Neurocrit Care

https://doi.org/10.1007/s12028-018-0537-5

REVIEW ARTICLE

Current Topics in the Management

of Acute Traumatic Spinal Cord Injury
Christopher D. Shank*, Beverly C. Walters and Mark N. Hadley

© 2018 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society

Abstract 
Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000
new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortal-
ity. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and
passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last
three decades, there have been considerable advancements in the management of patients with traumatic SCI. The
advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage
SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care
of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit
(ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes
areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute
SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review
initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical
collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues
including airway, hemodynamic, and pharmacological management, as well as future directions of care.
Keywords:  Spinal cord injury, Closed reduction of cervical fracture, Collar clearance in spinal cord injury, MAP
management, CSF diversion in spinal cord injury

Introduction/Epidemiology Motor vehicle accidents are the most common mech-

Acute traumatic spinal cord injury (SCI) affects more
than 250,000 people in the USA, with approximately
17,000 new cases each year [1]. It continues to be one of
the most significant causes of trauma-related morbidity
and mortality. The demographics of patients who suffer
acute traumatic SCI reflect the general trauma popula-
tion [2]. Patients who suffer acute traumatic SCI are pre-
dominately male (~ 80%); young males have an SCI rate
up to 20 times higher than young females [3]. Since the
1970s, the average age of acute traumatic SCI patients
has increased from 29 years to 42 years, [1] with a con-
comitant increase in geriatric SCI.
*Correspondence: cshank@uabmc.edu
Department of Neurosurgery, University of Alabama at Birmingham, 510‑
20th Street South, FOT 1060, Birmingham, AL 35294‑3410, USA
anism for acute traumatic SCI in the younger patient
population. Due to the presence of underlying spondylo-
sis and canal stenosis, falls represent the most common
mechanism for traumatic SCI in the elderly population
[4, 5]. The cervical spine is the most commonly affected
spinal region for both motor vehicle accident and fall-
associated SCI. The cervical spine, unfortunately, carries
the highest associated morbidity and mortality, particu-
larly in the elderly population [3, 4, 6].
Despite the introduction of primary injury prevention
education and vehicle safety devices, such as airbags and
passive restraint systems, traumatic SCI continues to
have a substantial impact on the healthcare system. Cost
estimates for lifetime care of a patient with traumatic SCI
range from $1,600,000 to $4,800,000 [7]. For patients with
traumatic SCI, life expectancy is significantly shorter, and
annual mortality is significantly higher, compared to age-
matched patients without traumatic SCI [1].
Over the last three decades, there have been consider-
able advances in the management of patients with trau-
matic SCI. The advent of spinal instrumentation has
improved the surgical treatment of spinal fractures and
the ability to manage SCI patients with spinal mechani-
cal instability. There has been a concurrent improvement
in the nonsurgical care of these patients with particular
focus on care delivered in the pre-hospital, emergency
room, and intensive care unit (ICU) settings [5].
Integrated trauma networks with emergency medical
services (EMS) providers trained in evaluation of patients
with potential SCI have resulted in efficient triage and
transportation of appropriate patients to SCI treatment
centers. Once at the definitive treatment facility, initial
evaluation and stabilization are achieved in a timely and
methodical fashion. Patients are then monitored in spe-
cialty ICUs designed for acute SCI care. The contempo-
rary management of patients with acute traumatic SCI
requires the application of medical evidence-based algo-
rithms and adherence to validated practice guidelines.
This article represents an overview of the critical aspects
of contemporary traumatic SCI care (Table 1) and notes
areas where further research inquiries are needed.
Pre‑hospital Management of Spinal Cord Injury
Triage and Immobilization
Twenty-five percent of SCIs occur after the initial injury
[8]. For this reason, SCI-directed care should begin at
the scene of injury. First responders must rapidly triage
patients and institute an SCI algorithm for patients with
known or suspected SCI. Once initial triage of the scene
is complete, patients with suspected SCI are extracted
and initial resuscitation measures are completed [9, 10].
