Acute Spinal Cord Injury

Epidemiology

  • Prevalence (2014 Data): there are approximately 276k persons with spinal cord injury in the US
  • Clinical Data
    • Study of Traumatic Spinal Cord Injury from 1993-2012 (JAMA, 2015) [MEDLINE]
      • Rate of Traumatic Spinal Cord Injury (2012): 54 cases per million
      • Rate of Traumatic Spinal Cord Injury Remained Stable from 1993-2012: however, due to the increase in population, the total number of cases increased
      • Largest Increase in the Number of Cases of Traumatic Spinal Cord Injury was Observed in Older Patients, Mainly Due to an Increase in the Number of Falls
      • In-Hospital Mortality Rate for Traumatic Spinal Cord Injury Remained High: especially in older patients

Risk Factors (Spine, 2001) [MEDLINE]


Etiology

  • General Comments

    • Review of Etiologies of Traumatic Spinal Cord Injury in the United States (Spinal Cord, 2012) [MEDLINE]
      • Motor Vehicle Accident (MVA): 48% of cases
      • Fall: 16% of cases
      • Violence (Including Gunshot Wounds, etc): 12% of cases
      • Sports Accident: 10% of cases
      • Other: 14% of cases
  • Fall

  • Demyelinating Spinal Cord Disease
    • xxxx
  • Gunshot Wound
  • Infection
  • Motor Vehicle Accident (MVA)
  • Spinal Stenosis (see xxxx, xxxx)
  • Tumor
  • Vascular Disease

Diagnosis

Spine MRI (see Spine Magnetic Resonance Imaging, Spine Magnetic Resonance Imaging)

  • xxx

Clinical Manifestations

General Comments

Acute Spinal Injury Association (ASIA) Impairment Scale

  • Grade A: Complete cord injury. No motor or sensory function is preserved in the sacral segments S4-5
  • Grade B: Sensory incomplete. Sensory but not motor function is preserved below the neurologic level and includes the sacral segmments (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body
  • Grade C: Motor incomplete. Motor function is preserved below the neurologic level and more than half of key muscle functions below the neurologic level of injury have a muscle grade <3 (Grades 0 to 2)
  • Grade D: Motor incomplete. Motor function is preserved below the neurologic level and at least half (half or more) of key muscle functions below the neurologic level of injury have a muscle grade ≥3
  • Grade E: Normal. Sensation and motor function are graded as normal in all segments and the patient had prior deficits.

Cardiovascular Manifestations

Neurogenic Shock (Usually with Bradycardia)

  • Epidemiology
    • Neurogenic Shock Occurs with Acute Spinal Cord Injury
    • No Difference in the Frequency of Neurogenic Shock by Level of Spinal Cord Injury (Arch Surg, 2003) [MEDLINE]
  • Physiology
    • Interruption of Autonomic Pathways in the Spinal Cord
  • Clinical
    • Sinus Bradycardia (see Sinus Bradycardia, Sinus Bradycardia)
      • Bradycardia is More Commonly Observed with High Cervical (C1-C5) Lesions within the First Two Weeks After Injury (J Am Coll Cardiol, 1987) [MEDLINE]
      • Patients with High Cervical Spinal Cord Injury (C1-C5) Had a Significantly Increased Risk for Cardiovascular Intervention, as Compared to Lower Cervical Spinal Cord Injuries (C6-C7) (Arch Surg, 2003)* [MEDLINE]
    • Hypotension (see Hypotension, Hypotension)

Gastrointestinal Manifestations

Stress Ulcers/Peptic Ulcer Disease (PUD) (see Peptic Ulcer Disease, Peptic Ulcer Disease)

  • Clinical Data
    • *Study of Risk Factors for Stress Ulcers After Trauma (J Trauma, 1995) [MEDLINE]
      • Clinical Stress Ulcers Developed in 0.17% of Trauma Patients, Despite Prophylaxis
      • Risk Factors for Stress Ulcers Included Severe Injury (ISS >16) and Spinal Cord Injury

Neurologic Manifestations

Acute Motor Deficit (see Acute Motor Deficit, Acute Motor Deficit)

  • xxx

Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia)

