Spinal Cord Injury and Spine Trauma

What is acute spinal cord injury?

A sudden injury to the “central pathway” that transmits all motor commands and sensory information to and from the brain.

Acute spinal cord injury (SCI) refers to damage to the spinal cord or the nerve roots within the spinal canal, most commonly after spinal trauma. It may cause:

• weakness or paralysis of the arms and/or legs,
• loss of sensation below the level of injury,
• sphincter dysfunction (bladder, bowel),
• autonomic nervous system disturbances (blood pressure, heart rate).

The initial injury (primary injury) is often followed by secondary injury due to swelling, ischemia, and inflammation, which can significantly worsen neurological status—this is why rapid, specialized management is critical.

What are the most common causes & mechanisms of injury?

SCI is usually associated with high-energy trauma, but it can also occur after a “low-energy” fall in older adults.

Most common causes:

• Road traffic accidents (collision, rollover, motorcycle).
• Falls from height or at ground level (especially in older adults with osteoporosis).
• Sports injuries (diving into shallow water, cervical injuries).
• Blunt or penetrating trauma (e.g., stab wounds, gunshot injuries).

Mechanisms include flexion, extension, compression, shear, or combinations, leading to fracture, dislocation, or canal narrowing with spinal cord compression.

How does it present clinically – which symptoms are red flags?

Any significant trauma with neurological symptoms below a level must be treated as a potential spinal cord injury until proven otherwise.

Typical signs/symptoms after trauma include:

• Sudden weakness in the arms, legs, or both.
• Loss of sensation (numbness, burning, reduced touch/temperature perception).
• Loss of bladder or bowel control.
• Difficulty breathing (especially in high cervical injuries).
• Severe neck or back pain after injury.

In the acute setting, a comprehensive neurological examination (motor, sensory, reflexes, sphincter function) is performed and documented in a standardized manner using the ASIA / ISNCSCI scale.

What is neurological assessment & the ASIA / ISNCSCI scale?

ASIA/ISNCSCI is the internationally accepted “language” for grading injury severity—guiding immediate decisions and prognosis.

The ISNCSCI / ASIA scale (American Spinal Injury Association) is a standardized system that includes:

• motor testing of key muscles by spinal level,
• sensory testing (light touch, pinprick) in defined dermatomes,
• specific assessment of sacral segments S4–S5 (perianal sensation, voluntary anal sphincter contraction).

Based on these findings, injuries are graded ASIA A–E:

• ASIA A: complete injury – no motor or sensory function below the level of injury, including no sacral function (S4–S5).
• ASIA B: sensory incomplete – sensory function preserved below the level of injury (including S4–S5), but no motor function.
• ASIA C: motor incomplete – motor function preserved below the level of injury; > 50% of key muscles have strength < 3/5.
• ASIA D: motor incomplete – motor function preserved; ≥ 50% of key muscles below the injury have strength ≥ 3/5.
• ASIA E: normal motor and sensory function.

In complete injuries (ASIA A), the Zone of Partial Preservation (ZPP)—the lowest level with any trace of function— helps refine prognosis.

What do complete (ASIA A) and incomplete (ASIA B–D) injuries mean?

“Complete” does not mean there is no hope—it means that, on the current exam, no neurological function is detected below the injury level.

A complete injury (ASIA A) means there is no sensory or motor function below the neurological level and no sacral sparing (S4–S5). In these cases, recovery potential is more limited; however, early support and rehabilitation remain absolutely essential for independence and complication prevention.

Incomplete injuries (ASIA B–D) generally have a better prognosis for neurological recovery. The greater the preserved motor function below the level of injury, the higher the likelihood of meaningful functional improvement over time.

Why is immediate spinal immobilization critical?

A significant proportion of spinal cord damage can occur after the initial accident—during movement, handling, or transport.

It is estimated that 3–25% of spinal cord injuries may worsen during transport or early care. Therefore:

• Any polytrauma patient is treated as having a potential spinal injury until proven otherwise.
• Cervical immobilization is applied with a rigid collar and lateral supports.
• The patient is transported on a spinal board/stretcher with straps, maintaining head–neck–torso alignment.

