Nervous System & Special Senses

Spinal cord injury: acute management

Clinical Overview and When to Suspect Spinal Cord Injury

— ~17,000 new traumatic SCIs/year in the US; bimodal age distribution (young males from MVCs/sports/violence; elderly from falls)

— Cervical injuries most common (~60%), especially C4–C7

— Elderly with cervical spondylosis are prone to central cord syndrome after even minor hyperextension (e.g., ground-level fall striking forehead)

— Any blunt trauma with neck/back pain, neurologic complaint, or distracting injury

— Unconscious trauma patient (assume SCI until cleared)

— High-energy mechanism: MVC >35 mph, fall >3× patient height, axial load (diving, football)

— Penetrating neck/back trauma

— Ankylosing spondylitis or DISH patients—any fall can cause unstable fracture

— Post-trauma neurogenic shock: hypotension + bradycardia + warm extremities

— No midline cervical tenderness

— No focal neurologic deficit

— Normal alertness

— No intoxication

— No painful distracting injury

Board pearl: A trauma patient with bradycardia and hypotension has neurogenic shock from cervical/high-thoracic SCI until proven otherwise—do not assume hemorrhage alone, which causes tachycardia. Look for the paradoxical warm, dry, well-perfused patient with low BP.

Definition: Acute traumatic or non-traumatic insult to the spinal cord producing motor, sensory, or autonomic dysfunction below the level of injury.

Epidemiology and mechanism:

When to suspect SCI in the ED:

Non-traumatic mimics to consider acutely: epidural abscess, epidural hematoma (anticoagulated patient), metastatic cord compression, transverse myelitis, spinal cord infarct (post-aortic surgery)

NEXUS low-risk criteria (all 5 required to forgo cervical imaging):

Canadian C-spine rule: alternative validated tool—any high-risk feature (age ≥65, dangerous mechanism, paresthesias) mandates imaging.

Presentation Patterns and Key History

— Complete: total loss of motor and sensory function below the level, including absent sacral sparing (no perianal sensation, no voluntary anal contraction, no great toe flexion)

— Incomplete: any preserved sacral function—better prognosis

— Central cord syndrome: elderly, hyperextension, upper extremity weakness > lower extremity ("man-in-a-barrel"), variable bladder dysfunction

— Anterior cord syndrome: flexion injury or anterior spinal artery occlusion—loss of motor, pain, temperature; preserved proprioception/vibration; worst prognosis

— Brown-Séquard: hemisection (penetrating trauma)—ipsilateral motor + dorsal column loss, contralateral pain/temperature loss starting 1–2 levels below

— Posterior cord: rare; loss of proprioception/vibration

— Conus medullaris: L1–L2 lesion—mixed UMN/LMN, early bowel/bladder dysfunction, saddle anesthesia

— Cauda equina: below L2—pure LMN, asymmetric, saddle anesthesia, urinary retention with overflow incontinence

— Exact mechanism, helmet/seatbelt use, restraint type

— Loss of consciousness, time of injury, any movement at scene

— Initial vs. current neurologic status (deterioration is critical)

— Spinal precautions maintained?

— Anticoagulant use (suspect epidural hematoma)

— Cancer history, IVDU, fever (non-traumatic etiologies)

— Underlying ankylosing spondylitis, RA, Down syndrome (atlantoaxial instability)

Step 3 management: When EMS reports a "walking" trauma patient who later develops weakness, suspect unstable injury that progressed—immediate full spinal immobilization, CT, and neurosurgical consult. Document the time of any neurologic change because operative urgency depends on it; deteriorating deficits push toward emergent decompression rather than delayed surgery.

Complete vs. incomplete injury:

Classic incomplete syndromes:

Key history to obtain (often from EMS):

Physical Exam Findings and Hemodynamic Assessment

— Test motor in 10 key muscles bilaterally (C5 elbow flex, C6 wrist ext, C7 elbow ext, C8 finger flex, T1 finger abd, L2 hip flex, L3 knee ext, L4 ankle dorsiflex, L5 great toe ext, S1 ankle plantar flex)

— Sensory in 28 dermatomes (light touch and pinprick)

— Mandatory: digital rectal exam for voluntary contraction + perianal sensation (S4–S5)—determines complete vs. incomplete

— A: complete

— B: sensory only below level

— C: motor preserved, majority of key muscles <3/5

— D: motor preserved, majority ≥3/5

— E: normal

— Neurogenic shock: SBP <90, HR <60 (loss of T1–L2 sympathetic outflow, unopposed vagal tone), warm/dry skin

— Distinguish from spinal shock (transient flaccid areflexia below the level lasting hours–weeks—a neurologic, not hemodynamic, phenomenon)

— Hemorrhagic shock causes tachycardia and cool extremities; always rule out concurrent bleeding before attributing hypotension to cord injury alone

— Priapism (parasympathetic unopposed)

— Diaphragmatic breathing with paradoxical abdominal motion (high cervical)

— Horner syndrome (C8–T2)

— Bulbocavernosus reflex: absence = spinal shock; return marks end of spinal shock

Key distinction: Spinal shock = neurologic (flaccidity + areflexia, transient); neurogenic shock = hemodynamic (hypotension + bradycardia from sympathectomy). Both can coexist but require different interventions—pressors and atropine for neurogenic shock; serial exams for spinal shock.

