Suspected acute spinal cord injury
Trauma with new weakness, numbness or paralysis, or a high-risk mechanism. Adult pathway.
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Orthopedic SurgeryEmergency
Acute Spinal Cord Injury Management (ATLS/ASIA)
Acute Spinal Cord Injury Management (ATLS/ASIA): Suspected acute spinal cord injury → Primary survey with spinal motion restriction → Hypotensive or MAP...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Primary survey with spinal motion restriction
Stop catastrophic external bleeding first, then airway with the spine in line (ATLS 11: xABCDE). Ankylosing spondylitis or DISH: keep the pre-injury position; do not force neutral.
- Airway: manual in-line stabilisation during intubation
- Injury at or above C5: high risk of respiratory failure; consider early intubation
- Laryngoscopy or suction can cause severe bradycardia: have atropine ready
- Circulation: in trauma, hypotension is bleeding until proven otherwise
- Pregnant, about 20 weeks or more: tilt the whole board about 20 degrees to the left, or push the uterus to the left by hand
- Penetrating trauma: routine spinal immobilisation is not recommended (linked to higher mortality); never let it delay resuscitation
- Disability: GCS, pupils, brief motor and sensory check
- Log-roll with a team; take off the hard board as soon as possible (pressure injury)
- Ankylosing spondylitis or DISH: pad and support in pre-injury position; a rigid collar can cause harm
03Decision Hypotensive or MAP below target?
SBP below 90 mmHg or MAP below 75-80 mmHg. In trauma, treat as haemorrhage until proven otherwise, even with bradycardia.
- If Yes
- Yes: SBP below 90 or MAP below 75-80 mmHg (any heart rate)
04Action Hypotensive or MAP below target: exclude and control bleeding first
Any heart rate. A cervical or high thoracic cord injury, or a beta-blocker, can mask the tachycardia of bleeding.
- eFAST, chest X-ray and pelvic X-ray; CT when safe
- Control bleeding; blood products per massive transfusion protocol
- Do not use permissive hypotension: it is contraindicated with spinal cord injury or TBI
- Polytrauma is common with spinal cord injury
05Action Bleeding excluded, still hypotensive: treat neurogenic shock
Loss of sympathetic tone, usually injury at T6 or above: hypotension, often bradycardia, warm and dry skin.
- Adults: MAP at least 75-80 mmHg, not above 90-95 mmHg. Children: no validated target; get paediatric critical care advice
- IV fluid to normovolaemia; avoid fluid overload
- Vasopressor to reach the MAP target; noradrenaline also supports heart rate
- Bradycardia: avoid phenylephrine (pure alpha agonist; can slow the heart further)
- Symptomatic bradycardia: atropine; pacing if no response
06Action Neurological exam (ISNCSCI)
Document early and repeat. It is the baseline to detect deterioration.
- Motor: 10 key muscles each side (C5-T1, L2-S1), graded 0-5
- Sensory: light touch and pinprick, 28 dermatomes each side (C2 to S4-5)
- Sacral sparing: S4-5 sensation, deep anal pressure, voluntary anal contraction
- Find the neurological level of injury (NLI)
- Obtunded or intoxicated: exam is limited; treat as spinal cord injury and repeat later
07Action ASIA Impairment Scale (AIS) grade
Classify completeness of injury from the ISNCSCI exam.
- A: Complete. No sensory or motor function in S4-5
- B: Sensory incomplete. Sensation below NLI including S4-5; no motor function more than 3 levels below the motor level
- C: Motor incomplete (voluntary anal contraction, or sensory incomplete with motor function more than 3 levels below the motor level). Fewer than half of key muscles below the NLI grade 3 or more
- D: Motor incomplete (as for C). Half or more of key muscles below the NLI grade 3 or more
- E: Normal sensory and motor function in a patient who had deficits
08Action CT whole spine, then MRI
CT the whole spine: injuries at a second level occur in about 10% of high-energy blunt trauma.
- CT: fracture, alignment and stability
- MRI when feasible, before surgery: cord compression, disc, haematoma, ligaments
- Ankylosing spondylitis or DISH: fractures are often unstable and easy to miss; low threshold for MRI
- CT angiography if vertebral artery injury is suspected
- Call the spinal surgical team early
09Warning Methylprednisolone: not routine; spinal surgeon decision only
AO Spine 2017: weak recommendations only. Head injury (GCS 14 or less): do not give; CRASH trial showed higher mortality.
- Do not start more than 8 h after injury; never give a 48-h infusion
- Within 8 h: a 24-h high-dose infusion is an option only, not a standard
- Discuss benefits and risks with the patient or family
10Warning Suxamethonium: avoid after the first 24-48 h from injury
Recent paraplegia or tetraplegia: risk of severe hyperkalaemia and cardiac arrest.
