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neuro.acute-spinal-cord-injury.v1PRODUCTION
neuro.acute-spinal-cord-injury.v1

Acute Traumatic Spinal Cord Injury (SCI)

neurologyacutesubacuteadultpediatricgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute traumatic SCI from blunt or penetrating mechanism — primary injury irreversible, all interventions are secondary-injury prevention (AANS/CNS 2013 PMID 23839357)

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SCI suspected

Patient inputs (15)

Drives mechanism (geriatric central-cord from minor hyperextension; young high-energy MVC; pediatric SCIWORA) and decompression-timing decisions (Fehlings AOSpine 2024 update PMID 38526922)

Blunt vs penetrating; high-energy vs minor; sports vs MVC vs fall — drives polytrauma workup + spinal stability assessment (AANS/CNS 2013 PMID 23839357)

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)

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)

Sacral sparing distinguishes complete (AIS A) from incomplete (AIS B-D) — drives prognosis, decompression timing, and rehab planning (AANS/CNS 2013 PMID 23839357)

STAT CT C-spine + T/L spine within first hour for fracture / dislocation / burst / facet jump (AANS/CNS 2013 PMID 23839357)

MRI within 24-48 h defines cord injury extent, hematoma, edema, ligamentous injury; required before surgical planning (Fehlings AOSpine 2017 MRI PMID 29164028)

Baseline for surgical clearance, anticoag thromboprophylaxis decisions (Fehlings AOSpine 2017 anticoag PMID 29164026)

Baseline for emergent surgery + LMWH timing (Fehlings AOSpine 2017 anticoag PMID 29164026)

GCS<13 + concurrent TBI overlay changes airway / ICU triage and may delay neurological assessment of cord function; AANS/CNS 2013 PMID 23839357

High cervical lesion (C3-C5) → diaphragm paralysis → respiratory failure; FVC <15 mL/kg or rising PaCO2 → elective intubation (AANS/CNS 2013 PMID 23839357)

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)

LMWH dose adjustment (CrCl<30 dose-reduce or switch to UFH); contrast-imaging safety (Fehlings AOSpine 2017 anticoag PMID 29164026)

Concurrent TBI is common in high-energy SCI; alters airway / MAP / ICP management (AANS/CNS 2013 PMID 23839357)

Hemorrhagic-shock screen — must rule out hemorrhagic shock BEFORE attributing hypotension to neurogenic shock (AANS/CNS 2013 PMID 23839357)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateninghigh_cervical_respiratory_failure
    High cervical SCI (C3-C5 phrenic involvement) with diaphragmatic paralysis / respiratory fatigue / rising PaCO2 / FVC <15 mL/kg (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneurogenic_shock_with_hemorrhage_overlay
    Hypotension in trauma patient with relative bradycardia + warm peripheries (above T6 SCI) — RULE OUT HEMORRHAGE FIRST (FAST, CT chest/abdomen/pelvis) (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcomplete_SCI_AIS_A
    ASIA Impairment Scale A — no motor or sensory function preserved in sacral segments S4-S5 (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningautonomic_dysreflexia_T6_plus
    T6 or above SCI with SBP >20 mmHg above baseline + headache ± bradycardia ± flushing above lesion + pallor / sweating below (Karsy/Hawryluk PMID 31363857)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcurrent_severe_TBI
    GCS ≤8 OR major intracranial lesion concurrent with SCI (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepenetrating_SCI
    Gunshot / stab / shrapnel SCI (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregeriatric_central_cord_minor_hyperextension
    Elderly patient with cervical spondylosis + minor hyperextension injury → central cord syndrome (upper>lower extremity weakness, bladder dysfunction, often AIS D) (Badhiwala/Fehlings PMID 30611186)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_SCIWORA
    Pediatric (<13 yr) SCI Without Radiographic Abnormality on CT — cord injury visible only on MRI (AANS/CNS 2013 PMID 23839357)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefailed_MAP_target_despite_pressors
    MAP <85 mmHg persistent despite norepinephrine + phenylephrine (Hawryluk PMID 25669633)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespinal_shock_phase_areflexia
    Acute SCI with areflexia + flaccidity below lesion (spinal shock, lasts hours-weeks; resolves into spasticity) (Karsy/Hawryluk PMID 31363857)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Acute SCI secondary-injury-prevention bundle: MAP ≥85 × 7 d + early decompression + DVT prophylaxis + spasticity + autonomic-dysreflexia (AANS/CNS 2013 PMID 23839357 + Fehlings AOSpine 2017 PMIDs 29164026/29164028/29164029 + Fehlings AOSpine 2024 update PMID 38526922 + Hawryluk PMID 25669633)
axis: acute_sci_secondary_injury_prevention_bundlestep 1 - Step 1 — MAP support ≥85 mmHg × 7 days (Hawryluk doctrine — improves cord perfusion + neurological recovery) (Hawryluk PMID 25669633; Catapano/Hawryluk PMID 27565460; Karsy/Hawryluk PMID 31363857)
Selected step "Step 1 — MAP support ≥85 mmHg × 7 days (Hawryluk doctrine — improves cord perfusion + neurological recovery) (Hawryluk PMID 25669633; Catapano/Hawryluk PMID 27565460; Karsy/Hawryluk PMID 31363857)" — Acute SCI confirmed; hemorrhagic shock ruled out (or controlled in parallel)
  • norepinephrine
    first line
    alpha_beta_agonist_vasopressor
    0.05-0.1 mcg/kg/min IV titrate to MAP ≥85 mmHg (typical adult start 5-10 mcg/min) • IV • continuous infusion
    triggers: MAP_<85_mmHg_after_isotonic_fluid_resuscitation, neurogenic_shock
    Norepinephrine preferred first-line vasopressor in acute SCI for combined alpha + mild beta support (treats both vasoplegia and relative bradycardia of high cord injuries) per Karsy/Hawryluk Curr Neurol Neurosci Rep 2019 (PMID 31363857); Hawryluk MAP-recovery doctrine (PMID 25669633)
    rxcui 7512
  • phenylephrine
    second line
    alpha_agonist_vasopressor
    0.5-1 mcg/kg/min IV (typical adult start 40-100 mcg/min); push-dose 50-200 mcg IV for transient hypotension • IV • continuous infusion
    triggers: tachyarrhythmia_with_norepinephrine, pure_vasoplegia_without_bradycardia
    Pure alpha-agonist alternative when tachyarrhythmia limits norepinephrine; can worsen bradycardia of high cervical injury — monitor for reflex bradycardia (AANS/CNS 2013 PMID 23839357)
    rxcui 8163