Pulmonary Manifestations

General Comments

  • Epidemiology
    • Pulmonary Complications (and Hospitalizations) are Common After Spinal Cord Injury
      • In a Canadian Study, Approximately 27.5% of Patients with Spinal Cord Injury were Hospitalized within 1 Year After Discharge, with 11.% of the Hospitalizations Being Due to a Respiratory Etiology (Spinal Cord, 2009) [MEDLINE]
      • In the US, the Overall Hospitalization Rate from 5-20 Years After Injury was 20-25%, with 8.1% Being Due to a Respiratory Etiology (Arch Phys Med Rehabil, 2004) [MEDLINE]
    • Pulmonary Diseases are the Second Most Common Cause of Death After Spinal Cord Injury, After Cardiovascular Diseases) (J Spinal Cord Med, 2006): pulmonary disease accounts for 20-30% of the mortality which occurs beyond the first year after injury [MEDLINE]

Atelectasis (see Atelectasis, Atelectasis)

  • Epidemiology: common
  • Physiology
    • Weakness of Diaphragm and Chest Wall Muscles, Resulting in Impaired Cough and Secretion Clearance

Dysphonia (see Dysphonia, Dysphonia)

  • Epidemiology
    • Occurs in Spontaneously Breathing Cervical Cord Injury Patients with Expiratory Muscle Weakness
  • Clinical
    • Decreased Vocal Amplitude
    • Lower Number of Syllables Per Breath

Dyspnea (see Dyspnea, Dyspnea)

  • Epidemiology: common
    • Prevalence of Dyspnea is Usually (But Not Always) Related to the Level of the Spinal Cord Injury (Spinal Cord, 1997) [MEDLINE]

Neurogenic Pulmonary Edema (see Neurogenic Pulmonary Edema, Neurogenic Pulmonary Edema)

  • Epidemiology: rare complication of spinal cord injury
    • In Acute Spinal Cord Injury, Neurogenic Pulmonary Edema is Associated with Complete Cervical Cord Injury
    • In Chronic Spinal Cord Injury, Neurogenic Pulmonary Edema is Associated with Cervical Cord Injury Above T6 in Conjunction with Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia)
    • Physiology
      • xxxx

Respiratory Failure (see Respiratory Failure, Respiratory Failure)

  • Epidemiology
    • Respiratory Failure is Common After Spinal Cord Injury: both acutely and chronically after the injury
  • Physiology
    • Acute Spinal Cord Injury Results in Flaccid Paralysis of All Muscles Caudal (Distal) to the Site of Spinal Cord Injury, Including the Respiratory Muscles: extent of ventilatory respiratory impairment depends on the level and severity of cord injury
      • Ventilatory Impairment is Most Common and Severe with Complete Cervical Cord Injuries, But May Also Occur in Thoracic Cord Injuries
    • Factors Contributing to Improvement in Respiratory Muscle Function in the Weeks Following Spinal Cord Injury
      • Decreased Spinal Cord Inflammation with Functional Descent of the Level of Neurologic Injury
      • Evolution from Flaccid Paralysis (Spinal Shock) to Spastic Paralysis
        • Abdominal and Intercostal Muscle Become Less Flaccid, Resulting in Rib Cage Stabilization
      • Increased Recruitment of Accessory Ventilatory Muscles
      • Retraining of Deconditioned Muscles

Pneumonia

  • Epidemiology
    • Risk of Pneumonia is the Highest in the First Year After Injury, But Remains High Over the Lifetime of the Patient with Spinal Cord Injury (Arch Phys Med Rehabil, 1994) [MEDLINE]*
    • Pneumonia Complicated 30% of Acute Spinal Cord Injury Cases During a Mean Follow-Up Period of 9.5 mo (J Neurosurg Spine, 2012) [MEDLINE]
  • Risk Factors for Pneumonia
    • Altered Level of Consciousness: due to sedating medications or concomitant head trauma
    • Aspiration (see Aspiration Pneumonia, Aspiration Pneumonia)
    • Bronchial Mucous Hypersecretion: occurs in 20% of acute cervical spinal cord injury cases, due to impairment of the peripheral sympathetic nervous system
    • Concomitant Rib Fractures/Thoracoabdominal Surgery: associated with the traumatic event
    • Decreased Spontaneous Sighing
    • Dysphagia (see Dysphagia, Dysphagia)
    • Expiratory Muscle Weakness: with ineffective cough
    • Ileus (see Ileus, Ileus): limits diaphragmatic excursion and increases the aspiration risk