ATLS sequence first: ABCs before detailed neuro exam. A C3–C5 lesion ("C3, 4, 5 keeps the diaphragm alive") threatens ventilation—intubate early if vital capacity falling, ascending level, or fatigue.

ASIA exam (American Spinal Injury Association):

ASIA Impairment Scale:

Hemodynamic assessment:

Other findings:

Diagnostic Workup — Initial Labs and Imaging

— CT cervical, thoracic, lumbar spine without contrast is the first-line modality in blunt trauma; plain films largely obsolete in adults

— CT captures fractures, subluxation, and many ligamentous clues (widened facet joints, prevertebral soft tissue swelling >7 mm at C2 or >22 mm at C6)

— Include CT head, chest/abdomen/pelvis per ATLS as indicated

— Use plain radiographs first in cooperative children with low/intermediate concern to minimize radiation

— Children <8 have relatively larger heads and more ligamentous injury → SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) more common; MRI is needed when symptoms exist despite normal CT/X-ray

— FAST exam to exclude intra-abdominal hemorrhage as cause of hypotension before ascribing it to neurogenic shock

— Chest X-ray (rib fractures, pneumothorax, mediastinal widening)

— Bladder scan or Foley—urinary retention is universal in acute SCI

CCS pearl: Order in this sequence on a CCS case: cervical collar/full spinal precautions → ABCs and IV access → type & cross + trauma labs → CT C/T/L spine → FAST → Foley → NGT → neurosurgery consult. Reassess vitals and neuro exam at each interval—deterioration changes the case.

Resuscitation labs: type and cross, CBC, BMP, coags, lactate, ABG, troponin (cardiac contusion if blunt chest trauma), tox screen, pregnancy test in women of reproductive age.

Imaging strategy:

Indications to image (adults): fail NEXUS or Canadian C-spine criteria, any neuro deficit, altered mental status, distracting injury, intoxication, age ≥65, dangerous mechanism.

Pediatric nuance:

ECG: obtain in any trauma patient with hemodynamic instability or high cord lesion (bradyarrhythmias from autonomic dysfunction).

Adjuncts:

NG decompression: ileus is near-universal with high SCI; place NGT to prevent aspiration.

Diagnostic Workup — Advanced and Confirmatory Studies

— Gold standard for cord parenchyma, ligamentous injury, epidural hematoma, disc herniation

— Indicated when: neurologic deficit present, CT inconclusive, persistent pain with normal CT, suspected SCIWORA, obtunded patient with concerning mechanism

— Length of cord signal change (edema/hemorrhage) correlates with prognosis; intramedullary hemorrhage portends worse recovery

— Obtain when there is cervical spine fracture through transverse foramen, displaced facet fracture, C1–C3 fracture, or basilar skull fracture (modified Denver criteria) to evaluate for blunt cerebrovascular injury (BCVI)—vertebral artery dissection can cause posterior circulation stroke

— Largely replaced by MRI; only useful in awake, cooperative patient with persistent pain and normal CT to assess dynamic instability—never in obtunded patients

— MRI with and without gadolinium for cord compression (metastasis, abscess), transverse myelitis, demyelination

— Add CBC, ESR/CRP, blood cultures for suspected epidural abscess

— CSF studies (after MRI excludes mass effect) for transverse myelitis: cell count, oligoclonal bands, NMO/MOG antibodies

— Coag panel + reversal labs for suspected epidural hematoma in anticoagulated patient

Board pearl: A patient with cancer history presenting with progressive back pain worse at night and lower extremity weakness needs an urgent whole-spine MRI with contrast and immediate IV dexamethasone—do not wait for radiation oncology to image. Time to treatment is the strongest predictor of ambulation outcome in metastatic epidural cord compression.

MRI spine (without contrast for trauma):

CT angiography of the neck:

Flexion-extension films:

Non-traumatic SCI workup:

Urodynamic studies: deferred to subacute setting after spinal shock resolves.

Pulmonary function (bedside): vital capacity <15 mL/kg or NIF less negative than −20 cmH₂O predicts respiratory failure in cervical SCI—intubate proactively.