Table 1 Key steps in  the management of  a patient
with acute traumatic SCI
1. Resuscitate (protect airway, maintain normotension), immobilize at
scene (EMS)
2. Rapid transport to nearest definitive SCI care facility
3. ABC’s, MAP management (85 mmHg)
4. No steroids
5. Radiographic assessment (CT initial study of choice)
6. Promptly realign cervical spine (closed vs open reduction)
7. Immobilize (external vs internal orthosis)
8. Maintain MAP perfusion parameters
9. MRI for mass lesion, extent of cord injury
10. Operative decompression early. Delay only for stabilization
ABC airway, breathing, circulation; CT computed tomography; EMS emergency
medical services; MAP mean arterial pressure; MRI magnetic resonance imaging;
SCI spinal cord injury
First responders are charged with the rapid determina-
tion of SCI likelihood [11, 12]. Patients who cannot be
cleared are immobilized for transport.
Prior to the dissemination of the Guidelines for the
Management of Acute Cervical Spine and Spinal Cord
Injuries [4], the approach for spinal clearance and spinal
immobilization by first responders was haphazard. Since
their publication, all first responders undergo protocol-
ized training for SCI recognition and spinal immobiliza-
tion using a NEXUS (National Emergency X-Radiography
Utilization)-like algorithm (Table  2). The ability of first
responders to accurately identify patients with potential
SCI, appropriately apply the clearance protocol, and con-
sistently identify patients who require spinal immobiliza-
tion is backed by numerous Class II and Class III medical
evidence studies [13–16].
Spinal immobilization carries some associated risk,
even when applied appropriately [17]. Even proper
immobilization may cause pain, delay transport, and
result in pressure ulcers if in place for too long [18–23].
Full spine immobilization may limit respiratory function
and increase the risk of aspiration [24–26]. Hard cervi-
cal collars may potentiate head injury by elevating intrac-
ranial pressure through impaired venous return [27, 28].
Some associated medical comorbidities, such as ankylos-
ing spondylitis, may contribute to immobilization-related
complications [29, 30]. Patients with penetrating neck
trauma who are immobilized have been reported to have
significantly higher mortality compared to those who
were not immobilized [31]. Because of the potential for
significant related morbidity and mortality, spinal immo-
bilization is not recommended for trauma patients who
are cleared by EMS protocol, or who have documented
medical contraindications to immobilization [32].
Patients who meet criteria for spinal immobilization
following trauma are placed in full spinal precautions. A
variety of spinal immobilization devices have been com-
paratively evaluated [33–37]; however, to date there is
no definitive evidence demonstrating superiority of any
single device over another. Historically, patients with
Table 2  Cervical spine clearance criteria for  first respond‑
ers
1. No spinal pain or tenderness
2. No significant multiple system trauma
3. No significant head or facial trauma
4. No extremity neurological deficit
5. No loss of consciousness
6. No altered mental status
7. No known or suspected intoxication
8. No significant distracting injury
suspected SCI were immobilized by first responders
with sandbags to the head and neck. Because the heavy
sandbags may slide or shift during transport or logroll
maneuvers, the American College of Surgeons Advanced
Trauma Life Support guidelines [2] and the Guidelines for
the Management of Acute Cervical Spine and Spinal Cord
Injuries [32] now recommend a hard cervical collar and
long board immobilization using tapes or straps to pre-
vent pathological motion at unstable vertebral segments.
Transportation of Patients with SCI
Once appropriately immobilized, the patient is trans-
ported to a treatment facility by EMS personnel. Ensur-
ing the rapid and safe transport of patients with acute
traumatic SCI takes precedence over the exact means of
transportation (ground ambulance, helicopter, or fixed-
wing aircraft) [38–43]. The recommendation for trans-
port of patients to certain treatment centers has led to
the de facto designation of acute traumatic SCI centers,
i.e., those facilities with the most experience and exper-
tise in managing patients with acute SCI. While some
evidence suggests that early transfer to these facilities
may improve the likelihood of neurological recovery and
reduce associated complication rates [44], such designa-
tions might be regarded as self-serving. Currently, there
is no licensing organization to regulate such designations.
Robust medical evidence supports several practice
guidelines surrounding the pre-hospital management of
patients with known or suspected acute SCI [15, 32, 38,
45, 46]. First responders are charged with the rapid initial
assessment and resuscitation of the patient, followed by