Sleep-Disordered Breathing

  • Epidemiology
    • Most Cervical Spinal Cord Injury Patients Have Sleep-Disordered Breathing and Poor Sleep (J Clin Sleep Med, 2014) [MEDLINE]: likely related to sleep-associated hypoventilation
  • Clinical

Venous Thromboembolism (Deep Venous Thrombosis and Acute Pulmonary Embolism) (see Deep Venous Thrombosis, Deep Venous Thrombosis and Acute Pulmonary Embolism, Acute Pulmonary Embolism)

  • Epidemiology
    • Risk of Venous Thromboembolism is Increased in Spinal Cord Injury, Relative to General Population (Thromb Res, 2014) [MEDLINE]
      • Risk Appears to Be Highest within the First 3 mo After Injury

Treatment

Triage

Recommendations (Consortium for Spinal Cord Medicine Guidelines) [LINK]

  • Transfer Patient with Spinal Cord Injury to a Level 1 Trauma Center as Soon as Possible

Respiratory Support

Mechanical Ventilation (see Mechanical Ventilation-General, Mechanical Ventilation-General)

  • Intubation Considerations (see Airway Management, Airway Management)
    • Rapid-Sequence Intubation with In-Line Spinal Immobilization: preferred intubation technique
    • Fiberoptic Intubation: alternative intubation technique
  • Tidal Volume Considerations
    • Rationale
      • Higher Tidal Volumes May Prevent Atelectasis
      • Higher Tidal Volumes May Decrease Dyspnea
    • Clinical Data
      • Use of Higher Tidal Volumes (>20 mg/kg) was Associated with Improved Weaning in Quadriplegia (with High Level, C3-C4) with Respiratory Failure (Spinal Cord, 1999) [MEDLINE]: however, many of these trials used uncuffed endotracheal tubes (resulting in leak and lower effective tidal volumes)
      • Higher Tidal Volumes (20 ml/kg) were Safe, But There was No Difference in Median Days to Wean, Ventilator-Associated Pneumonia, or Atelectasis (Spinal Cord, 2016) [MEDLINE]
    • Recommendations
      • Avoid Plateau Pressure ≥30 cm H2O
      • If High Tidal Volume is Utilized, Longer Ventilator Tubing May Be Required to Increase the Dead Space and Avoid Significant Hypocapnia
  • Positive End-Expiratory Pressure (PEEP) Considerations
    • Recommendations: optimal PEEP level is unknown, but 0-5 cm H2O is probably recommended
  • Weaning Considerations
    • Trendelenburg Position (see Trendelenburg Position, Trendelenburg Position)
      • Trendelenburg Positioning in Motor Complete Cervical Spinal Cord Injury Raises Diaphragmatic Position in the Chest (Due to Shift of Abdominal Contents) and Improves Weaning (J Rehabil Res Dev, 2010) [MEDLINE]: the higher the diaphragm is in the chest, the more effective it is able to contract
    • Duration of Mechanical Ventilation
      • Mean Duration of Mechanical Ventilation Following Acute Low Cervical Spinal Cord Injury (C5-T1) was 3-4 wks (J Trauma, 2008) [MEDLINE]
  • Modalities of Long-Term Ventilatory Support
    • High Cervical Cord Injury with Bulbar Muscle Weakness (Affecting the Lower Cranial Nerves at the Craniocervical Junction): associated with weakness of pharyngeal and palatial muscles, which may result in aspiration
      • Tracheostomy and Long-Term Mechanical Ventilation
    • Cervical Cord Injury with Intact Bulbar Muscle Function
      • Noninvasive Positive-Pressure Ventilation (NIPPV) (see Noninvasive Positive-Pressure Ventilation, Noninvasive Positive-Pressure Ventilation): usually the first choice
        • Nasal Interface
        • Oronasal Interface
        • Lip-Seal Interface
        • Angled Mouth Piece Interface: may better enable speech
      • Glossopharyngeal Breathing: gulping boluses of air into the lung
      • Abdominal Respirator
        • Intermittent Abdominal Pressure Ventilator (IAPV)/Exsufflation Belt
      • Abdominal Binder: may be used in the seated position to mimic the function of the non-functional abdominal muscles (binder compresses the abdominal contents, increasing intra-abdominal pressure and shifting diaphragm upward into a position which better facilitates inspiration)
      • Diaphragmatic Pacing (see Diaphragmatic Pacing, Diaphragmatic Pacing): may be used for patients with complete injury above C3 (above the takeoff of the phrenic nerve) with associated diaphragmatic paralysis
        • Concomitant Tracheostomy is Usually Required Since Diaphragmatic Pacing is Not Synchronous with Activation of the Oropharyngeal Muscles (Which Prevent Airway Collapse During Sleep): this prevent upper airway obstruction during sleep, maintains ability to suction secretions, and assists in the management of the patient if the diaphragmatic pacemaker fails