Risk Stratification and First-Line Management Logic

— Maintain spinal immobilization (rigid collar + log roll)—remove backboard ASAP to prevent pressure injury (<2 hours)

— Airway: low threshold for intubation in C5 or higher lesion; use in-line cervical stabilization during intubation, video laryngoscopy preferred

— Breathing: monitor VC, NIF, ABG; watch for ascending edema in first 72 hours

— Circulation: target MAP 85–90 mmHg for 7 days (AANS guideline) to optimize cord perfusion

— Crystalloid bolus first (rule out hemorrhage)

— If neurogenic shock persists: norepinephrine (α + β, supports HR and BP); avoid pure α-agonists (phenylephrine) which can worsen reflex bradycardia

— Atropine for symptomatic bradycardia; consider transcutaneous/transvenous pacing if recurrent

— No longer routinely recommended by AANS/CNS (2013) due to lack of clear benefit and increased pneumonia, sepsis, GI bleed risk

— May be considered case-by-case within 8 hours for non-penetrating SCI, but is not standard of care

— Contraindicated in penetrating SCI, age <13, pregnancy, moderate/severe TBI, >8 hours from injury

Step 3 management: The single highest-yield intervention beyond stabilization is MAP augmentation to 85–90 mmHg for 7 days. On exam stems, choose norepinephrine over phenylephrine for neurogenic shock and avoid high-dose methylprednisolone as the "correct" answer.

Immediate priorities (parallel, not sequential):

Hemodynamic management:

Methylprednisolone:

Temperature: maintain normothermia; therapeutic hypothermia remains investigational.

DVT prophylaxis: mechanical immediately; pharmacologic (LMWH) within 72 hours once bleeding risk acceptable and after neurosurgery clearance.

Stress ulcer prophylaxis: PPI for high cervical injuries.

Pharmacotherapy — First-Line Drug Regimen

— Norepinephrine: start 0.05 μg/kg/min, titrate to MAP 85–90

— Epinephrine: alternative if bradycardia prominent (β1 chronotropy)

— Dopamine: historically used but arrhythmogenic; second-line

— Atropine 0.5–1 mg IV for HR <50 with symptoms; may need repeat dosing or glycopyrrolate

— For refractory bradycardia: isoproterenol infusion or transcutaneous pacing

— Multimodal: acetaminophen scheduled, low-dose opioids (avoid hypotension), ketamine adjunct

— Avoid NSAIDs acutely (renal hypoperfusion, GI bleed risk with steroids if used)

— Mechanical (SCDs) immediately

— Enoxaparin 30 mg SC q12h or 40 mg daily within 72 hours after neurosurgical clearance

— Continue ≥8–12 weeks—SCI patients have one of the highest VTE rates in medicine

— IVC filter only if anticoagulation contraindicated long-term

— PPI (pantoprazole 40 mg IV daily) for stress ulcer prophylaxis

— Bowel regimen (docusate, senna, bisacodyl suppository) once ileus resolves to prevent fecal impaction

Board pearl: For metastatic epidural cord compression, the sequence is dexamethasone immediately → emergent MRI → radiation oncology + neurosurgery consult. Do not delay steroids waiting for imaging if suspicion is high—neurologic function at presentation is the best predictor of post-treatment ambulation.

Vasopressors and chronotropes (neurogenic shock):

Analgesia:

Sedation for intubated patients: propofol (watch hypotension), fentanyl; dexmedetomidine useful but can worsen bradycardia.

DVT prophylaxis:

GI:

Bladder: indwelling Foley initially, transition to clean intermittent catheterization when stable to reduce UTI/stone risk.

Spasticity (subacute, not acute): baclofen, tizanidine, dantrolene later.

Neuropathic pain: gabapentin/pregabalin as it evolves.

Steroids: dexamethasone 10 mg IV load then 4 mg q6h only for metastatic epidural cord compression—not traumatic SCI.

Procedures and Surgical Management

— Rigid cervical collar (Philadelphia, Aspen)

— Log roll for transfers; remove backboard within 2 hours

— Halo vest for select C1–C2 injuries (elderly tolerate poorly—higher mortality)

— Manual in-line stabilization (MILS), not traction

— Video laryngoscopy or fiberoptic if anatomy permits

— Cricothyrotomy if can't intubate/can't oxygenate

— Avoid succinylcholine after 48–72 hours post-injury (hyperkalemia from up-regulated ACh receptors); rocuronium preferred subacutely

— Early decompression (<24 hours) improves neurologic recovery (STASCIS trial)—indicated for incomplete cervical SCI with ongoing compression, deteriorating exam, unstable fracture

— Approach: anterior cervical discectomy and fusion (ACDF) for disc/anterior bony compression; posterior laminectomy ± fusion for posterior compression or multilevel disease

— Thoracolumbar: posterior pedicle screw fixation

— Cervical facet dislocations may be reduced with awake traction (Gardner-Wells tongs, sequential weights) in cooperative patient—obtain pre-reduction MRI if patient obtunded to exclude disc herniation

— Foley catheter (mandatory acutely)

— NG/OG tube for ileus

— Arterial line for MAP titration

— Central venous access for vasopressors

— IVC filter only if anticoagulation contraindicated and high VTE risk

— Epidural abscess: emergent surgical drainage + IV antibiotics (vancomycin + ceftriaxone empirically)

— Epidural hematoma on anticoagulation: reverse coagulopathy (PCC for warfarin/DOACs, protamine for heparin) and emergent decompression

CCS pearl: For unstable cervical fracture with incomplete deficit, advance the clock to neurosurgery consult and OR within 24 hours; meanwhile continue MAP 85–90, serial neuro exams q1h, DVT prophylaxis (mechanical), and reassess airway frequently—ascending edema commonly peaks 48–72 hours.

