommended [117]. Among others, these include:
● Spinal cord cooling [125127].
● Electrical stimulation [128].
● Autologous macrophages [129].
● Thyrotropinreleasing hormone [130].
● Neuroprotective agents (eg, riluzole, minocycline, basic fibroblast growth factor) [131].
● Neuronal growth factors [18].
Gangliosides are endogenous compounds in cell membranes, which are believed to have the potential to
protect nerve cells and promote axon growth. GM1 ganglioside treatment has been studied in two
randomized clinical trials. In one study, 34 patients were treated within 72 hours of TSCI for 18 to 32 days.
Treatment was associated with a higher likelihood of improving by at least two grades compared with placebo
[132]. However, in a followup trial of 797 patients with TSCI, there was no difference between placebo and
treated patients in a similar outcome measure [133]. Gangliosides are not recommended in the treatment of
TSCI [134].
PROGNOSIS — Early death rates after admission for traumatic spinal cord injury (TSCI) range from 4 to 20
percent [1,4,135138]. The patient's age, spinal cord level of injury, and neurologic grade predict survival.
Severe systemic injuries, traumatic brain injury, and medical comorbidity also increase mortality [137139].
Compared with spinal cord injuries in the thoracic cord or lower, patients with C1 to C3 injuries have a 6.6fold
increased risk of death, C4 to C5 injuries a 2.5 increased risk, and C6 to C8 a 1.5 increased risk [59].
Survivors of TSCI have a reduced life expectancy as well. (See "Chronic complications of spinal cord injury
and disease", section on 'Life expectancy'.)
Rates of motor score improvements are also related to the initial severity and level of injury of injury [140142].
The greatest degrees of improvement are seen in those with incomplete injury and also in those without
significant comorbidities or medical complications, such as infection [143,144]. Among patients with complete
TSCI (ASIA grade A), 10 to 15 percent improve, 3 percent to ASIA grade D [40]; less than 10 percent will be
ambulatory at one year [142]. Among patients with an initial ASIA grade B, 54 percent recover to grade C or
D, and 40 percent regain some ambulatory ability. Independent ambulation is possible for 62 and 97 percent
of patients with an initial ASIA grade of C and D, respectively. Most recovery in patients with incomplete TSCI
takes place in the first six months [145]. The general expectations for functional recovery based on motor level
are outlined in the Table (table 4) [146]. These assume an uncomplicated, complete SCI (ASIA grade A)
followed by appropriate rehabilitation interventions in a healthy, motivated individual.
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Patients with TSCI are at risk for a number of medical complications. These are discussed in detail separately.
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(See "Chronic complications of spinal cord injury and disease".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”
and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easyto
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
indepth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Paraplegia and quadriplegia (The Basics)")
SUMMARY AND RECOMMENDATIONS — Traumatic spinal cord injury (TSCI) is a problem that largely
affects young male adults as a consequence of motor vehicle accidents, falls, or violence. (See 'Epidemiology'
above.)
● Most TSCI occurs with injury to the vertebral column, producing mechanical compression or distortion of
the spinal cord with secondary injuries resulting from ischemic, inflammatory, and other mechanisms.
(See 'Pathophysiology' above.)
● Most TSCI is associated with injury to brain, limbs, and/or viscera, which can obscure its presentation.
(See 'Clinical presentation' above.)
● The neurologic injury produced by TSCI is classified according to the spinal cord level and the severity of
neurologic deficits (table 2). Half of TSCIs involve the cervical spinal cord and produce quadriparesis or
quadriplegia. (See 'Clinical presentation' above.)
● The initial evaluation and management of patients with TSCI in the field and emergency department
focuses on the ABCDs (airway, breathing, circulation, and disability), evaluating the extent of traumatic
injuries, and immobilizing the potentially injured spinal column. (See 'Initial evaluation and treatment'
above.)