application of a validated spinal clearance protocol and
spinal immobilization when necessary. Fully immobilized
patients are then rapidly transported to an SCI treatment
facility where in-hospital care begins upon arrival. The
existing data on field triage, EMS assessment, and immo-
bilization techniques are designated as Class II or Class
III medical evidence. Further prospective, in-field inves-
tigation of these protocols is warranted. The transporta-
tion of patients to designated acute SCI treatment centers
is based on Class III medical evidence. Further quality
assessment studies are needed to help define “definitive
treatment center” and quantify the operational quality
(based on validated patient outcomes scores) between
centers and over designated time periods.
Initial Hospital Evaluation of Patients with Spinal
Cord Injury
Initial Patient Assessment
Patients with known or suspected acute SCI are evalu-
ated immediately upon arrival to the definitive treatment
facility. Initial evaluation is carried out by emergency
medicine, critical care, trauma surgery, and neurosurgery
personnel according to Advanced Trauma Life Support
guidelines. Spinal precautions are maintained through-
out the primary survey, secondary survey, and adjunct
evaluations. After completion of the initial assessment
and initial resuscitative measures, attention is turned to
the spinal evaluation. The basic neurological examina-
tion obtained during the primary survey is insufficient to
determine the level and severity of an acute SCI. Several
neurological assessment tools have been developed to
provide acute and reproducible measures for diagnosing
acute SCI, as well as measuring change in neurological
function over time [47].
The most widely utilized and validated neurological
assessment tool for acute SCI is the American Spinal
Injury Association (ASIA) scoring system and the ASIA
Impairment Scale (AIS) [48]. Trained personnel carried
out a detailed motor examination, a light-touch sensory
examination, and an assessment for sacral nerve root
function by evaluating rectal tone. The components of
the neurological examination are recorded on the ASIA
scale form (Fig. 1), which allows for rapid visualization of
neurological level and injury severity. Repeating this step
over time allows for longitudinal assessment and delinea-
tion of improvement or decline in neurological function.
After each examination, an AIS may be derived from the
compiled data points. While multiple Class I medical evi-
dence studies have corroborated the ASIA scale as the
most valid and reliable assessment tool for determining
neurological loss after acute traumatic SCI [49, 50], its
utility may be influenced by level of consciousness, age,
intoxication, or distracting injuries [51].
Radiographic Evaluation
After the initial evaluation and stabilization of the patient
are complete, attention is turned to adjunctive evalu-
ations, including radiographic analysis of the spine. In
conjunction with an accurate and reproducible neuro-
logical examination, spinal imaging provides important
information regarding injury severity, spinal instability,
as well as the need for further immobilization or more
definitive treatment.
Historically, the initial trauma evaluation included a
lateral cervical spine X-ray as an adjunct to the primary
survey (usually obtained in conjunction with AP chest
and AP pelvis X-rays). For patients with a high likelihood
of SCI or with a spinal fracture visualized on primary
survey adjunctive X-rays, a full spine X-ray series was
obtained. Over the last two decades, computed tomogra-
phy (CT) has largely supplanted plain X-rays as the imag-
ing modality of choice for evaluating trauma patients.
Several authors have compared the utility of plain X-rays
and CT imaging in the initial radiographic assessment of
patients with known or suspected acute traumatic SCI
 Fig. 1  American spinal injury association (ASIA) Form [48]
[52–54]. These multiple Class I medical evidence studies
individually and collectively demonstrate the diagnostic
superiority of CT imaging over plain X-rays in patients
with known or suspected SCI. They form the basis of
the Level I recommendation supporting the use of high-
quality CT imaging as the diagnostic modality of choice
for patients with known or suspected SCI. Cervical spinal
X-rays represent a secondary option, in the absence of
high-quality CT imaging [55].
Cervical Spinal Clearance
The replacement of plain film X-rays with CT imaging for
the initial radiographic evaluation of patients with known
or suspected SCI has resulted in increased direct health-
care costs and radiation exposure to these patients [55].
In light of increasing costs and known complications of
prolonged immobilization, several authors evaluated the
need for radiographic investigation and continued spinal
immobilization in a variety of patients [56, 57]. For the
purposes of determining the need for radiographic evalu-
ation and continued spinal immobilization, patients with