- Applies to later intubation, surgery and ICU procedures
- Use a non-depolarising neuromuscular blocker
- The risk lasts months after injury
11Decision Surgical lesion (cord compression or unstable injury)?
Spinal surgeon decides with CT and MRI.
- If Yes
12Action Surgical lesion: decompress and stabilise within 24 h of injury
AO Spine/Praxis 2024: offer early surgery (within 24 h of injury) to adults with acute SCI, any level or AIS grade.
- Operate within 24 h of injury when feasible
- Reduce, decompress and stabilise; approach per injury pattern
- On anticoagulants: plan urgent reversal before surgery
- Keep the MAP target during anaesthesia
- High-risk surgery: intraoperative neurophysiological monitoring
13Action ICU or high-dependency care
Adults: keep MAP at least 75-80 mmHg, not above 90-95 mmHg, for 3-7 days. Children: paediatric ICU advice.
- Watch breathing and cough; injury at or above C5: consider early intubation
- VTE: LMWH or low-dose heparin within 72 h of injury if bleeding risk allows
- Active bleeding, new intracranial or spinal haematoma: mechanical prophylaxis until the team agrees
- Injury at T6 or above: autonomic dysreflexia (sudden high BP, headache). Sit up if the spine allows, loosen clothing, check catheter and bowel. SBP 150 mmHg or more: consider a fast, short-acting antihypertensive
- No suxamethonium after 24-48 h from injury
- Pressure care, bladder catheter, bowel care, temperature control
- Early nutrition and psychological support
14Outcome Early referral to a spinal cord injury unit and rehabilitation
All AIS grades. Prognosis depends on level and grade; repeat ISNCSCI exams to track recovery.
If No15Action No surgical lesion: non-operative care
The spinal team decides bracing and when to mobilise.
- Keep spinal precautions until the spinal team clears them
- Collar or brace as the spinal team advises
- New or worse deficit: repeat MRI and call the spinal surgeon
- Path rejoins step 13Shared downstream outcome
If No- No: MAP in target
16Action MAP in target: keep it there and recheck often
Adults: MAP at least 75-80 mmHg, not above 90-95 mmHg. Shock can appear later.
- Frequent blood pressure and heart rate checks
- MAP falls below 75-80 mmHg: exclude bleeding first, then fluid and vasopressor
- Path rejoins step 06Shared downstream outcome
Guideline Source
AO Spine/Praxis Clinical Practice Guidelines for Acute Spinal Cord Injury (Global Spine J 2024) + ISNCSCI (ASIA, revised 2019) + ATLS
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult guidance. Children: no validated MAP target and SCIWORA occurs; get paediatric trauma advice.
- Exam is limited when obtunded or intoxicated; image the spine and treat as injured until cleared.
- MAP targets rest on very low-quality evidence (AO Spine/Praxis 2024, weak recommendation).
- Methylprednisolone is not standard care; use only as a specialist decision within 8 h.
Contraindicated Populations
Children and adolescents: MAP targets and surgical-timing recommendations are for adults; use paediatric trauma guidance
Applicable Regions
USEUAUNZ
AU: Noradrenaline = norepinephrine. Refer early to the state spinal cord injury unit through the local trauma or retrieval service.
NZ: Refer early to the regional spinal injury unit through the local trauma service.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Spinal Cord Injury Management (ATLS/ASIA)?
The Acute Spinal Cord Injury Management (ATLS/ASIA) is a emergency clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on AO Spine/Praxis Clinical Practice Guidelines for Acute Spinal Cord Injury (Global Spine J 2024) + ISNCSCI (ASIA, revised 2019) + ATLS.
What guideline is the Acute Spinal Cord Injury Management (ATLS/ASIA) based on?
This algorithm is based on AO Spine/Praxis Clinical Practice Guidelines for Acute Spinal Cord Injury (Global Spine J 2024) + ISNCSCI (ASIA, revised 2019) + ATLS (DOI: 10.1177/21925682231183969).
What are the limitations of the Acute Spinal Cord Injury Management (ATLS/ASIA)?
Known limitations include: Adult guidance. Children: no validated MAP target and SCIWORA occurs; get paediatric trauma advice.; Exam is limited when obtunded or intoxicated; image the spine and treat as injured until cleared.; MAP targets rest on very low-quality evidence (AO Spine/Praxis 2024, weak recommendation).; Methylprednisolone is not standard care; use only as a specialist decision within 8 h.. Individual patient factors may require deviation from these recommendations.
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