Suspected Spinal Cord Injury
Trauma with neurological deficit or high-risk mechanism
All Pathways
Orthopedic SurgeryEmergency
Acute Spinal Cord Injury Management (ATLS/ASIA)
Acute Spinal Cord Injury Management (ATLS/ASIA): Suspected Spinal Cord Injury → ATLS Primary Survey + C-Spine Immobilization → Hemodynamic Status? → Neu...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action ATLS Primary Survey + C-Spine Immobilization
Maintain spinal precautions
- Airway with C-spine protection
- Breathing - watch for respiratory failure (high cervical)
- Circulation - assess for neurogenic shock
- Disability - brief neuro exam
- Maintain neutral alignment
- Log-roll for examination
03Decision Hemodynamic Status?
Differentiate shock types
04Action Neurogenic Shock
Loss of sympathetic tone (high cervical/thoracic)
- Hypotension with bradycardia
- Warm, dry extremities
- Vasodilation below injury level
- Fluids cautiously (avoid overload)
- Vasopressors: Norepinephrine or Phenylephrine
- Target MAP ≥85 mmHg (AO Spine recommendation)
05Action Detailed Neurological Exam (ASIA/ISNCSCI)
Motor and sensory assessment
- Motor: Key muscles C5-T1, L2-S1 (0-5 scale)
- Sensory: Light touch and pinprick (28 dermatomes)
- Determine Neurological Level of Injury (NLI)
- Assess sacral sparing (S4-5 sensation, anal contraction)
- Deep tendon reflexes
- Rectal exam (tone, sensation)
06Decision ASIA Impairment Scale
Classify completeness of injury
- A: Complete - No motor/sensory below level, no sacral sparing
- B: Sensory incomplete - Sensory preserved, no motor below level
- C: Motor incomplete - Motor preserved <half muscles grade ≥3
- D: Motor incomplete - Motor preserved ≥half muscles grade ≥3
- E: Normal - Normal motor and sensory
07Action Spinal Imaging
CT and MRI
- CT cervical spine (whole spine if indicated)
- MRI for cord compression, disc herniation, ligamentous injury
- Assess stability (3-column concept)
- Look for: Fracture, dislocation, disc, hematoma
08Decision Cord Compression Present?
Potentially reversible pathology
09Action Urgent Surgical Decompression
Time-sensitive intervention
- Within 24 hours if incomplete injury (AO Spine)
- Anterior/posterior approach based on pathology
- Restore spinal alignment
- Decompress neural elements
- Stabilize with instrumentation
10Action Spine Stabilization
Based on injury pattern
- Cervical: Halo, traction, or surgical fusion
- Thoracic/Lumbar: Posterior instrumentation
- Unstable fractures require fixation
- Consider deformity correction
11Action ICU Care & Monitoring
Prevent complications
- Ventilator support if C3-C5 injury
- Autonomic dysreflexia prevention (T6 and above)
- DVT prophylaxis (LMWH when safe)
- Early nutrition
- Temperature regulation (poikilothermia)
- Psychological support
12Outcome Rehabilitation
Transfer to SCI rehab center
13Outcome Complete Injury
Prognosis depends on level and completeness
14Action Supportive Care
If no surgically treatable compression
- Maintain MAP ≥85 mmHg for 5-7 days
- Prevent secondary injury
- DVT prophylaxis (start when safe)
- Skin care, pressure ulcer prevention
- Bowel/bladder management
- Respiratory care (may need ventilation)
- Path rejoins step 10Shared downstream outcome
15Warning ⚠️ Methylprednisolone Controversy
Not routinely recommended
- High-dose steroids: Limited evidence of benefit
- Significant side effects (infection, GI bleed)
- AO Spine: Not recommended as standard
- If used: Within 8 hours of injury only
- Discuss risks/benefits with patient/family
16Action Rule Out Hemorrhagic Shock
Do not attribute hypotension solely to SCI
- Hypotension with tachycardia = hemorrhage
- FAST exam, chest X-ray, pelvic X-ray
- Polytrauma common with SCI
- Address bleeding sources first
- Path rejoins step 05Shared downstream outcome
Guideline Source
ATLS + AO Spine Guidelines + ASIA Classification
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Neurological exam limited in obtunded patients
- Steroids controversial - not routinely recommended
- Surgical timing depends on injury pattern and stability
- Pediatric considerations differ (SCIWORA)
Applicable Regions
USEU
Version 1Next review: 2027-01-11
Next steps
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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 ATLS + AO Spine Guidelines + ASIA Classification.
What guideline is the Acute Spinal Cord Injury Management (ATLS/ASIA) based on?
This algorithm is based on ATLS + AO Spine Guidelines + ASIA Classification (DOI: 10.1097/BRS.0000000000002237).
What are the limitations of the Acute Spinal Cord Injury Management (ATLS/ASIA)?
Known limitations include: Neurological exam limited in obtunded patients; Steroids controversial - not routinely recommended; Surgical timing depends on injury pattern and stability; Pediatric considerations differ (SCIWORA). Individual patient factors may require deviation from these recommendations.
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