PassFinals
Neurology

Spinal Cord Injury

Spinal cord injury disrupts motor, sensory and autonomic pathways below a lesion; early priorities are spinal protection, oxygenation, perfusion and specialist trauma care, with neurogenic shock and autonomic dysreflexia as key emergencies.

In a nutshell

Spinal cord injury causes motor, sensory and autonomic loss below a neurological level. Manage suspected traumatic injury with <C>ABCDE, spinal protection, urgent imaging, serial ASIA/ISNCSCI assessment and early spinal-team referral. Exclude haemorrhage before diagnosing neurogenic shock. Autonomic dysreflexia is a hypertensive emergency in lesions at or above T6: sit the patient upright and remove bladder, bowel or other triggers.

Classic presentation

After trauma, a patient has weakness with a sensory level, urinary retention or priapism and possibly hypotension with relative bradycardia. A high cervical injury may cause respiratory failure. Later, severe hypertension with headache and sweating in a person with a lesion at or above T6 suggests autonomic dysreflexia.

Key points

  • Primary cord damage is followed by a secondary cascade; avoid hypoxia, hypotension and unnecessary spinal movement.
  • Use a formal ASIA/ISNCSCI examination and document sacral sparing; a clinical incomplete syndrome does not replace formal classification.
  • Spinal shock is flaccid areflexia; neurogenic shock is hypotension with relative bradycardia after competing causes of shock are assessed.
  • Do not use methylprednisolone, nimodipine or naloxone for neuroprotection in acute traumatic spinal cord injury.
  • Autonomic dysreflexia usually reflects bladder or bowel distension: sit upright, monitor blood pressure frequently and remove the trigger.
  • Exact haemodynamic targets and autonomic-dysreflexia drug doses must come from the local spinal-injury protocol and current BNF.
  • High cervical injury requires early respiratory, swallowing and critical-care assessment.
  • Pressure, VTE, respiratory, bladder, bowel, orthostatic and spasticity complications need planned prevention and follow-up.

First-line investigation

Immediate <C>ABCDE and formal neurological assessment, followed by urgent CT according to the NICE trauma pathway and MRI when neurological deficit, evolving injury or unexplained cord dysfunction remains.

Management

Resuscitate and protect the spine

  • Use <C>ABCDE, in-line spinal stabilisation, oxygenation and circulation support; transfer suspected acute traumatic injury through the major-trauma pathway and escalate early.1

Classify, image and reassess

  • Perform serial ASIA/ISNCSCI examinations, urgent CT and MRI when indicated, and document respiratory function, cough, sacral sparing and the cause of any hypotension.1,2

Support perfusion and breathing

  • After haemorrhage is excluded, use the local spinal or neurocritical-care haemodynamic protocol; assess swallowing, vital capacity and cough, and provide specialist respiratory support when needed.2,3,6

Treat autonomic dysreflexia as an emergency

  • For severe hypertension in a lesion at or above T6, sit upright, loosen clothing, check blood pressure frequently, empty or troubleshoot the bladder, assess bowel and other triggers, and use local BNF-based medication protocol if hypertension persists.4,5,6

Prevent complications and rehabilitate

  • Use specialist plans for pressure and skin care, VTE prevention, bladder and bowel management, range of movement, orthostatic symptoms, pain, spasticity, equipment and lifelong spinal-injury follow-up.2,7,8

Exam traps

  • Do not call hypotension neurogenic until haemorrhage and other trauma causes have been assessed.
  • Spinal shock is not the same as neurogenic shock; areflexia and hypotension describe different processes.
  • Autonomic dysreflexia requires sitting upright and trigger removal before protocolised antihypertensive treatment; do not lay the patient flat.
  • Sacral sparing means the injury is incomplete, but prognosis still depends on the full formal examination and level.
  • A normal CT does not exclude cord injury when neurological deficit persists; discuss MRI with the spinal team.
  • NICE advises against methylprednisolone, nimodipine and naloxone for acute traumatic spinal cord neuroprotection.

Illustrations

Cervical spinal cord oedema on MRISagittal T2-weighted cervical MRI showing focal cord hyperintensity and surrounding oedema after traumatic cord injury, with a caption reminding learners that MRI findings must be interpreted alongside the neurological examination and spinal-team plan.Rivera-Alvarado HL et al., Cureus 2025, CC-BY-4.0 · CC-BY-4.0

Key sources

  1. NICE NG41, Spinal injury: assessment and initial management (NICE guideline published 17 February 2016: pre-hospital spinal protection, major-trauma transfer, CT and MRI pathways, ASIA charting, spinal-team escalation, and no methylprednisolone, nimodipine or naloxone for neuroprotection in acute traumatic spinal cord injury)Updated 17 Feb 2016
  2. NICE NG211, Rehabilitation after traumatic injury (NICE guideline published 18 August 2021: respiratory and swallowing assessment, cough assistance, pressure care, autonomic dysreflexia, orthostatic hypotension, range of movement, equipment and specialist rehabilitation after traumatic spinal cord injury)Updated 18 Aug 2021
  3. Global Spine Journal, A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management (2024 international specialist guideline used only because NICE does not specify a universal MAP target or duration; recommendations vary and local UK spinal-injury or neurocritical-care protocols take precedence)Updated 9 Apr 2024
  4. NHS England, Patients at risk of autonomic dysreflexia (NHS England patient-safety alert published 26 July 2018: autonomic dysreflexia is potentially life-threatening after spinal cord injury, particularly above T6, and bowel care can trigger it)Updated 26 Jul 2018
  5. Royal National Orthopaedic Hospital, Autonomic dysreflexia (Current UK spinal-injury-centre advice: recognise hypertension, headache, sweating or flushing, sit upright, check blood pressure frequently, remove bladder or bowel triggers, use local emergency prescribing protocol and observe after resolution)
  6. BNF, current prescribing information relevant to acute spinal cord injury and autonomic dysreflexia (UK prescribing source for vasoactive treatment, atropine and short-acting antihypertensive options; direct access was restricted and the available browser session was unavailable, so unsupported doses were omitted)
  7. NICE NG89, Venous thromboembolism in over 16s (Current NICE VTE-prevention recommendations used for the hospitalised trauma and immobility component; spinal-injury teams must individualise prophylaxis around bleeding, surgery and neurological injury)Updated 21 Mar 2018
  8. Royal National Orthopaedic Hospital, Neurogenic bowel (Current UK spinal-injury-centre advice on individualised bowel programmes and bowel dysfunction as a common cause of emergency presentation and autonomic dysreflexia)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.