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neuro.acute-spinal-cord-injury.v1

Acute Traumatic Spinal Cord Injury (SCI)

neurologyacutesubacuteadultpediatricgeriatricacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Lane F id+neuro-acute campaign new-build (2026-05-26). Acute traumatic SCI engine encodes the Hawryluk MAP ≥85 × 7 d doctrine (PMID 25669633), STASCIS / Fehlings AOSpine 2017+2024 early-decompression-within-24-h doctrine (PMIDs 22384132, 29164036, 38526922), the AANS/CNS 2013 (PMID 23839357) explicit de-emphasis of routine methylprednisolone (Level III "option", not standard), and the Fehlings AOSpine 2017 (PMID 29164026) within-72-h DVT prophylaxis recommendation. PubMed-MCP verification 2026-05-26: 14 evidence PMIDs all live-verified — AANS/CNS 2013 update 23839357, AANS/CNS 2013 DVT 23417195, STASCIS 22384132, Fehlings AOSpine 2017 intro 29164036 + anticoag 29164026 + MRI 29164028 + rehab 29164029, Fehlings AOSpine 2024 decompression update 38526922 (newer than the orchestrator-supplied 2017-only anchor), Hawryluk MAP 25669633 + 27565460 + Karsy/Hawryluk 31363857, Badhiwala/Fehlings 30611186, Sygen/GM-1 11805614, NASCIS III 9168289. No fabrications detected in orchestrator-supplied PMID anchors (was a search-string-only brief, not PMID candidates). RxCUI live-verification (RxNav curl 2026-05-26) — norepinephrine 7512 ✓, phenylephrine 8163 ✓, enoxaparin 67108 ✓, baclofen 1292 ✓, methylprednisolone 6902 ✓, nitroglycerin 4917 ✓, nifedipine 7417 ✓; CRITICAL FAB CATCH — tizanidine candidate 38400 = atomoxetine (WRONG, would have administered ADHD medication for spasticity), corrected to verified tizanidine RxCUI 57258. Heparin 5224 also verified. Registry-id resolution — used `workup.spinal_cord_compression` (existing, NICE NG234 + Patchell anchor; closest registry match for traumatic SCI decompression workup), `workup.acute_compartment_syndrome` (polytrauma overlay), `workup.burn_management` (concurrent burn overlay); calculators `calc.ckd_epi_2021` (LMWH dosing), `calc.nihss` (concurrent stroke overlay), `calc.caprini` (VTE risk overlay), `calc.clinical_frailty_scale` (geriatric central-cord); panels `panel.cbc / panel.renal / panel.lft / panel.coag / panel.inflammation` all resolve. Schema-blocked: no `workup.traumatic_sci` or `workup.atls_polytrauma` or `protocol.sci_map_doctrine` exists in clinical-tools-registry.ts at this build — flagged for future depth-pass registry expansion. Settings shipped: ed / icu / inpatient / transition / outpatient (5). Top-level settings: acute / inpatient / transition (3, per Lane F wave 2 brief). Severity triggers: 10 (high-cervical-respiratory / neurogenic-shock-with-hemorrhage-overlay / complete-SCI-AIS-A / autonomic-dysreflexia / penetrating / geriatric-central-cord / pediatric-SCIWORA / concurrent-severe-TBI / spinal-shock / failed-MAP). Methylprednisolone explicitly de-emphasised per AANS/CNS 2013 (PMID 23839357) — coded as `optional_consider` in regimen builder Step 3 with informed-consent + 8-h window + harm disclosure; many centres OMIT entirely. §5.5.2 Bayesian depth-pass NOT performed at this build — LR derivations for ASIA recovery prediction, AOSpine 2024 ultra-early surgery subgroups, and CFS-adjusted decompression decision-making flagged for future depth-pass-2.

Entry points (7)

  • symptom
    Blunt trauma (MVC / fall / sports) with focal motor or sensory deficit (AANS/CNS 2013 PMID 23839357)
    blunt_trauma_with_focal_motor_or_sensory_deficit
  • symptom
    Penetrating neck / back injury (GSW / stab) with focal deficit (AANS/CNS 2013 PMID 23839357)
    penetrating_neck_or_back_injury_with_deficit
  • symptom
    High cervical (C3-C5 phrenic involvement) injury with diaphragm paralysis / respiratory failure → STAT intubation (AANS/CNS 2013 PMID 23839357)
    high_cervical_injury_with_respiratory_failure
  • symptom
    Neurogenic shock — hypotension + relative bradycardia + warm peripheries above T6 (Karsy/Hawryluk Curr Neurol Neurosci Rep 2019 PMID 31363857)
    neurogenic_shock_hypotension_with_bradycardia
  • symptom
    Elderly fall with neck hyperextension → central cord syndrome (upper extremity > lower extremity weakness) (Badhiwala/Fehlings J Neurosurg Spine 2018 PMID 30611186)
    elderly_minor_hyperextension_central_cord
  • imaging
    CT cervical/thoracolumbar spine with fracture-dislocation, subluxation, or burst fracture (AANS/CNS 2013 PMID 23839357)
    ct_spine_fracture_dislocation_or_subluxation
  • imaging
    MRI spine — cord signal abnormality (T2 hyperintensity, hemorrhage, edema, transection) (Fehlings AOSpine 2017 MRI guideline PMID 29164028)
    mri_spine_cord_signal_change_or_edema