outpatient playbook — drug actions (3)

  1. 1. baclofen or tizanidine
    rxcui 1292
    titrated maintenance; reassess need annually • PO • TID
    trigger: Persistent spasticity
    Lifelong spasticity management (Fehlings AOSpine 2017 rehab PMID 29164029)
  2. 2. anticholinergic for neurogenic bladder (e.g., oxybutynin)
    titrated; consider intradetrusor onabotulinum-toxin A for refractory • PO or intravesical • BID-TID
    trigger: Detrusor overactivity confirmed on urodynamics
    Neurogenic bladder management (Fehlings AOSpine 2017 rehab PMID 29164029)
  3. 3. gabapentin or pregabalin for neuropathic pain
    titrated to effect • PO • TID
    trigger: Neuropathic pain VAS ≥4
    First-line for SCI neuropathic pain (Fehlings AOSpine 2017 rehab PMID 29164029)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Blunt trauma (MVC / fall / sports) with focal motor or sensory deficit (AANS/CNS 2013 PMID 23839357); Penetrating neck / back injury (GSW / stab) with focal deficit (AANS/CNS 2013 PMID 23839357); High cervical (C3-C5 phrenic involvement) injury with diaphragm paralysis / respiratory failure → STAT intubation (AANS/CNS 2013 PMID 23839357).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Traumatic Spinal Cord Injury (SCI)** (neuro.acute-spinal-cord-injury.v1).
Phenotype framing: 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)
Scope: Acute traumatic SCI from blunt or penetrating mechanism — primary injury irreversible, all interventions are secondary-injury prevention (AANS/CNS 2013 PMID 23839357)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute SCI secondary-injury-prevention bundle: MAP ≥85 × 7 d + early decompression + DVT prophylaxis + spasticity + autonomic-dysreflexia (AANS/CNS 2013 PMID 23839357 + Fehlings AOSpine 2017 PMIDs 29164026/29164028/29164029 + Fehlings AOSpine 2024 update PMID 38526922 + Hawryluk PMID 25669633)** — step "Step 1 — MAP support ≥85 mmHg × 7 days (Hawryluk doctrine — improves cord perfusion + neurological recovery) (Hawryluk PMID 25669633; Catapano/Hawryluk PMID 27565460; Karsy/Hawryluk PMID 31363857)".
1. norepinephrine 0.05-0.1 mcg/kg/min IV titrate to MAP ≥85 mmHg (typical adult start 5-10 mcg/min) IV continuous infusion (alpha_beta_agonist_vasopressor, first line) — Norepinephrine preferred first-line vasopressor in acute SCI for combined alpha + mild beta support (treats both vasoplegia and relative bradycardia of high cord injuries) per Karsy/Hawryluk Curr Neurol Neurosci Rep 2019 (PMID 31363857); Hawryluk MAP-recovery doctrine (PMID 25669633)
2. phenylephrine 0.5-1 mcg/kg/min IV (typical adult start 40-100 mcg/min); push-dose 50-200 mcg IV for transient hypotension IV continuous infusion (alpha_agonist_vasopressor, second line) — Pure alpha-agonist alternative when tachyarrhythmia limits norepinephrine; can worsen bradycardia of high cervical injury — monitor for reflex bradycardia (AANS/CNS 2013 PMID 23839357)