potential spinal injuries may be classified as: awake and
asymptomatic, awake and symptomatic, or obtunded/
unevaluable. The need for radiographic investigation
and continued spinal immobilization differs among these
groups.
Patients who are awake must meet a strict set of cri-
teria to qualify as asymptomatic (Table 3). These criteria
are based on two robust and validated decision-making
tools: the NEXUS criteria [56] and the Canadian C-Spine
Rule [58]. Both of these criteria had near-perfect sensi-
tivity for the identification of cervical spinal injury with-
out reliance of radiographic imaging. Multiple Class I
Table 3 Cervical collar clearance criteria for  the awake
and asymptomatic patient
1. No midline cervical tenderness
2. No focal neurological deficit
3. Normal alertness and mentation
4. No intoxicants or confounders
5. No distracting injury
medical evidence studies have corroborated the ability
of these or similar algorithms to accurately identify sig-
nificant spinal injury in adult trauma patients [57, 59].
Accordingly, radiographic evaluation and continued spi-
nal immobilization are not required in the awake, asymp-
tomatic trauma patient [55].
Patients who are awake but do not meet the strict cri-
teria set forth in Table  3 are defined as symptomatic.
Because these patients have a higher propensity for har-
boring a spinal injury, they deserve radiographic evalua-
tion of the spinal axis with high-quality CT imaging or
multi-dimensional plain X-rays if CT is unavailable [55].
Patients found to have a spinal fracture are managed
according to the type of injury. Significant controversy
exists about patients with normal CT imaging and persis-
tent neck pain. Several authors have evaluated the utility
of dynamic X-rays [60–62] (flexion/extension X-rays) and
magnetic resonance imaging [63, 64] (MRI) in this patient
population with conflicting results. A lack of Class I or
Class II medical evidence, as well as an evidentiary dis-
cordance among the existing Class III medical evidence
studies regarding the utility of dynamic X-rays or MRI
in awake trauma patients with normal CT imaging but
persistent neck pain, has led to a Level III recommenda-
tion regarding collar clearance in this subpopulation [55]
(Table 4).
Patients who are obtunded or otherwise unevaluable
are initially assessed according to the awake, sympto-
matic algorithm: high-quality CT imaging or plain X-rays
if CT imaging is unavailable. As in the awake, sympto-
matic algorithm, patients with radiographic evidence of
spinal injury are managed according to the type of injury.
Significant controversy arises for obtunded/unevalu-
able patients with normal CT imaging with respect to
collar clearance. The utility of dynamic imaging in this
patient population is uncertain [65, 66]. The inability of
the patient to actively flex or extend their neck carries
the potential for significant morbidity with passive range
of motion [60]. Given its unproven utility and potential
for catastrophic neurological injury if done in the pres-
ence of an unstable spinal injury, dynamic X-rays are
not recommended in obtunded or unevaluable trauma
patients. The studies that have evaluated the use of MRI
in this subpopulation have similarly mixed results. It is
unclear that MRI adds significantly to the diagnostic yield
of CT imaging in the initial radiographic evaluation of
obtunded/unevaluable trauma patients. MRI evaluation
may delay extubation, lengthen hospital stay, and reveal
neck soft tissue signal change of questionable clinical
significance if done more than 48  h after the injury was
sustained. The lack of Class I or Class II medical evi-
dence, as well as the evidentiary ambiguity of the existing
Class III medical evidence regarding the utility of MRI
in obtunded or unevaluable trauma patients, has led to
a Level III recommendation regarding collar clearance in
this subpopulation [55] (Table 5).
Closed Reduction of Cervical Fracture/Dislocation
The cervical region is the most injured spinal region due
to its relative mobility and lack of protection [5, 67]. A
combination of force vectors may result in a fracture/
dislocation-type injury with disruption of one or both
facet joints. The resulting translation or subluxation may
result in an acute SCI through compromise of the spinal
canal and direct spinal cord compression. While cervi-
cal fracture/dislocation-associated SCIs carry the highest
morbidity and mortality, they are often amenable to early
closed reduction [4, 68].
Closed reduction, when performed properly, restores
the natural alignment of the cervical spinal column in
an effort to decompress the cervical spinal cord. Histori-
cally, this was achieved through manual reduction under
anesthesia (MUA). The patient was anesthetized, and the
fracture/dislocation was reduced without the use of assis-
tive devices. Despite the safe and successful use of MUA
throughout the mid-twentieth century [69, 70], many