Spinal immobilization techniques:

Airway management:

Surgical decompression:

Closed reduction:

Other procedures:

Non-traumatic interventions:

Special Populations — Elderly and Renal/Hepatic Impairment

— Central cord syndrome is the dominant pattern—pre-existing cervical spondylosis + hyperextension (often a low-energy fall)

— Upper-extremity weakness disproportionate to lower; bladder dysfunction variable

— Lower threshold to image: NEXUS/Canadian rules less sensitive in age ≥65

— Avoid halo vests—high morbidity (pneumonia, pressure ulcers, dysphagia)

— Higher mortality at every ASIA grade

— Even minor trauma → epidural hematoma risk

— Reverse promptly: 4-factor PCC for warfarin/factor Xa inhibitors (off-label), idarucizumab for dabigatran, andexanet alfa for apixaban/rivaroxaban

— Vitamin K 10 mg IV alongside PCC for warfarin

— Norepinephrine: no renal adjustment

— Enoxaparin: reduce to 30 mg SC daily if CrCl <30; consider unfractionated heparin SC 5000 U q8h instead for ESRD

— Gabapentin/pregabalin: dose-reduce for CrCl <60

— Avoid IV contrast unless essential; if needed, hydrate with isotonic fluid (consistent with MAP goal)

— Acetaminophen: max 2 g/day in significant hepatic dysfunction

— Benzodiazepines (if used for sedation): prefer lorazepam (no active metabolites) over midazolam/diazepam

— Coagulopathy may worsen bleeding from surgical sites—correct INR with FFP/PCC pre-op

— Brittle, fused spine—three-column fractures from minor trauma; extension injuries common

— Image the entire spine; CT often misses fractures through fused segments—MRI more sensitive

— Avoid forcing the neck into neutral if patient has fixed kyphosis—immobilize in their baseline position

Step 3 management: An 80-year-old on apixaban falls and develops progressive paraparesis—give andexanet alfa, obtain emergent MRI, and call neurosurgery. The combination of anticoagulation reversal + early decompression saves cord function.

Elderly patients:

Anticoagulated elderly patient:

Polypharmacy considerations: beta-blockers blunt the tachycardic response, masking hemorrhage; antihypertensives compound neurogenic hypotension—hold acutely.

Renal impairment:

Hepatic impairment:

Ankylosing spondylitis/DISH:

Special Populations — Pregnancy and Pediatrics

— Position pregnant trauma patient in left lateral tilt (15°) on the backboard to relieve IVC compression

— Maternal resuscitation is fetal resuscitation—do not withhold imaging; shielded CT delivers minimal fetal dose

— Avoid hypotension aggressively; uteroplacental perfusion depends on maternal MAP

— Fetal monitoring for ≥4 hours after viable-gestation trauma (≥23 weeks); longer if contractions, bleeding, or abnormal tracing

— Methylprednisolone (if ever considered) is generally avoided in pregnancy

— Autonomic dysreflexia in late-pregnancy SCI mimics preeclampsia—differentiate by trigger (bladder distention, labor) and time course

— RhoGAM if Rh-negative mother with any abdominal trauma

— SCIWORA common <8 years due to ligamentous laxity and large head-to-body ratio—normal X-ray/CT does not exclude cord injury

— MRI is the test of choice when symptoms persist

— Pediatric C-spine clearance tools: PECARN criteria (altered mental status, focal deficit, neck pain, torticollis, substantial torso injury, predisposing condition, diving, high-risk MVC)

— Use pediatric backboards with occipital recess to avoid forced cervical flexion

— Atlantoaxial instability in Down syndrome, Klippel-Feil, Morquio, juvenile RA, achondroplasia—obtain flexion-extension films before sports clearance, image early after trauma

— Birth-related SCI: cervical traction during delivery—evaluate floppy newborn with absent reflexes below a level

Board pearl: A child with a normal C-spine CT but persistent weakness after a sports injury has SCIWORA until MRI proves otherwise. Maintain immobilization, admit, obtain MRI, and consult pediatric neurosurgery—do not clear the collar based on CT alone.

Pregnancy:

Pediatrics:

Non-accidental trauma: any infant with spinal injury and inconsistent history—mandatory child protective services report and full skeletal survey.