Chest Physiotherapy (Chest PT) (see Chest Physiotherapy, Chest Physiotherapy)

  • Rationale: useful to clear airway secretions
  • Technique
    • Percussive Therapy to the Chest with Positional Change and Postural Drainage of Secretions

Manually-Assisted Cough (Quad Cough)

  • Rationale: useful to clear airway secretions
  • Contraindications
  • Technique: forceful upper abdominal thrust directed posterior and cephalad, timed to coincide with expiration or a voluntary cough
    • Preceding the Quad Cough with a Deep Inspiration or Glossopharyngeal Breathing Improves the Success of Quad Cough Maneuver
  • Clinical Efficacy
    • xxxx

Management of Dyspnea (see Dyspnea, Dyspnea)

  • Clinical Efficacy
    • Meta-Analysis/Systematic Review Suggests that Respiratory Muscle Training in Cervical Spinal Cord Injury Improves Respiratory Muscle Strength (and Possibly Lung Volumes), But Does Not Improve Dyspnea (Cochrane Database Syst Rev, 2013) [MEDLINE]
  • Recommendations: physical activity/exercise is probably recommended

Mechanical Insufflation-Exsufflation Device (Cough Assist Device) (see Mechanical Insufflation-Exsufflation Device, Mechanical Insufflation-Exsufflation Device)

  • Rationale: useful to clear airway secretions
  • Technique
    • Insufflation Pressure at 40 to 60 cm H2O, Followed Immediately Exsufflation Pressure at -40 to -60 cm H2O
    • May Be Performed Concomitantly with Quad Cough
    • Device May Be Provided for Home Use
  • Clinical Efficacy
    • Mechanical Insufflation-Exsufflation Device is Commonly Used for Patients with Motor-Complete Quadriplegia and Outpatient Usage May Decrease Hospitalizations in Smokers with Spinal Cord Injury (J Spinal Cord Med, 2010) [MEDLINE]

Respiratory Muscle Training

  • Technique: inspiration or expiration through a device with a narrow orifice (or against a resistance) once-twice per day 5-6x per week
  • Clinical Data
    • Respiratory Muscle Training in Spinal Cord Injury Improves Respiratory Muscle Strength (Assessed by Peak Maximal Inspiratory/Expiratory Pressures and Vital Capacity), But Unclear if There is Any Benefit in Weaning

Tracheostomy (see Tracheostomy, Tracheostomy)

  • Fenestrated, Cuffed Trachesotomy: usually recommended in mechanically-ventilated patients to allow phonation
    • Tidal Volume May Need to Be Increased to Compensate for Loss of the Tidal Volume Through the Mouth Due to Leakage: leakage can be minimized by the patient controlling glottic patency or by using accessory ventilatory muscles
    • Insert Non-Fenestrated Inner Cannula During Sleep to Occlude Fenestration and Allow Adequate Ventilation
  • Passey-Muir Valve: instead of a fenestrated tracheostomy, Passey-Muir valve may be used (with a cuffed tracheostomy) with prior cuff deflation
    • However, Caution Must Be Exercised to Avoid Placement of the Passey-Muir Valve without First Deflating the Tracheostomy Cuff: this error may result in complete airway occlusion

Vaccination

Recommendations (Consortium for Spinal Cord Medicine Guidelines) [LINK]

  • Provide Airway and Ventilatory Support Early in the Course in Patients with High Tetraplegia

Management of Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia

  • xxxx

Management of Neurogenic Shock

General Recommendations

  • Maintain Mean Arterial Blood Pressure (MAP) 85-90 mm Hg in the First 7 Days After Acute Spinal Cord Injury (Neurosurgery, 2002) [MEDLINE]
  • Management of Bradycardia May Require External Pacing or Atropine

Recommendations (Consortium for Spinal Cord Medicine Guidelines) [LINK]

  • Prevent and Treat Hypotension

Glucocorticoids (see Corticosteroids, Corticosteroids)