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Drives mechanism (geriatric central-cord from minor hyperextension; young high-energy MVC; pediatric SCIWORA) and decompression-timing decisions (Fehlings AOSpine 2024 update PMID 38526922)
  • mechanism_of_injuryrequired
    demographic • used at CONTEXT
    Blunt vs penetrating; high-energy vs minor; sports vs MVC vs fall — drives polytrauma workup + spinal stability assessment (AANS/CNS 2013 PMID 23839357)
  • gcsrequired
    vital • used at RED_FLAGS
    GCS<13 + concurrent TBI overlay changes airway / ICU triage and may delay neurological assessment of cord function; AANS/CNS 2013 PMID 23839357
  • sbp_map_hrrequired
    vital • used at TREATMENT
    MAP <85 mmHg or SBP <90 mmHg is the single strongest secondary-injury driver; relative bradycardia + warm peripheries discriminate neurogenic from hemorrhagic shock (Hawryluk J Neurotrauma 2015 PMID 25669633; Catapano/Hawryluk World Neurosurg 2016 PMID 27565460)
  • respiratory_rate_spo2required
    vital • used at RED_FLAGS
    High cervical lesion (C3-C5) → diaphragm paralysis → respiratory failure; FVC <15 mL/kg or rising PaCO2 → elective intubation (AANS/CNS 2013 PMID 23839357)
  • asia_motor_sensory_examrequired
    symptom • used at INITIAL_WORKUP
    ASIA/ISNCSCI motor + sensory + rectal-tone + sacral-sensation exam yields AIS A-E grade and neurological level; required at baseline + serial (AANS/CNS 2013 PMID 23839357)
  • rectal_tone_sacral_sensationrequired
    symptom • used at INITIAL_WORKUP
    Sacral sparing distinguishes complete (AIS A) from incomplete (AIS B-D) — drives prognosis, decompression timing, and rehab planning (AANS/CNS 2013 PMID 23839357)
  • ct_cervical_thoracolumbar_spinerequired
    imaging • used at INITIAL_WORKUP
    STAT CT C-spine + T/L spine within first hour for fracture / dislocation / burst / facet jump (AANS/CNS 2013 PMID 23839357)
  • mri_spine_within_24_48hrequired
    imaging • used at INITIAL_WORKUP
    MRI within 24-48 h defines cord injury extent, hematoma, edema, ligamentous injury; required before surgical planning (Fehlings AOSpine 2017 MRI PMID 29164028)
  • ct_head_for_concurrent_tbi
    imaging • used at INITIAL_WORKUP
    Concurrent TBI is common in high-energy SCI; alters airway / MAP / ICP management (AANS/CNS 2013 PMID 23839357)
  • cbc_with_plateletsrequired
    lab • used at INITIAL_WORKUP
    Baseline for surgical clearance, anticoag thromboprophylaxis decisions (Fehlings AOSpine 2017 anticoag PMID 29164026)
  • coag_pt_inr_apttrequired
    lab • used at INITIAL_WORKUP
    Baseline for emergent surgery + LMWH timing (Fehlings AOSpine 2017 anticoag PMID 29164026)
  • creatinine_egfrrequired
    lab • used at TREATMENT
    LMWH dose adjustment (CrCl<30 dose-reduce or switch to UFH); contrast-imaging safety (Fehlings AOSpine 2017 anticoag PMID 29164026)
  • lactate_base_deficit
    lab • used at RED_FLAGS
    Hemorrhagic-shock screen — must rule out hemorrhagic shock BEFORE attributing hypotension to neurogenic shock (AANS/CNS 2013 PMID 23839357)
  • time_of_injuryrequired
    history • used at CONTEXT
    Decompression-timing window — <24 h preferred per Fehlings AOSpine 2024 update PMID 38526922; <8 h triggers the now-disfavoured methylpred consent discussion (NASCIS III PMID 9168289)

12-phase flow (12)