Complications and Adverse Outcomes

— Atelectasis, pneumonia, mucus plugging (impaired cough)

— Ascending cord edema can convert C5 lesion into C3 ventilator dependence within 72 hours

— Diaphragmatic pacing or chronic vent dependence for high cervical lesions

— Persistent neurogenic hypotension/bradycardia for days–weeks

— Autonomic dysreflexia (lesion at or above T6): noxious stimulus below the level → massive sympathetic surge → severe hypertension, bradycardia, headache, flushing above level, pale/cold below

— Triggers: bladder distention (most common), fecal impaction, pressure ulcer, ingrown toenail, labor

— Management: sit patient upright, loosen clothing, identify and remove trigger (catheterize bladder first), short-acting antihypertensive (nitroglycerin paste, nifedipine bite-and-swallow)

Key distinction: Neurogenic shock = early, hypotension + bradycardia from sympathectomy. Autonomic dysreflexia = chronic complication of T6 or above lesions, hypertensive emergency triggered by a noxious stimulus—opposite direction of BP. Recognizing the difference can be life-saving (stroke, MI, seizure, death from untreated dysreflexia).

Respiratory:

Cardiovascular:

VTE: DVT/PE incidence among highest in medicine—prophylaxis ≥8–12 weeks.

GI: ileus, stress ulcer, neurogenic bowel with chronic constipation/impaction.

GU: neurogenic bladder, recurrent UTIs, urolithiasis, vesicoureteral reflux, renal failure (leading cause of late mortality historically).

Skin: pressure injuries (sacrum, heels, occiput)—reposition q2h, specialty mattress, off-load heels.

Musculoskeletal: spasticity, contractures, heterotopic ossification (hips, knees—warm, swollen joint weeks–months out; elevated alkaline phosphatase; treat with etidronate, NSAIDs, radiation).

Metabolic: SIADH, hyponatremia, hypercalcemia (immobilization).

Psychiatric: depression, suicide risk markedly elevated—screen routinely.

Sexual dysfunction: erectile dysfunction, retrograde ejaculation, fertility issues.

Temperature dysregulation: poikilothermy below the lesion.

When to Escalate Care — ICU, Consult, and Transfer

— All acute cervical SCI

— Thoracic SCI with hemodynamic instability or respiratory compromise

— Need for vasopressors, mechanical ventilation, or close MAP titration

— Unstable spine awaiting surgery

— Autonomic instability (recurrent bradycardia requiring atropine)

— Neurosurgery or orthopedic spine (depends on institution)—within 1 hour of diagnosis

— Trauma surgery for polytrauma

— Anesthesia for difficult airway planning

— Critical care for ICU co-management

— Physical medicine & rehab (PM&R)—engage early to plan disposition

— Social work, case management—rehabilitation placement requires early coordination

— If receiving facility lacks 24/7 neurosurgery, spine-capable OR, or ICU with vent capacity → transfer to Level I trauma center or designated spinal cord injury model system center

— EMTALA: stabilize first; document accepting physician, mode of transport, equipment needed (cervical collar, vacuum mattress, vent)

— Air transport for time-critical cases when ground transport >30–45 minutes

— Send all imaging electronically before patient arrives

— Provide last neuro exam, MAP/HR trends, medications given, time of injury

— Use structured handoff (SBAR, I-PASS) to reduce error

— Falling VC, ascending sensory level, new bradycardia—intubate and call neurosurgery STAT

— New paraparesis post-spinal anesthesia or epidural catheter—emergent MRI for epidural hematoma

CCS pearl: On the CCS, advance the clock in short intervals (15–60 minutes) after diagnosing acute SCI; re-examine vitals and neurologic status repeatedly. Missing a deterioration that needed earlier intubation or surgery costs points. Order neurosurgery consult, ICU bed, and MAP monitoring early.

ICU admission criteria:

Consultations to obtain immediately:

Transfer criteria:

Communication and handoff:

CCS-specific escalation triggers:

Key Differentials — Same-Category (Neurologic) Causes

— Vertebral artery dissection from neck trauma can cause lateral medullary (Wallenberg) syndrome or cerebellar infarct

— Crossed findings (ipsilateral face, contralateral body), vertigo, dysphagia distinguish from cord lesion

— CT angiography neck mandatory with high-cervical fractures

— Anterior spinal artery syndrome: post-aortic surgery, aortic dissection, severe hypotension, vasculitis

— Sudden onset (vs. progressive in compression), preserved dorsal column, MRI shows "pencil-like" T2 hyperintensity

— Anticoagulated patient, recent neuraxial procedure (epidural anesthesia), AVM rupture

— Sudden back pain + ascending paraparesis—emergent decompression within hours for recovery

— Triad: fever + back pain + neurologic deficit (only 13% have all three)

— IVDU, diabetes, recent spine procedure, bacteremia

— MRI with contrast; empiric vancomycin + ceftriaxone; emergent surgical drainage for deficit

— Subacute (hours–days), often post-viral or autoimmune (MS, NMO, MOG, lupus, sarcoid)

— MRI: cord T2 hyperintensity spanning multiple segments

— Treat with high-dose IV methylprednisolone; PLEX if refractory

— Ascending flaccid paralysis, areflexia, no sensory level, autonomic dysfunction

— CSF: albuminocytologic dissociation; NCS shows demyelination

— Treat with IVIG or plasmapheresis—not steroids

Key distinction: A sensory level points to cord pathology; glove-and-stocking distribution with areflexia points to peripheral (GBS). On exam, find the highest dermatome of deficit and check reflexes—this separates intramedullary/extramedullary cord disease from polyneuropathy.