Agents

Contraindications

  • Concomitant Presence of Moderate-Severe Traumatic Brain Injury (TBI) (see Traumatic Brain Injury, Traumatic Brain Injury): corticosteroids have been associated with increased mortality in this population
  • Penetrating Acute Spinal Cord Injury: corticosteroids are generally not used in this population

Clinical Efficacy

  • National Acute Spinal Cord Injury Study (NASCIS) II Trial of Corticosteroids, Naloxone, and Placebo in Acute Spinal Cord Injury (J Neurosurg, 1992) [MEDLINE]
    • At One Year, There was No Difference in Neurologic Outcome
    • However, in the Subset Who Were Treated within 8 hrs with Methlyprednisolone, There was a Modest Improvement in Motor Recovery, as Compared to Placebo
    • There was No Difference in Wound Infections
  • National Acute Spinal Cord Injury Study (NASCIS) III Trial of Corticosteroids, Tirilizad, and Placebo in Acute Spinal Cord Injury (J Neurosurg, 1998) [MEDLINE]
    • At One Year, For Patients Treated with Methylprednisolone within 3 hrs, There was No Difference in Neurologic Outcome
    • At One Year, For Patients Treated with Methylprednisolone Between 3-8 hrs (and Maintained x 48 hrs), There was Greater Motor (But Not Functional) Recovery
    • In Patients Treated with 48 hrs of Methylprednisolone, Rate of Severe Sepsis and Severe Pneumonia was Higher, as Compared to the Shorter Duration of Treatment
    • Mortality Rate was the Same in All Groups
    • Authors’ Recommendations
      • For Group in Whom Methylprednisolone is Started within 3 hrs of Injury, 24 hr Maintenance is Appropriate
      • For Patients Started on Methylprednisolone 3-8 hrs After Injury, 48 hr Maintenance Therapy is Appropriate
  • Meta-Analysis of NASCIS II and Two Other Small Trials of Steroids in Acute Spinal Cord Injury (Cochrane Database Syst Rev, 2012) [MEDLINE]
    • High-Dose Methylprednisolone Therapy is the Only Pharmacologic Therapy Which Has Been Demonstrated to Have Efficacy in a Phase 3 Randomized Trial When Administered within 8 hrs of Injury
    • One Trial Demonstrated Additional Benefit by Extending the Maintenance Dose from 24 hrs to 48 hrs, if Start of Treatment Must Be Delayed to Between 3-8 hrs After Injury

Recommendations (Consortium for Spinal Cord Medicine Guidelines) [LINK]

  • No Clinical Evidence Exists to Definitively Recommend Any Protective Pharmacologic Agent (Including Corticosteroids) in the Treatment of Acute Spinal Cord Injury to Improve Functional Recovery
  • If Methylprednisolone Has Previously Been Started, Stop as Soon as Possible in Neurologically Normal Patients and in Those Who Prior Neurologic Symptoms Have Resolved

Recommendations (American Association of Neurological Surgeons and Congress of Neurological Surgeons) (Neurosurgery, 2013) [MEDLINE]

  • Use of Glucocorticoids in Acute Spinal Cord Injury is Not Recommended

Gastrointestinal Stress Ulcer Prophylaxis

General Recommendations

Venous Thromboembolism Prophylaxis

Speech Therapy

  • Indicated to Assist with the Management of Dysphonia

Bladder Management

General Reocmmendations

  • Foley Catheterization During the First 3-4 days with Transition to Intermittent Bladder Catheterization: as this decreases the risk of urinary tract infection

References

General

  • Self-reported prevalence of pulmonary symptoms in subjects with spinal cord injury. Spinal Cord. 1997;35(10):652 [MEDLINE]
  • Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976). 2001;26(24 Suppl):S2 [MEDLINE]
  • Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehabil. 2004;85(11):1757 [MEDLINE]
  • Long-term survival of persons ventilator dependent after spinal cord injury. J Spinal Cord Med. 2006;29(5):511-9 [MEDLINE]
  • Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study. Spinal Cord. 2009 Aug;47(8):604-9. Epub 2009 Mar 10 [MEDLINE]
  • Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord. 2012 May;50(5):365-72. Epub 2012 Jan 24 [MEDLINE]
  • Traumatic spinal cord injury in the United States, 1993-2012. JAMA. 2015 Jun;313(22):2236-43 [MEDLINE]