Table 4  Cervical collar clearance criteria for the awake and symptomatic patient

1. Continue cervical immobilization until asymptomatic

2. Discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs
3. Discontinue cervical immobilization following a normal MRI obtained within 48 h of injury
4. Discontinue cervical immobilization at the discretion of the treating physician
MRI magnetic resonance imaging

Table 5  Cervical collar clearance criteria for the obtunded or unevaluable patient

1. Continue cervical immobilization until asymptomatic

2. Discontinue cervical immobilization following a normal MRI obtained within 48 h of injury
3. Discontinue cervical immobilization at the discretion of the treating physician
MRI magnetic resonance imaging

Fig. 2  Gardner-Wells tongs. (From Thompson and Zlololow 2012)
[117]
Fig. 3  Halo ring and immobilization vest. (From Williams 2013) [118]
practitioners reported increasing reliance on awake, tong
(Fig.  2) or halo ring-assisted (Fig.  3) reduction through-
out the 1980s and 1990s. Over the last 30  years, many
authors have reported improved control during reduc-
tion and lauded the ability to intermittently examine the
patient [68, 71–73].
The timing of reduction is of greater concern than the
method of reduction. Early reduction of cervical frac-
ture/dislocation injuries has been correlated with both
ease of reduction and neurological improvement [74,
75]. For this reason, significant debate has surrounded
the issue of MRI timing with respect to closed reduc-
tion. Many authors have raised concerns regarding the
high incidence of disk injury in patients with traumatic
cervical fracture/dislocation-type injuries and the poten-
tial for further neurological injury if closed reduction is
attempted in this setting [76–78]. Currently, there is no
evidence to suggest that the presence of disk pathology
may potentiate neurological injury during closed reduc-
tion in an awake, evaluable patient [79]. Indeed, some
authors have reported improvement in disk pathol-
ogy following early closed reduction [80]. Accordingly,
there appears to be no benefit to a pre-reduction MRI
in an awake, evaluable patient [81, 82]. Conversely, the
inability to examine an obtunded/unevaluable patient
increases the potential for reduction-associated morbid-
ity. A pre-reduction MRI is recommended in this sub-
population [83].
The measures taken during the initial hospital evalua-
tion happen in rapid succession in an effort to improve
patient outcome through early diagnosis and interven-
tion. The rapid and accurate assessment of the patient
using the ASIA scoring system facilitates communica-
tion among treatment teams and allows for longitudinal
assessment of the patient’s neurological improvement
over time. Early collar clearance or radiographic evalua-
tion based on validated criteria helps reduce cost, limit
unnecessary radiation exposure, limit morbidity asso-
ciated with prolonged immobilization, and accurately
identify all significant spinal injuries. The existing medi-
cal evidence for collar clearance in awake, symptomatic
or obtunded, unevaluable patients is predominately Class
II and Class III. A prospective, Class I medical evidence
study may help elucidate the optimum clearance strategy
for each of these subpopulations. Additional prospec-
tive studies may help define the utility and role of MRI
in trauma patients. After diagnosis of a fracture/disloca-
tion-type injury, rapid reduction of compressive pathol-
ogy is attempted. There are numerous Class II and Class
III medical evidence studies describing the benefits of
open or closed reduction. A comparative, prospective
trial comparing open and closed reduction of cervical
fracture/dislocation injuries is warranted.
Critical Care Issues in Acute Spinal Cord Injury
Respiratory/Airway Management
Acute SCI is often associated with profound cardiopul-
monary dysfunction. Catastrophic airway loss and res-
piratory insufficiency are more common in patients with
higher AIS grade or higher anatomic level of injury [84,
85]; however, they may be present in patients with lower
cervical or thoracic SCI due to loss of intercostal muscu-
lature function. Several authors have evaluated the effects
of acute SCI on the respiratory system, noting decreased
forced vital capacity, increased airway secretions, and
compromised gas exchange [86, 87]. Importantly, patients
with acute SCI may develop profound respiratory compli-
cations in a delayed manner as atelectasis and soft tissue
edema sets in hours or days after the injury [88].
Initial airway management for patients with acute trau-
matic SCI includes establishment of a definitive airway
to provide assistance with oxygenation and ventilation.
While video or fiberoptic laryngoscopy may be utilized
when readily available, multiple studies have evaluated
the safety and efficacy of standard orotracheal intubation
[89, 90]. No patients suffered a new or worse neurological
deficit following standard laryngoscopy and orotracheal
intubation when combined with standard in-line cervi-
cal stabilization (Figure  4). Additional cadaveric studies
have compared cervical segmental mobility during stand-
ard laryngoscopy and orotracheal intubation in cadavers
with and without cervical spinal fractures [91, 92]. When
combined with in-line cervical spine immobilization,