  1. 1FRAME
    Acute traumatic SCI from blunt or penetrating mechanism — primary injury irreversible, all interventions are secondary-injury prevention (AANS/CNS 2013 PMID 23839357)
    advance: SCI suspected
  2. 2ENTRY
    Trauma activation + ATLS A-B-C-D-E + full spinal immobilization (rigid collar + long board removal after log-roll); STAT trauma surgery + neurosurgery + anesthesia at bedside (AANS/CNS 2013 PMID 23839357)
    inputs: mechanism_of_injury, age
    advance: Trauma bay activation complete
  3. 3CONTEXT
    Mechanism + time of injury + concurrent injuries (head / chest / abdomen / pelvis / long-bone); polytrauma vs isolated SCI; baseline comorbidities (anticoagulants, antiplatelets, frailty) (AANS/CNS 2013 PMID 23839357)
    inputs: mechanism_of_injury, time_of_injury, age
    advance: Mechanism + comorbidity mapped
  4. 4RED_FLAGS
    Airway compromise (high cervical / respiratory fatigue / rising PaCO2) → STAT intubation; hemorrhagic-shock overlay → STAT massive transfusion + source control; impending herniation if concurrent TBI; GCS≤8 (AANS/CNS 2013 PMID 23839357)
    inputs: gcs, respiratory_rate_spo2, sbp_map_hr, lactate_base_deficit
    advance: Life threats addressed; SCI workup proceeds in parallel
  5. 5INITIAL_WORKUP
    STAT CT C-spine + T/L spine; ASIA/ISNCSCI exam with sacral sparing check; MRI spine within 24-48 h; CBC, coags, CMP, lactate; CT head if mechanism warrants (AANS/CNS 2013 PMID 23839357; Fehlings AOSpine 2017 MRI PMID 29164028)
    inputs: ct_cervical_thoracolumbar_spine, mri_spine_within_24_48h, asia_motor_sensory_exam, rectal_tone_sacral_sensation, cbc_with_platelets, coag_pt_inr_aptt, creatinine_egfr
    actions: workup.spinal_cord_compression, panel.cbc, panel.renal, panel.coag
    advance: Bony + cord injury mapped; AIS grade assigned
  6. 6BRANCHING_WORKUP
    Vertebral artery imaging (CTA) for cervical fracture across foramen transversarium; flexion-extension films for ligamentous injury (only if neurologically intact + cooperative); pediatric SCIWORA → MRI mandatory; geriatric central-cord workup (Badhiwala/Fehlings J Neurosurg Spine 2018 PMID 30611186)
    advance: Adjacent vascular / ligamentous injury mapped
  7. 7DIFFERENTIAL
    Acute traumatic SCI vs cauda equina syndrome (separate dossier) vs spinal cord ischemia (anterior spinal artery) vs transverse myelitis (separate) vs epidural abscess (separate) vs epidural hematoma (post-procedural / anticoagulant) vs functional / conversion (rare in trauma) (AANS/CNS 2013 PMID 23839357)
    advance: Traumatic-SCI confirmed; non-traumatic mimic excluded
  8. 8RISK_STRATIFICATION
    AIS grade A-E + neurological level + age + concurrent TBI/polytrauma → prognosis; AIS A complete cord injury = worst prognosis; central cord syndrome = best motor recovery; <24 h to decompression doubles 2-grade AIS improvement at 6 mo (STASCIS PMID 22384132)
    inputs: asia_motor_sensory_exam, time_of_injury
    advance: Severity tier + decompression-timing plan assigned
  9. 9TREATMENT
    Step 1 — MAP support ≥85 mmHg × 7 d (norepinephrine first-line; phenylephrine acceptable; AVOID dopamine due to arrhythmia and tachycardia) per Hawryluk MAP doctrine (PMID 25669633, 27565460, 31363857); Step 2 — STAT surgical decompression + stabilisation within 24 h (STASCIS PMID 22384132; Fehlings AOSpine 2024 update PMID 38526922); Step 3 — methylprednisolone is an "option" only — NOT routinely recommended (AANS/CNS 2013 PMID 23839357 graded Level III; potential harms: sepsis, GI bleed, hyperglycemia); if administered, NASCIS protocol within 8 h with informed-consent on equipoise (NASCIS III PMID 9168289); Step 4 — DVT prophylaxis once stable (LMWH within 72 h if no active bleeding) per Fehlings AOSpine 2017 PMID 29164026; Step 5 — bowel/bladder/pressure-injury/respiratory bundle; Step 6 — autonomic-dysreflexia recognition + treatment in T6+ injuries (nitroglycerin SL / nifedipine if SBP>150 refractory)
    inputs: sbp_map_hr, creatinine_egfr, time_of_injury
    actions: workup.spinal_cord_compression, workup.acute_compartment_syndrome
    advance: MAP optimised + decompression decision made + DVT plan documented
  10. 10DISPOSITION
    Neuro-ICU or trauma-ICU for all complete or high-cervical SCI; step-down or specialised SCI unit for stable incomplete SCI; transfer to designated SCI rehab centre once medically stable (Fehlings AOSpine 2017 rehab PMID 29164029)
    inputs: gcs, asia_motor_sensory_exam
    advance: Bed allocated or transfer initiated
  11. 11MONITORING
    Continuous BP / MAP × 7 d; serial ASIA exam daily; platelet count for HIT (4Ts) if heparin; respiratory mechanics (FVC, NIF) in cervical SCI; pressure-injury surveillance; bowel/bladder regimens (Karsy/Hawryluk PMID 31363857; AANS/CNS 2013 PMID 23839357)
    inputs: sbp_map_hr, asia_motor_sensory_exam
    advance: Monitoring bundle in place
  12. 12FOLLOWUP
    SCI rehab centre referral; long-term complications: autonomic dysreflexia (T6+), neurogenic bladder, neurogenic bowel, pressure injury, spasticity, heterotopic ossification, mood/cognition, sexuality/fertility, vocational; lifelong management (Fehlings AOSpine 2017 rehab PMID 29164029)
    advance: SCI rehab + long-term management plan documented