● Patients with suspected TSCI because of neck pain or neurologic deficits and all trauma victims with
impaired alertness or potentially distracting systemic injuries require continued immobilization until
imaging studies exclude an unstable spine injury. (See 'Imaging' above.)
• All patients with potential TSCI should receive complete spinal imaging with plain xrays or helical
computed tomography (CT) scan.
• Patients with abnormal screening imaging studies or in whom TSCI remains strongly suspect despite
normal screening imaging studies should have followup CT scanning with fine cuts through the
region of interest (based on localized pain and/or neurologic signs).
• Magnetic resonance imaging (MRI) can be useful to further define the extent of TSCI and should be
performed on stable patients with TSCI as well as on patients suspected to have TSCI (because of
neck pain or neurologic deficits) despite a normal CT scan.
● Patients with TSCI require urgent neurosurgical consultation to manage efforts at decompression and
stabilization. (See 'Decompression and stabilization' above.)
● There is limited evidence that glucocorticoid therapy improves neurologic outcomes in patients with acute
TSCI, and such therapy is not endorsed by major society guidelines. (See 'Glucocorticoids' above.)
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• Because the neurologic benefits are uncertain, we recommend NOT using glucocorticoid therapy in
cases when there are clear risks associated with such therapy, such as penetrating injury,
multisystem trauma, moderate to severe traumatic brain injury, and other comorbid conditions
associated with risk of complications from glucocorticoid therapy (Grade 1B). (See
'Contraindications' above.)
• In other patients who present within eight hours of isolated, nonpenetrating TSCI, administration of
intravenous (IV) methylprednisolone can be considered with knowledge of potential risks and
uncertain benefits. The standard dose is 30 mg/kg IV bolus, followed by an infusion of 5.4 mg/kg per
hour for 23 hours. (See 'Evidence' above.)
● Patients with acute TSCI require admission to an intensive care unit for monitoring and treatment of
potential acute, lifethreatening complications, including cardiovascular instability and respiratory failure.
Patients with TSCI should receive prophylaxis to protect against deep venous thrombosis and pulmonary
embolism (Grade 1A). (See 'Medical care' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 4819 Version 21.0
GRAPHICS
Classification of spinal injuries
Mechanisms of spinal injury Stability
Flexion
Anterior wedge fracture Stable
Flexion teardrop fracture Extremely unstable поменять

прокси
Clay shoveler's fracture Stable
Subluxation Potentially unstable
Bilateral facet dislocation Always unstable
Atlantooccipital dislocation Unstable
Anterior atlantoaxial dislocation with or without fracture Unstable
Odontoid fracture with lateral displacement Unstable
Fracture of transverse process Stable
Flexionrotation
Unilateral facet dislocation Stable
Rotary atlantoaxial dislocation Unstable
Extension
Posterior neural arch fracture (C1) Unstable
Hangman's fracture (C2) Unstable
Extension teardrop fracture Usually stable in flexion; unstable in extension
Posterior atlantoaxial dislocation with or without fracture Unstable
Vertical compression
Burst fracture of vertebral body Stable
Jefferson fracture (C1) Extremely unstable
Isolated fractures of articular pillar and vertebral body Stable
Reproduced with permission from: Marx, JA, Hockberber, RS, Walls, RM. Rosen's emergency medicine: concepts and
clinical practice, 6th ed, Mosby, Inc., St. Louis 2006. Copyright ©2006 Elsevier.
Graphic 52922 Version 1.0
American Spinal Injury Association (ASIA) impairment scale (AIS)
American Spinal Injury Association Scale (ASIA)
A Complete cord injury. No motor or sensory function is preserved in the sacral segments S45.
B Sensory incomplete. Sensory but not motor function is preserved below the neurologic level and
includes the sacral segmments (light touch or pin prick at S45 or deep anal pressure) AND no motor
function is preserved more than three levels below the motor level on either side of the body.