standard orotracheal intubation did not exceed physiolog-
ical parameters associated with critical hyperextension.
Indeed, there was no significant difference in the degree
of extension in the injured and non-injured groups. Based
on this evidence, the American College of Surgeons
Advanced Trauma Life Support guidelines recommend
direct laryngoscopy with orotracheal intubation in con-
junction with standard in-line cervical spinal immobiliza-
tion for establishing a definitive airway in trauma patients
with known or suspected spinal injury [2].
Patients with persistent respiratory compromise or the
inability to manage airway secretions require chronic air-
way management in the form of tracheostomy. Several
authors have evaluated clinical predictors and timing of
tracheostomy in patients with acute SCI [93–95]. While
no Class I or Class II medical evidence studies are avail-
able, early tracheostomy may shorten ICU length of stay
and decrease laryngotracheal complications [96]. Early
tracheostomy is recommended even in patients with
recent anterior cervical surgery [97, 98].
Hemodynamic Management
Cardiovascular collapse may develop following acute SCI
due to volume loss or neurogenic shock. The develop-
ment of hypotension is thought to contribute to spinal
cord ischemia and secondary neurological injury. The
avoidance of hypotension and the continued perfusion
of the injured spinal cord through augmentation of the
mean arterial pressure (MAP) are essential. Initial vol-
ume resuscitation is carried out with intravenous crys-
talloid, according to Advanced Trauma Life Support
guidelines. Vasopressors may be initiated for refractory
hypotension.
Fig. 4  Manual in-line cervical stabilization [2]
Several authors have provided Class III medical evi-
dence for the use of MAP augmentation in patients with
acute SCI [99–101]. All authors reported neurological
improvement in those patients that underwent MAP aug-
mentation for a period of time following injury, although
the degree of neurological improvement varied between
studies. More recently, a correlation was demonstrated
between time spent above the MAP target (85  mmHg)
and neurological improvement in the first seven days
postinjury [102]. Based on these observational studies,
the avoidance of hypotension and the maintenance of
MAP > 85  mmHg for the first seven days postinjury are
recommended [103].
The limited data on MAP augmentation following
acute SCI have left several unanswered questions. What
is the ideal MAP target? Does the MAP target vary based
on level and severity of injury? What is the ideal duration
of MAP maintenance? What is the ideal vasopressor to
be used during this period? Might spinal cord perfusion
be improved with concurrent MAP augmentation and
cerebrospinal fluid (CSF) diversion? Prospective, com-
parative studies are needed to answer these questions
and tailor the hemodynamic care delivered to patients
with acute SCI.
Use of Steroids Following Acute Spinal Cord Injury
The concept of neuroprotection in acute traumatic SCI
has been the subject of considerable scientific research
and debate. A number of agents have been purported to
reduce primary insult and minimize secondary injury,
most notably methylprednisolone (MP). The National
Acute Spinal Cord Injury Studies (NASCIS I, II, and III)
were designed to evaluate the potential neuroprotective
effects of MP following acute SCI [104–106]. For each of
these studies, patients were randomized to receive either
MP or placebo at varying doses and time points following
injury. Despite negative results from the NASCIS I and
III trials, many practitioners continued to administer MP
to patients following acute SCI, citing the positive results
of the NASCIS II trial.
Detailed analysis of the NASCIS II trial reveals mul-
tiple scientific irregularities which have discredited its
results [107]. The preplanned end points outlined in the
initial study protocol were all negative. The study authors
applied an arbitrary 8-h treatment window in a post
hoc manner. Only the right body motor change scores
from a small subset of patients were extracted from this
arbitrary treatment window to demonstrate the pur-
ported benefit. Given the negative overall trial result and
reported positive result from the arbitrary 8-h treatment
window group, it follows intuitively that those patients
who received MP outside the 8-h treatment window
must have experienced an overall negative treatment
effect. Evaluation of the NASCIS II patients treated out-
side the 8-h window confirms this result. Patients who
received MP had higher rates of sepsis, respiratory fail-
ure, and death. These results were confirmed in NASCIS
III and in at least two additional studies [108, 109].
To date, there is no scientifically valid evidence sup-
porting the use of MP or any other medication as a neu-
roprotective agent following acute traumatic SCI. Several
randomized trials have demonstrated not only a lack
of benefit, but a trend toward more complications and
higher overall mortality in patients who received “neuro-
protective” MP following acute SCI. These studies form
the basis of the Level I recommendation against the use
of MP following acute traumatic SCI.
CSF Diversion Following Acute Spinal Cord Injury
The use of intracranial pressure (ICP) monitors in
patients with severe traumatic brain injury (TBI) has