Immobilization reduces flexion/extension and translational forces across injured segments, protecting the spinal cord from further mechanical injury. At the same time, clinicians weigh benefit versus potential complications (discomfort, pressure injury, airway challenges), particularly in penetrating trauma.

Which imaging studies are needed (X-ray, CT, MRI)?

The goal is early identification of fractures, dislocations, or instability—and, when needed, intramedullary injury.

Imaging selection depends on:

• the mechanism of injury,
• the neurological status (complete vs incomplete deficit, pain, tenderness),
• whether the patient is cooperative or sedated/in ICU.

General principles:

• In symptomatic patients (neck/back pain, neurological signs), the preferred test for bony injury is high-quality CT of the spine.
• MRI is essential to evaluate the spinal cord, ligaments, discs, and degree of compression. The pattern and extent of T2 signal change can also provide prognostic information.
• Plain X-rays may be used if CT is not available, but are insufficient to fully exclude injury—especially in the cervical spine.

In patients who cannot be examined clinically (e.g., deep sedation), MRI often guides when it is safe to discontinue immobilization.

How is acute cardiopulmonary & intensive care management provided?

Spinal cord injury is not only an “orthopedic” problem—it is also an intensive care condition.

Patients with acute SCI, especially cervical injuries, require close monitoring in an ICU or high-dependency unit. Priorities include:

• Airway and breathing support – in high cervical injuries (C1–C4), intubation and mechanical ventilation may be required.
• Hemodynamic stabilization – treatment of neurogenic shock, bradycardia, hypotension.
• Maintaining adequate spinal cord perfusion: a common target is mean arterial pressure (MAP) around 85–90 mmHg for the first 7 days to limit secondary ischemic injury.
• Prevention of complications – pneumonia, thromboembolic events, pressure ulcers, spasticity.

Close cardiopulmonary monitoring is important not only during the first hours, but for at least 7–10 days after injury, as disturbances may persist or appear later.

What is the role of neurosurgical decompression & stabilization?

The goal of surgery is to relieve pressure on the spinal cord and nerves and to stabilize the spine when necessary to protect them.

Typical indications for urgent or early surgery include:

• Fracture–dislocation or instability with mechanical compression of the spinal cord.
• Significant cord or nerve root compression from bone fragments, disc material, or hematoma.
• Progressive neurological deterioration or worsening despite initial stabilization.

Depending on the level, techniques may include:

• Anterior or posterior decompression (corpectomy, laminectomy, foraminotomy).
• Instrumented fusion with screws, rods, and grafts to stabilize and restore alignment.

The decision for surgery is made case-by-case, based on neurological status, overall medical condition, imaging findings, and rehabilitation potential.

What happens after the hospital – rehabilitation & physiotherapy?

The post-acute course is a marathon—structured rehabilitation is as important as the surgical or acute management itself.

Long-term care typically includes:

• Specialized physiotherapy & occupational therapy – strengthening, contracture prevention, transfer and mobility training.
• Training with assistive devices (wheelchair, walkers, braces/orthoses).
• Neurourology follow-up – management of neurogenic bladder and bowel.
• Psychological & social support for the patient and the family.
• Prevention of secondary complications (pressure ulcers, osteoporosis, thrombosis, spasticity).

Neurological reassessment is performed periodically, especially within the first year, when the clinical picture typically stabilizes. Many patients with incomplete injuries show meaningful functional improvement within the first 12 months.

Which factors affect prognosis & functional outcome?

Outcome depends not only on the injury itself—severity, level, general health, and rehabilitation quality all matter.

Key prognostic factors:

• Injury severity by ASIA – ASIA B–D generally have substantially better recovery potential than ASIA A.
• Injury level – higher (closer to the neck) injuries have greater impact on function and survival.
• MRI findings – extent of intramedullary signal change, degree of compression.
• Associated injuries, hypoxia, hypotension – worsen outcomes.
• Time to stabilization & decompression and the quality/intensity of rehabilitation.

In general, neurological status tends to stabilize within about one year. Clear, realistic counseling for the patient and family is essential for psychological adjustment and planning.