Clinical

Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia)

  • Early autonomic dysreflexia. Spinal Cord. 2000;38(4):229 [MEDLINE]

Cardiovascular

  • Cardiovascular abnormalities accompanying acute spinal cord injury in humans: incidence, time course and severity. J Am Coll Cardiol. 1987;10(1):46 [MEDLINE]
  • Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg. 2003;138(10):1127 [MEDLINE]

Stress Ulcers/Peptic Ulcer Disease (PUD) (see Peptic Ulcer Disease, Peptic Ulcer Disease)

  • A risk analysis of stress ulceration after trauma. J Trauma. 1995;39(2):289 [MEDLINE]

Pneumonia

  • Incidence of respiratory complications following spinal cord injury. Arch Phys Med Rehabil. 1994;75(3):270 [MEDLINE]
  • Predictors of pulmonary complications in blunt traumatic spinal cord injury. J Neurosurg Spine. 2012 Sep;17(1 Suppl):38-45 [MEDLINE]

Sleep-Disordered Breathing

  • Sleep disordered breathing in chronic spinal cord injury. J Clin Sleep Med. 2014 Jan;10(1):65-72 [MEDLINE]

Venous Thromboembolism

  • Increased risk of deep vein thrombosis and pulmonary thromboembolism in patients with spinal cord injury: a nationwide cohort prospective study. Thromb Res. 2014 Apr;133(4):579-84. Epub 2014 Jan 11 [MEDLINE]

Treatment

General

  • Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery. 1993;33(6):1007 [MEDLINE]
  • Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. 1997;87(2):239 [MEDLINE]
  • The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators. Spinal Cord. 1999 Apr;37(4):284-8 [MEDLINE]
  • Definitive establishment of airway control is critical for optimal outcome in lower cervical spinal cord injury. J Trauma. 2008;65(6):1328 [MEDLINE]
  • Trendelenburg chest optimization prolongs spontaneous breathing trials in ventilator-dependent patients with low cervical spinal cord injury. J Rehabil Res Dev. 2010;47(3):261-72 [MEDLINE]
  • Mechanical insufflation-exsufflation device prescription for outpatients with tetraplegia. J Spinal Cord Med. 2010;33(2):128-34 [MEDLINE]
  • Critical care of traumatic spinal cord injury. J Intensive Care Med. 2013 Jan;28(1):12-23. Epub 2011 Apr 11 [MEDLINE]
  • Respiratory care of patients with cervical spinal cord injury: a review. Crit Care Resusc. 2012 Mar;14(1):64-73 [MEDLINE]
  • Respiratory muscle training for cervical spinal cord injury. Cochrane Database Syst Rev. 2013 [MEDLINE]
  • A comparison of high vs standard tidal volumes in ventilator weaning for individuals with sub-acute spinal cord injuries: a site-specific randomized clinical trial. Spinal Cord. 2016 Mar;54(3):234-8. Epub 2015 Sep 15 [MEDLINE]
  • Consortium for Spinal Cord Medicine. Early Acute Management in Adults with Spinal Cord Injury. Clinical practice guideline for healthcare providers. 2008 [LINK]
  • Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 [MEDLINE]
  • Consortium for Spinal Cord Medicine. Prevention of Thromboembolism in individuals with Spinal Cord Injury. Clinical practice guideline for healthcare providers. 3rd Edition 2016. [LINK]
  • Consortium for Spinal Cord Medicine. Respiratory Management Following Spinal Cord Injury. Clinical practice guideline for healthcare providers. 2005. [LINK]
  • Consortium for Spinal Cord Medicine. Acute Management of Autonomic Dysreflexia. Clinical practice guideline for healthcare providers. 2nd Edition, 2001. [LINK]

Blood Pressure Management

  • Blood pressure management after acute spinal cord injury. Neurosurgery. 2002;50(3 Suppl):S58 [MEDLINE]

Corticosteroids (see Corticosteroids, Corticosteroids)

  • NASCIS II Trial. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg. 1992;76(1):23 [MEDLINE]
  • NASCIS III Trial. Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow up. Results of the third National Acute Spinal Cord Injury randomized controlled trial. J Neurosurg. 1998;89(5):699 [MEDLINE]
  • Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;1:CD001046. Epub 2012 Jan 18 [MEDLINE]
  • Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 [MEDLINE]