Setting playbook (outpatient) — Lifelong SCI management: prevent secondary complications (UTI, pressure injury, autonomic dysreflexia, neuropathic pain, mood, cardiovascular disease, osteoporosis); maximise function; community reintegration; vocational support (Fehlings AOSpine 2017 rehab PMID 29164029)
3. baclofen or tizanidine titrated maintenance; reassess need annually PO TID — Persistent spasticity (Lifelong spasticity management (Fehlings AOSpine 2017 rehab PMID 29164029))
4. anticholinergic for neurogenic bladder (e.g., oxybutynin) titrated; consider intradetrusor onabotulinum-toxin A for refractory PO or intravesical BID-TID — Detrusor overactivity confirmed on urodynamics (Neurogenic bladder management (Fehlings AOSpine 2017 rehab PMID 29164029))
5. gabapentin or pregabalin for neuropathic pain titrated to effect PO TID — Neuropathic pain VAS ≥4 (First-line for SCI neuropathic pain (Fehlings AOSpine 2017 rehab PMID 29164029))

Non-pharmacologic actions:
- Annual influenza + COVID + pneumococcal vaccination per ACIP 2026 (Fehlings AOSpine 2017 rehab PMID 29164029)
- Pressure-injury surveillance + offloading (Fehlings AOSpine 2017 rehab PMID 29164029)
- Cardiovascular risk reduction (exercise per ability, lipid control, BP) (Fehlings AOSpine 2017 rehab PMID 29164029)
- Vocational + community-reintegration support (Fehlings AOSpine 2017 rehab PMID 29164029)
- Caregiver respite + mental health support (Fehlings AOSpine 2017 rehab PMID 29164029)

AVOID / contraindication checks:
- No_routine_high_dose_methylprednisolone_for_SCI_AANS_CNS_2013_grades_it_Level_III_option_only (PMID 23839357)
- No_methylprednisolone_for_penetrating_SCI_or_pediatric_SCI_<13yr (AANS/CNS 2013 PMID 23839357)
- No_methylprednisolone_beyond_8h_from_injury (AANS/CNS 2013 PMID 23839357; NASCIS III PMID 9168289)
- No_dopamine_first_line_for_neurogenic_shock_due_to_tachyarrhythmia (Karsy/Hawryluk PMID 31363857)
- No_LMWH_until_active_bleeding_ruled_out_typically_24 72h (Fehlings AOSpine 2017 PMID 29164026)
- No_routine_IVC_filter_in_acute_SCI (Fehlings AOSpine 2017 anticoag PMID 29164026)
- No_aggressive_BP_lowering_in_acute_SCI_perfusion_dependent_cord (Hawryluk PMID 25669633)
- No_sublingual_nifedipine_for_autonomic_dysreflexia_use_PO_immediate_release (Karsy/Hawryluk PMID 31363857)
- No_abrupt_baclofen_discontinuation_taper_to_avoid_withdrawal (Fehlings AOSpine 2017 rehab PMID 29164029)

Monitoring

Regimen monitoring:
- continuous arterial BP MAP target >=85 mmHg x 7d (Hawryluk PMID 25669633)
- serial ASIA motor sensory exam daily in acute phase (AANS/CNS 2013 PMID 23839357)
- platelet count q3d x 2wk if heparin for HIT 4Ts (Fehlings AOSpine 2017 anticoag PMID 29164026)
- FVC NIF q4h in cervical SCI for respiratory decline (AANS/CNS 2013 PMID 23839357)
- pressure injury q2h repositioning skin check each shift (Fehlings AOSpine 2017 rehab PMID 29164029)
- bladder scan q4-6h until intermittent catheterisation program established (Fehlings AOSpine 2017 rehab PMID 29164029)
- serial LFTs if tizanidine (Fehlings AOSpine 2017 rehab PMID 29164029)

Setting (outpatient) monitoring:
- Annual SCI-clinic visit (Fehlings AOSpine 2017 rehab PMID 29164029)
- Urodynamics + renal US q1-2 y (Fehlings AOSpine 2017 rehab PMID 29164029)
- DEXA q1-2 y (Fehlings AOSpine 2017 rehab PMID 29164029)

Follow-up plan: 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)
- Close-out criterion: SCI rehab + long-term management plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Lifelong SCI management: prevent secondary complications (UTI, pressure injury, autonomic dysreflexia, neuropathic pain, mood, cardiovascular disease, osteoporosis); maximise function; community reintegration; vocational support (Fehlings AOSpine 2017 rehab PMID 29164029)