Stroke (especially posterior circulation):

Spinal cord infarction:

Epidural hematoma (non-traumatic):

Epidural abscess:

Transverse myelitis:

Guillain-Barré syndrome:

Multiple sclerosis flare: younger patient, prior episodes, optic neuritis, oligoclonal bands.

Cauda equina syndrome: disc herniation L4–L5/L5–S1—surgical emergency for saddle anesthesia + urinary retention.

Key Differentials — Other-Category Causes

— Known cancer (breast, lung, prostate, multiple myeloma, renal) with progressive back pain worse at night, then weakness

— MRI whole spine + IV dexamethasone immediately

— Radiation oncology vs. surgical decompression depends on stability, life expectancy, radiosensitivity

— Insidious back pain, fever, elevated ESR/CRP, IVDU or bacteremia

— MRI shows disc + adjacent endplate involvement

— Blood cultures + image-guided biopsy before antibiotics if stable

— Inconsistent exam (Hoover sign positive, give-way weakness, distractible findings)

— Diagnosis of exclusion after thorough workup

Board pearl: Sudden paraplegia + back/chest pain + unequal upper-extremity pulses = aortic dissection with cord ischemia until proven otherwise. CT angiography of the chest/abdomen/pelvis is the diagnostic test; consult vascular/cardiothoracic surgery before any anticoagulation.

Metastatic epidural cord compression:

Vertebral osteomyelitis/discitis:

Conversion disorder/functional neurologic disorder:

Hysterical hyperventilation/syncope: mimics post-traumatic neurologic complaint but resolves rapidly.

Hypoglycemia: can cause focal deficits; check glucose in every altered patient.

Tick paralysis: ascending flaccid paralysis from neurotoxin; remove tick, symptoms resolve hours later.

Botulism: descending paralysis, bulbar symptoms first, pupil involvement.

Toxic-metabolic encephalopathy: generalized weakness, no clear level.

Aortic dissection with malperfusion: chest/back pain + paraplegia from anterior spinal artery involvement—CT angio chest/abdomen/pelvis if pulse deficits or BP discrepancy >20 mmHg between arms.

Compartment syndrome: missed in immobilized SCI patient because pain is absent—monitor compartments in extremity injuries with measurements not symptoms.

Acute intermittent porphyria: abdominal pain + autonomic dysfunction + motor neuropathy + psychiatric symptoms; urine PBG.

Polio/West Nile virus poliomyelitis: asymmetric flaccid paralysis, fever, CSF pleocytosis.

Secondary Prevention and Long-Term Discharge Plan

— Enoxaparin 30 mg SC q12h for ≥8–12 weeks (longer if persistent motor deficit)

— Baclofen (start 5 mg TID, titrate) or tizanidine for spasticity

— Gabapentin or pregabalin for neuropathic pain

— Stool softener + stimulant laxative; scheduled bowel program (every 1–2 days, often with suppository or digital stimulation)

— Bladder management: clean intermittent catheterization q4–6h; consider oxybutynin for detrusor overactivity

— PPI weaned once off steroids and bleeding risk low

— SSRI/SNRI if depression screening positive

— Pneumococcal and annual influenza vaccines (chronic respiratory risk)

— Pressure injury prevention education: weight shifts q15 min in wheelchair, daily skin checks

— Calcium + vitamin D, bisphosphonate consideration for immobilization osteoporosis

— Annual renal ultrasound + serum creatinine for neurogenic bladder

— Routine UTI prevention (avoid prophylactic antibiotics—encourages resistance)

— Refer to SCI model system rehabilitation center for inpatient rehab

— Driving evaluation, vocational rehab, home modifications (ramps, grab bars, accessible bathroom)

— Adaptive sports and peer support groups

— Sexual health and fertility counseling

— Recognize autonomic dysreflexia (sit up, find trigger, call for help)

— Recognize early signs of UTI, pressure injury, DVT

— Bowel/bladder program adherence

Step 3 management: At discharge, the high-yield order set is VTE prophylaxis × 8–12 weeks, bowel/bladder program, spasticity and neuropathic pain meds, mental health screening, vaccine update, and rehab referral. Document caregiver teaching on autonomic dysreflexia—an exam favorite.