been studied extensively. Despite a paucity of compara-
tive studies due to a lack of clinical equipoise in the USA,
the use of ICP monitors in patients with severe TBI
remains a Level II recommendation based on numerous
descriptive studies [110]. The use of ICP monitors with
the ability to divert CSF (e.g., external ventricular drains)
allows practitioners to lower ICP, preventing ischemic
insult, and secondary brain injury. Such devices confer a
therapeutic advantage.
Prevention of secondary spinal cord injury is the primary
objective of contemporary SCI care. The concept of spinal
cord perfusion pressure optimization (analogous to cerebral
perfusion pressure) has garnered increasing attention over
the last several years [111]. Based on favorable outcomes
following CSF diversion for aortic surgery-related spinal
cord ischemia [112, 113], several authors evaluated the con-
cept of CSF diversion in acute traumatic SCI [114, 115]. A
Department of Defense-funded, multicenter, randomized
trial evaluating the use of CSF diversion is currently under-
way comparing “standard” MAP augmentation with MAP
augmentation and continuous CSF diversion [116]. The
results of this Class I medical evidence study will help
inform an evidence-based practice guideline on this issue.
Surgical Management of Acute Spinal Cord Injury
The topics discussed above reflect SCI care delivered
outside the operating room. Because surgical treatment
studies are onerous to design and effectively execute,
there is comparatively little high-level medical evidence
on the surgical management of acute SCI. The accumu-
lated medical evidence on the surgical management of
patients with acute SCI and their associated recommen-
dations are presented in the Guidelines for the Manage-
ment of Acute Cervical Spine and Spinal Cord Injuries [5].
A detailed discussion of the current topics in the surgical
care of patients with acute SCI is beyond the scope of this
article and is an appropriate topic for future discussion.
Conclusion
Acute traumatic SCI is a complex and potentially devas-
tating disease process. The work of many authors over the
last 70 years has contributed to a growing body of scien-
tific research. Increasingly, physicians are looking to high-
level medical evidence rather than anecdotal “expert”
testimony to guide their management decisions. Because
of the pathophysiological complexity of many disease
processes, and the sheer volume of published medical
evidence, we must periodically review and synthesize the
existing data on particularly complex topics. Here we have
presented such a discourse on the current topics in the
care of patients with acute traumatic spinal cord injury.
Acknowledgements
Dr. Shank is the Worthen Family Clinical Scholar at the University of Alabama at
Birmingham Department of Neurological Surgery.
Author’s Contributions
All authors contributed to this manuscript in accordance with ICMJE criteria.
Compliance with Ethical Standards
Funding
No authors have funding to report relevant to this project.
Conflict of interest
The authors declare that they have no conflicts of interest.
References
1. National Spinal Cord Injury Statistical Center. Spinal cord injury (SCI)
2016 facts and figures at a glance. J Spinal Cord Med. 2016;39(4):493–4.
 2. American College of Surgeons. Advanced trauma live support (ATLS)
student manual. Chicago: American College of Surgeons; 2012.
3. Vollmer D, Eichler M, Jenkins III A. Spinal trauma: assessment of the cer-
vical spine after trauma. In: Youmans Neurological Surgery. p. 3166–80.
4. Hadley MN, Walters BC. Guidelines for the management of acute cervi-
cal spine and spinal cord injuries. Neurosurgery. 2013;72(3):1–259.
5. Shank CD, Walters BC, Hadley MN. Management of acute traumatic
spinal cord injuries. Handb Clin Neurol. 2017;140:275–98.
6. Hadley MN, Walters BC, Grabb PA. Guidelines for the manage-
ment of acute cervical spine and spinal cord injuries. Neurosurgery.
2002;50(3):S2–199.
7. Bellon K, Kolakowsky-Hayner SA, Chen D, McDowell S, Bitterman B,
Klaas SJ. Evidence-based practice in primary prevention of spinal cord
injury. Top Spinal Cord Inj Rehabil. 2013;19(1):25.
8. Toscano J. Prevention of neurological deterioration before admission to
a spinal cord injury unit. Paraplegia. 1988;26(3):143–50.
9. Kossuth LC. The removal of injured personnel from wrecked vehicles. J
Trauma. 1965;5(6):703–8.
10. Farrington JD. Extrication of victims–surgical principles. J Trauma.
1968;8(4):493–512.
11. Rimel RW, Jane JA, Edlich RF. An educational training program for the
care at the site of injury of trauma to the central nervous system. Resus-
citation. 1981;9(1):23–8.
12. Moylan JA. Trauma injuries: triage and stabilization for safe transfer.
Postgrad Med. 1985;78(5):166–71.
13. San Mateo County C. EMS System Policy Memorandum #f-3A. 1991.
14. Brown LH, Gough JE, Simonds WB. Can EMS providers adequately
assess trauma patients for cervical spinal injury? Prehospital Emerg
Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir.
1998;2(1):33–6.
15. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance
protocol identify all patients with injuries? An argument for selective
immobilization. Ann Emerg Med. 2001;37(6):609–15.
16. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A state-
wide, prehospital emergency medical service selective patient spine
immobilization protocol. J Trauma. 2006;61(1):161–7.