Disposition criteria:
- Lifelong SCI-clinic follow-up indefinite (Fehlings AOSpine 2017 rehab PMID 29164029)

Escalation triggers (move to higher acuity):
- New deficit / unexplained pain / autonomic dysreflexia crisis → urgent SCI-clinic + imaging (Karsy/Hawryluk PMID 31363857)
- Recurrent UTI / hydronephrosis → urology referral (Fehlings AOSpine 2017 rehab PMID 29164029)
- Stage 2+ pressure injury → wound team + reassess offloading (Fehlings AOSpine 2017 rehab PMID 29164029)
- PHQ-9 ≥15 / suicidality → urgent psych referral (Badhiwala/Fehlings PMID 30611186)

Patient Action Plan

**Acute SCI recovery + complication-prevention action plan**
Personalised values: asia_grade, neurological_level, autonomic_dysreflexia_risk, bladder_regimen, spasticity_regimen, anticoag_plan.

**Doing well — stable recovery** (green):
Triggers:
- stable_function
- intact_skin
- effective_bladder_bowel_regimen
- no_autonomic_dysreflexia_episodes
Actions:
- Continue rehab program + bladder/bowel/skin routines
- Take spasticity + anticoag + other medications as prescribed
- Reposition every 2 hours when in bed; pressure relief every 15-30 min in chair
- Keep all SCI-clinic, urology, and PCP appointments

**Caution — call SCI clinic same day** (yellow):
Triggers:
- new_pressure_redness_>1h
- new_UTI_symptoms
- worsening_spasticity
- mild_autonomic_dysreflexia_headache_BP_rise
- mood_concerns
- fall_without_new_deficit
Actions:
- Call SCI clinic / PCP same day
- For autonomic dysreflexia: sit up, loosen restrictive clothing, check + drain bladder, check + clear bowel
- For pressure redness: offload immediately + skin protection
- For UTI symptoms: bring urine sample to clinic

**Emergency — call 911 / go to ED** (red):
Triggers:
- new_weakness_or_sensory_loss
- severe_autonomic_dysreflexia_SBP_>200_or_persistent
- major_bleeding
- severe_chest_pain_or_dyspnea
- high_fever_with_altered_mental_status
- unable_to_void_+_bladder_distension
Actions:
- Call 911 / go to nearest ED
- Bring SCI summary card + medication list + autonomic-dysreflexia card
- Tell ED you have an SCI at [level] — they MUST treat AD with sit-up + trigger removal + SL nitroglycerin if SBP>150
Contact provider when:
- Any red-zone trigger
- After any ED visit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] High cervical SCI (C3-C5 phrenic involvement) with diaphragmatic paralysis / respiratory fatigue / rising PaCO2 / FVC <15 mL/kg (AANS/CNS 2013 PMID 23839357)
- [LIFE_THREATENING] Hypotension in trauma patient with relative bradycardia + warm peripheries (above T6 SCI) — RULE OUT HEMORRHAGE FIRST (FAST, CT chest/abdomen/pelvis) (AANS/CNS 2013 PMID 23839357)
- [LIFE_THREATENING] ASIA Impairment Scale A — no motor or sensory function preserved in sacral segments S4-S5 (AANS/CNS 2013 PMID 23839357)

Citations

- AANS/CNS 2013 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries (Walters/Hadley, Neurosurgery 2013) + AOSpine/AANS-CNS 2017 Joint Guidelines (Fehlings, Global Spine J) + AOSpine 2024 Update on Timing of Decompressive Surgery (Fehlings, Global Spine J 2024) [PMID:23839357](https://pubmed.ncbi.nlm.nih.gov/23839357/)
- Cited evidence (PMID 23417195) [PMID:23417195](https://pubmed.ncbi.nlm.nih.gov/23417195/)
- Cited evidence (PMID 22384132) [PMID:22384132](https://pubmed.ncbi.nlm.nih.gov/22384132/)
- Cited evidence (PMID 29164036) [PMID:29164036](https://pubmed.ncbi.nlm.nih.gov/29164036/)
- Cited evidence (PMID 29164026) [PMID:29164026](https://pubmed.ncbi.nlm.nih.gov/29164026/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AANS/CNS 2013 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries (Walters/Hadley, Neurosurgery 2013) + AOSpine/AANS-CNS 2017 Joint Guidelines (Fehlings, Global Spine J) + AOSpine 2024 Update on Timing of Decompressive Surgery (Fehlings, Global Spine J 2024) — PMID:23839357
  • Cited evidence (PMID 23417195) — PMID:23417195
  • Cited evidence (PMID 22384132) — PMID:22384132
  • Cited evidence (PMID 29164036) — PMID:29164036
  • Cited evidence (PMID 29164026) — PMID:29164026