Discharge medications (typical regimen after stabilization):

Secondary prevention of complications:

Lifestyle and rehabilitation:

Caregiver education:

Follow-Up, Monitoring, and Counseling

— Spine surgery: 2 weeks (wound check), 6 weeks (imaging), 3 months, 6 months, then annually with flexion-extension films or CT to assess fusion

— PM&R: weekly during inpatient rehab, then every 3 months in year 1, every 6–12 months thereafter

— Primary care: integrate within 2 weeks of discharge for med reconciliation, depression screen, pressure injury assessment

— Urology: at 3 months for urodynamics; renal ultrasound annually

— Neurologic: serial ASIA exams to track recovery; most improvement occurs in first 6–12 months

— Renal: BUN/creatinine, urine culture if symptomatic only

— Bone density: DEXA at 12 months, then every 1–2 years

— Skin: every visit

— Mental health: PHQ-9 at every visit (suicide risk 3–5× general population)

— Pulmonary: spirometry, vaccination status

— C5: feeding with adaptive equipment, electric wheelchair

— C6: independent transfers possible, manual wheelchair with adaptations

— C7: independent ADLs, manual wheelchair, drive with hand controls

— T1 and below: full upper-extremity function; ambulation with bracing possible at lower levels

— L2 and below: community ambulation often achievable

— Realistic prognosis (incomplete > complete recovery; 24-hour ASIA exam after spinal shock resolves predicts best)

— Sexual function, fertility (men: electroejaculation; women: fertility usually preserved, high-risk pregnancy)

— Driving, employment, school re-entry

— Substance use—alcohol/drugs are risk factors for re-injury

CCS pearl: When advancing the clock in outpatient follow-up after SCI, order the PHQ-9, renal ultrasound (annual), DEXA (at 1 year), urodynamics (at 3 months), pulmonary function if cervical lesion. Multidisciplinary follow-up across PM&R, urology, primary care, and mental health is the standard of care.

Follow-up cadence:

Monitoring parameters:

Rehabilitation goals:

Counseling topics:

Ethical, Legal, and Patient Safety Considerations

— Patient with high cervical SCI may have intact cognition but be unable to sign—use verbal consent with witness, documented thoroughly

— Intubated/sedated patient: identify surrogate per state hierarchy (spouse → adult child → parent → sibling)

— Emergency exception applies for life- or limb-threatening interventions when surrogate unavailable

— Document discussion of operative risks specifically including failure to recover neurologic function, infection, and inability to walk or regain function

— Devastating high cervical SCI (C1–C3, ventilator-dependent) with elderly, frail, or significant comorbidity warrants early palliative care consult

— Discuss long-term ventilator dependence, tracheostomy, PEG, and quality-of-life expectations

— Honor existing DNR/DNI when documented, but verify currency and relevance

— Suspected non-accidental trauma in children or vulnerable adults → child/adult protective services

— Gunshot wounds and stab wounds → law enforcement reporting per state law

— Motor vehicle crashes involving impairment → some states require physician reporting of impaired drivers

— Highest-risk handoff points: ED → ICU, ICU → floor, hospital → rehab, rehab → home

— Medication reconciliation errors (especially DVT prophylaxis discontinued prematurely, missed bowel program) are common

— Use structured handoff and "teach-back" with patient/caregiver

— Pressure injury within 2 hours of immobilization—remove backboards quickly

— Cervical collars: skin breakdown at chin/occiput; inspect every shift

— Falls in rehab phase: orthostatic from autonomic dysfunction—educate on gradual mobilization

— Insurance status drives rehab access; advocate for SCI model system placement when clinically indicated

— Document medical necessity carefully for durable medical equipment denials

Board pearl: A patient with new C2 quadriplegia who is alert and asks to withdraw ventilator support has the right to refuse life-sustaining treatment after capacity assessment, palliative care involvement, and time for adjustment. Respect autonomy while ensuring treatable depression isn't driving the decision.

Informed consent edge cases:

Advance directives and goals of care:

Mandatory reporting:

Transition-of-care risks:

Patient safety in immobilization:

Equity considerations:

High-Yield Associations and Rapid-Fire Facts

Key distinction: MAP goal 85–90 in SCI is higher than the standard sepsis target of 65—because injured cord tissue is perfusion-dependent. Choosing the higher number on a test stem is almost always correct in acute SCI.

C3, 4, 5 keeps the diaphragm alive—lesions above C3 → ventilator dependence.

Neurogenic shock = hypotension + bradycardia + warm extremities (T6 and above lesions).

Spinal shock = transient flaccid areflexia; resolution marked by return of bulbocavernosus reflex.

Central cord syndrome = elderly + hyperextension + arms > legs.

Anterior cord = worst prognosis; preserved proprioception.

Brown-Séquard = penetrating; ipsilateral motor/dorsal column, contralateral pain/temp.

MAP goal 85–90 mmHg × 7 days to optimize cord perfusion.

Norepinephrine is the pressor of choice; avoid phenylephrine.

Methylprednisolone is no longer standard for traumatic SCI (AANS 2013).

Early surgical decompression (<24 h) improves outcomes in cervical incomplete SCI.

Succinylcholine after 48–72 hours post-injury → fatal hyperkalemia.

Autonomic dysreflexia: T6 and above; bladder distention #1 trigger; sit up + find trigger + nifedipine/nitroglycerin.

SCIWORA = children <8; MRI is the test.

Ankylosing spondylitis + minor trauma = three-column fracture; image entire spine with MRI.

Aortic dissection can present as paraplegia (anterior spinal artery).

