Neurology · Topic 7 of 22

Acute Spinal Cord Injury

Neurology · neurotrauma

Acute Spinal Cord Injury

Immobilize, secure the airway in cervical injury, treat neurogenic shock and hold MAP at least 75–80 mmHg for 3–7 days to perfuse the cord.

Key numbers

Keep MAP at least 75–80 mmHgMAP ≥ 75–80 mmHg

Injury at or above C5: respiratory failure≤ C5

Autonomic dysreflexia: sudden hypertension, injury ≥ T6SBP ↑ > 20 mmHg

Decompress within 24 hours≤ 24 h

01 · The numberKeep MAP at least 75–80 mmHg

Augment MAP to at least 75–80 mmHg, but not actively above 90–95 mmHg, for 3–7 days after acute SCI to perfuse the injured cord; avoid any hypotension.

02 · Look forNeurogenic shock: hypotension, bradycardia, warm skin

Neurogenic shock follows cervical or high thoracic cord injury: loss of sympathetic tone gives hypotension with bradycardia and warm, dry skin — unlike other forms of shock, the skin is not cold and clammy.

03 · Look forAutonomic dysreflexia: sudden hypertension, injury ≥ T6

In SCI at or above T6, a trigger below the lesion (usually bladder or bowel) causes autonomic dysreflexia: SBP > 20 mmHg above baseline, pounding headache, flushing and sweating above the lesion, relative bradycardia.

Causes & risk factors

Why it happens

Injury at or above C5: respiratory failure must knowCervical injury at or above C5 impairs phrenic and respiratory muscle function — expect respiratory failure and usually intubate; injuries at or above C3 are often ventilator dependent.

Presentation

What you'll see

Central cord: arms weaker than legsCentral cord syndrome follows hyperextension in a narrowed (congenital or degenerative) cervical canal: arm weakness exceeds leg weakness, with variable sensory loss.

Anterior cord: motor and pain lostAnterior cord syndrome (direct injury or anterior spinal artery) causes bilateral loss of motor function and pain and temperature below the lesion, with vibration and proprioception preserved.

Brown-Séquard: ipsilateral motor, contralateral pain lossBrown-Séquard syndrome (cord hemisection) causes ipsilateral weakness and loss of position sense below the lesion with contralateral loss of pain and temperature.

Diagnosis & monitoring

Work-up

Sacral sparing makes an injury incompleteClassify by ASIA Impairment Scale: A = complete (no motor or sensory function in S4–S5); B–D = incomplete, with sacral (S4–S5) sparing and increasing motor function; E = normal.

Do right now

In this order

First moves

Immobilize the whole spine immediately

→

Injury at or above C5: respiratory failure≤ C5

→

Neurogenic shock: hypotension, bradycardia, warm skin

→

Keep MAP at least 75–80 mmHgMAP ≥ 75–80 mmHg

Why each step

Immobilize the whole spine immediatelyImmobilize the spine in any at-risk patient (rigid collar, flat firm surface) until imaging and examination clear it, and keep manual in-line stabilization during intubation.

Injury at or above C5: respiratory failureCervical injury at or above C5 impairs phrenic and respiratory muscle function — expect respiratory failure and usually intubate; injuries at or above C3 are often ventilator dependent.

Neurogenic shock: hypotension, bradycardia, warm skinNeurogenic shock follows cervical or high thoracic cord injury: loss of sympathetic tone gives hypotension with bradycardia and warm, dry skin — unlike other forms of shock, the skin is not cold and clammy.

Keep MAP at least 75–80 mmHgAugment MAP to at least 75–80 mmHg, but not actively above 90–95 mmHg, for 3–7 days after acute SCI to perfuse the injured cord; avoid any hypotension.

Management

Orders

Autonomic dysreflexia: sit up, find the triggerTreat autonomic dysreflexia by sitting the patient upright with legs lowered, loosening clothing and devices, checking BP every 1–2 minutes, then catheterizing (or checking the indwelling catheter for kinks) and checking for fecal impaction.

SBP still > 150: short-acting antihypertensiveIf SBP stays ≥ 150 mmHg once the trigger is addressed, give a short-acting antihypertensive: nitroglycerin (paste or 0.4 mg SL); after recent PDE-5 inhibitor use, nifedipine IR 10 mg or captopril 25 mg SL.

Above T6: norepinephrine, not pure phenylephrineRestore volume first, then use vasopressors for the MAP goal: injuries above T6–T7 need agents with chronotropic and inotropic effect (norepinephrine, dopamine); lower injuries may respond to phenylephrine.

Decompress within 24 hoursGet CT, then MRI for neurologic deficits, and consult spine surgery: decompression within 24 hours of injury improves neurologic recovery in both incomplete and complete injuries.

Cervical fracture: get CT angiographyA cervical spine fracture, subluxation or ligamentous injury warrants CT angiography to exclude carotid or vertebral artery injury.

VTE prophylaxis is requiredImmobile SCI patients need VTE prophylaxis, plus turning every 2 hours and bladder, bowel and pulmonary care; consider a removable IVC filter only if anticoagulation is contraindicated.

Red flags & don'ts

Avoid harm

No routine high-dose methylprednisolone avoidHigh-dose methylprednisolone is not routinely recommended for acute SCI: trials show no consistent benefit and more wound infection, pulmonary embolism, sepsis and death.

Neurogenic shock or spinal shock?

Commonly confused

What it is	Hemodynamic: loss of sympathetic tone
Findings	Hypotension, bradycardia, warm dry skin
Typical injury	Cervical or high thoracic (above T6)
Course and treatment	Fluids, then norepinephrine to the MAP goal

More detail

Reference

Show 5 reference facts

Keep oxygen saturation at or above 90% to prevent cord ischemia.

Complete injury causes immediate flaccid paralysis with loss of sensation, reflexes and anal tone; over hours to weeks this becomes spastic paralysis with hyperreflexia as descending inhibition is lost.

Conus medullaris and cauda equina lesions cause saddle anesthesia, bowel and bladder dysfunction and lax anal tone; cauda equina weakness is lower motor neuron and often asymmetric.

Bladder stimuli (distension, a blocked catheter, UTI) and bowel distension are the two commonest autonomic dysreflexia triggers; others include skin pressure or sores, ingrown toenails, menstruation and labor.

Pneumonia is a frequent cause of death after high cervical injury, especially in ventilator-dependent patients; return of some function in the first week predicts a better recovery.

Pearl

Hypotension with bradycardia and warm, dry skin after a cervical injury is neurogenic shock until proven otherwise — but look for bleeding too.

Sources · Merck Manual Professional — Spinal Trauma (2026) · Kwon BK et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management. Global Spine J 2024;14(3 Suppl):187S–211S · Clinical Practice Guideline Development for Autonomic Dysreflexia in Spinal Cord Injury. Med J Islam Repub Iran 2023 (draws on the Consortium for Spinal Cord Medicine guideline) · Consortium for Spinal Cord Medicine (PVA). Krassioukov A et al. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows. Top Spinal Cord Inj Rehabil 2021;27(2):225–290 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).