C Motor incomplete. Motor function is preserved below the neurologic level and more than half of key
поменять
muscle functions below the neurologic level of injury have a muscle grade <3 (Grades 0 to 2). прокси
D Motor incomplete. Motor function is preserved below the neurologic level and at least half (half or
more) of key muscle functions below the neurologic level of injury have a muscle grade ≥3.
E Normal. Sensation and motor function are graded as normal in all segments and the patient had prior
deficits.
Muscle function is graded using the International Standards for Neurologic Classification of Spinal Cord Injury.
For an individual to receive a grade of C or D (ie, motor incomplete status), he or she must have either (1)
voluntary anal sphincter contraction or (2) sacral sensory sparing with sparing of motor function more than three
levels below the motor level for that side of the body.
Patients without an initial spinal cord injury do not receive an AIS grade.
American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised
2013; Atlanta, GA. Reprinted 2013. Used with permission. Copyright © 2013 American Spinal Injury Association.
American Spinal Injury Association (ASIA) impairment scale (AIS) remained unchanged in the International Standards
for Neurological Classification of Spinal Cord Injury (ISNCSCI) (Updated 2015). To download a PDF version of the
ISNCSCI worksheet: http://asiaspinalinjury.org/wp
content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf.
The thoracolumbar spinal cord injury classification severity score
Score
1. Morphology type
Compression:
Compression fracture 1
Burst fracture 1
поменять
Translational/rotational 3 прокси
Distraction 4
2. Neurologic involvement
Intact 0
Nerve root 2
Conus medullaris:
Incomplete 3
Complete 2
Cauda equina 3
3. Posterior ligament complex
Intact 0
Injury suspected/indeterminate 2
Injured 3
Data from: Vaccaro AR, Zeiller SC, Hulbert RJ, et al. The thoracolumbar injury severity score: a proposed treatment
algorithm. J Spinal Disord Tech 2005; 18:209.
Expected functional recovery following complete spinal cord injury by spinal
level
Spinal
Activities of daily living Mobility/locomotion
level
C1C4 Feeding possible with balanced forearm orthoses Operate power chair with tongue, chin, or breath

Computer access by tongue, breath, voice controller
controls
поменять
Weight shifts with power tilt and recline chair прокси
Mouth stick use
C5 Drink from cup, feed with static splints and setup Propel chair with hand rim projections short
Oral/facial hygiene, writing, typing with equipment distances on smooth surfaces
Dressing upper body possible Power chair with hand controller
Sidetoside weight shifts
C6 Feed, dress upper body with setup Bed mobility with equipment
Dressing lower body possible Level surface transfers with assistance
Forward weight shifts Propel indoors with coated hand rims
C7 Independent feeding, dressing, bathing with Independent bed mobility, level surface transfers
adaptive equipment, builtup utensils Wheelchair use outdoors (power chair for school
or work)
C8 Independent in feeding, dressing, bathing Propel chair, including curbs and wheelies
Bowel and bladder care with setup Wheelchairtocar transfers
T1 Independent in all selfcare Transfer from floor to wheelchair
T2L1 Stand with braces for exercise
L2 Potential for swingto gait with long leg braces
indoors
Use of forearm crutches
L3 Potential for community ambulation
Potential for ambulation with short leg braces
L4S1 Potential for ambulation without assistive devices
Reproduced with permission from: Physical Medicine and Rehabilitation, 2nd ed, Randall Braddom (ED), WB Saunders
Company, 2000. Copyright © 2000 Elsevier.
Contributor Disclosures
Robert R Hansebout, MD, FRCS(C), FACS Nothing to disclose Edward Kachur, MD, FRCS(C) Nothing to
disclose Michael J Aminoff, MD, DSc Equity Ownership/Stock Options: Trust, which is independently
managed by a financial company. The portfolio may include medical or drug companies. Maria E Moreira,
MD Nothing to disclose Janet L Wilterdink, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multilevel review process, and through requirements for references to beпоменять
прокси
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

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