Metastatic epidural cord compression: dexamethasone first, then MRI, then radonc/neurosurgery.

GBS = ascending, areflexia, no sensory level, albuminocytologic dissociation.

Bulbocavernosus reflex absent in spinal shock; return signals end.

Renal failure historically the #1 late cause of death—now respiratory complications and sepsis lead.

Suicide risk 3–5× general population—screen routinely.

Atlantoaxial instability: Down syndrome, Klippel-Feil, Morquio, achondroplasia, juvenile RA.

Heterotopic ossification: warm swollen hip weeks–months out; elevated alk phos.

Left lateral tilt for pregnant trauma patient on backboard.

Vertebral artery dissection → CTA neck for high-cervical fractures.

Board Question Stem Patterns

Step 3 management: Question stems frequently test the wrong answer choice of "high-dose methylprednisolone" or "phenylephrine"—remember the right pressor (norepinephrine), the right BP target (MAP 85–90), and the right next step (early surgical consult).

Stem 1 — Neurogenic shock: "22-year-old man after MVC, BP 80/50, HR 50, warm extremities, weak legs." → Norepinephrine + atropine + MAP 85–90; not more crystalloid alone.

Stem 2 — Central cord syndrome: "78-year-old falls forward, hits forehead, has weakness greater in arms than legs." → Diagnosis is central cord; CT then MRI; admit, consult neurosurgery, MAP goal 85–90.

Stem 3 — Autonomic dysreflexia: "32-year-old with T4 paraplegia develops headache, BP 210/110, flushing above chest, pale below." → Sit upright, catheterize bladder first (most common trigger), nitroglycerin paste if BP persists.

Stem 4 — Methylprednisolone trap: "Trauma patient with SCI, what is next step?" → Not high-dose steroids; MAP support, surgical consult, imaging.

Stem 5 — Succinylcholine after SCI: "Intubation needed 1 week after SCI for pneumonia, patient develops cardiac arrest after RSI." → Hyperkalemia from succinylcholine; use rocuronium subacutely.

Stem 6 — Metastatic cord compression: "Breast cancer history, night back pain, new leg weakness." → Dexamethasone now, then emergent MRI, then radonc.

Stem 7 — Epidural abscess: "IVDU with fever and back pain, new urinary retention." → MRI with contrast, blood cultures, vanc + ceftriaxone, neurosurgery.

Stem 8 — SCIWORA: "6-year-old with normal CT but weak legs after trampoline injury." → MRI; maintain immobilization.

Stem 9 — Aortic dissection mimic: "Tearing chest pain radiating to back + sudden paraplegia + BP differential between arms." → CTA chest, vascular surgery.

Stem 10 — Ankylosing spondylitis fall: "AS patient minor fall, neck pain, normal C-spine X-ray." → CT/MRI entire spine; assume unstable fracture.

Stem 11 — Anticoagulant + back pain: "Patient on apixaban develops back pain and leg weakness." → Andexanet, emergent MRI, neurosurgery.

Stem 12 — Discharge planning: "Patient with T6 SCI ready for discharge—what is essential?" → DVT prophylaxis 8–12 weeks, bowel/bladder program, AD education, rehab referral.

One-Line Recap

Acute spinal cord injury management hinges on immobilization, airway control, MAP 85–90 mmHg for 7 days with norepinephrine, urgent imaging (CT then MRI), and early surgical decompression (<24 hours for incomplete cervical injury)—while methylprednisolone is no longer routinely recommended.

Board pearl: When stuck between answer choices, choose MAP 85–90 with norepinephrine, MRI, and early neurosurgical decompression—and reject high-dose methylprednisolone and phenylephrine. These three principles drive the majority of Step 3 SCI questions.

Hemodynamics: Distinguish neurogenic shock (hypotension + bradycardia, warm) from hemorrhagic shock (tachycardia, cool) and spinal shock (transient flaccid areflexia). Treat neurogenic shock with crystalloid then norepinephrine and atropine; target MAP 85–90 for 7 days to optimize cord perfusion.

Diagnostics: CT C/T/L spine is first-line imaging for blunt trauma; MRI for any neurologic deficit, SCIWORA suspicion, or non-traumatic etiology. ASIA exam (motor + sensory + rectal) determines complete vs. incomplete and prognosticates recovery.

Definitive management: Early surgical decompression within 24 hours improves outcomes in incomplete cervical SCI. Avoid succinylcholine after 48–72 hours. DVT prophylaxis (mechanical immediately, LMWH within 72 hours) for ≥8–12 weeks. Foley, NGT, PPI, bowel program standard.

Complications and longitudinal care: Watch for ascending edema (intubate proactively), autonomic dysreflexia (T6 and above; sit up + find trigger), neurogenic bowel/bladder, pressure injuries, depression. Multidisciplinary follow-up with PM&R, urology, primary care, and mental health; vaccines and DEXA at 1 year; rehab placement at an SCI model system center optimizes functional recovery.