17. Liew SC, Hill DA. Complication of hard cervical collars in multi-trauma
patients. Aust N Z J Surg. 1994;64(2):139–40.
18. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain
and tissue-interface pressures during spine-board immobilization. Ann
Emerg Med. 1995;26(1):31–6.
19. Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between
pressure sores and immobilization in the immediate post-injury period.
Orthopedics. 1987;10(4):571–3.
20. Mawson AR, Biundo JJ, Neville P, Linares HA, Winchester Y, Lopez A. Risk
factors for early occurring pressure ulcers following spinal cord injury.
Am J Phys Med Rehabil Assoc Acad Physiatr. 1988;67(3):123–7.
21. Hewitt S. Skin necrosis caused by a semi-rigid cervical collar in a venti-
lated patient with multiple injuries. Injury. 1994;25(5):323–4.
22. Blaylock B. Solving the problem of pressure ulcers resulting from cervi-
cal collars. Ostomy Wound Manag. 1996;42(4):26–8.
23. Black CA, Buderer NM, Blaylock B, Hogan BJ. Comparative study of risk
factors for skin breakdown with cervical orthotic devices: Philadelphia
and Aspen. J Trauma Nurs Off J Soc Trauma Nurses. 1998;5(3):62–6.
24. Bauer D, Kowalski R. Effect of spinal immobilization devices on pul-
monary function in the healthy, nonsmoking man. Ann Emerg Med.
1988;17(9):915–8.
25. Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkis-
son A. Respiratory effects of spinal immobilization in children. Ann
Emerg Med. 1991;20(9):1017–9.
26. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization.
Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State
EMS Dir. 1999;3(4):347–52.
27. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial
pressure. Injury. 1996;27(9):647–9.
28. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intrac-
ranial pressure. Am J Emerg Med. 1999;17(2):135–7.
29. Podolsky SM, Hoffman JR, Pietrafesa CA. Neurologic complications
following immobilization of cervical spine fracture in a patient with
ankylosing spondylitis. Ann Emerg Med. 1983;12(9):578–80.
30. Thumbikat P, Hariharan RP, Ravichandran G, McClelland MR, Mathew
KM. Spinal cord injury in patients with ankylosing spondylitis: a 10-year
review. Spine. 2007;32(26):2989–95.
31. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating
trauma: more harm than good? J Trauma. 2010;68(1):115–20.
32. Theodore N, Hadley MN, Aarabi B, et al. Prehospital cervical spinal
immobilization after trauma. Neurosurgery. 2013;72(Suppl 2):22–34.
33. Cline JR, Scheidel E, Bigsby EF. A comparison of methods of cervical
immobilization used in patient extrication and transport. J Trauma.
1985;25(7):649–53.
34. De Lorenzo RA. A review of spinal immobilization techniques. J Emerg
Med. 1996;14(5):603–13.
35. McCabe JB, Nolan DJ. Comparison of the effectiveness of different
cervical immobilization collars. Ann Emerg Med. 1986;15(1):50–3.
36. Rosen PB, McSwain NE, Arata M, Stahl S, Mercer D. Comparison of two
new immobilization collars. Ann Emerg Med. 1992;21(10):1189–95.
37. Del Rossi G, Heffernan TP, Horodyski M, Rechtine GR. The effectiveness
of extrication collars tested during the execution of spine-board trans-
fer techniques. Spine J Off J North Am Spine Soc. 2004;4(6):619–23.
38. Hachen HJ. Emergency transportation in the event of acute spinal cord
lesion. Paraplegia. 1974;12(1):33–7.
39. Hachen HJ. Idealized care of the acutely injured spinal cord in Switzer-
land. J Trauma. 1977;17(12):931–6.
40. Tator CH, Rowed DW, Schwartz ML, et al. Management of acute spinal
cord injuries. Can J Surg J Can Chir. 1984;27(3):289–93.
41. Tator CH, Duncan EG, Edmonds VE, Lapczak LI, Andrews DF. Changes
in epidemiology of acute spinal cord injury from 1947 to 1981. Surg
Neurol. 1993;40(3):207–15.
42. Boyd CR, Corse KM, Campbell RC. Emergency interhospital trans-
port of the major trauma patient: air versus ground. J Trauma.
1989;29(6):789–93.
43. Burney RE, Waggoner R, Maynard FM. Stabilization of spinal injury for
early transfer. J Trauma. 1989;29(11):1497–9.
44. DeVivo MJ, Go BK, Jackson AB. Overview of the national spinal cord
injury statistical center database. J Spinal Cord Med. 2002;25(4):335–8.
45. Domeier RM, Swor RA, Evans RW, et al. Multicenter prospective
validation of prehospital clinical spinal clearance criteria. J Trauma.
2002;53(4):744–50.
46. Theodore N, Aarabi B, Dhall SS, et al. Transportation of patients with
acute traumatic cervical spine injuries. Neurosurgery. 2013;72(Suppl
2):35–9.
47. Hadley MN, Walters BC, Aarabi B, et al. Clinical assessment following
acute cervical spinal cord injury. Neurosurgery. 2013;72(Suppl 2):40–53.
48. ASIA/IMSOP. International Standards for Neurological and Functional
Classification of Spial Cord Injury- Revised 2000. 2000.
49. Kirshblum SC, Memmo P, Kim N, Campagnolo D, Millis S, American Spi-
nal Injury Association. Comparison of the revised 2000 American Spinal
Injury Association classification standards with the 1996 guidelines. Am
J Phys Med Rehabil Assoc Acad Physiatr. 2002;81(7):502–5.
50. Savic G, Bergström EMK, Frankel HL, Jamous MA, Jones PW. Inter-rater
reliability of motor and sensory examinations performed accord-
ing to American Spinal Injury Association standards. Spinal Cord.
2007;45(6):444–51.
51. Burns AS, Lee BS, Ditunno JF, Tessler A. Patient selection for clinical trials:
the reliability of the early spinal cord injury examination. J Neuro-
trauma. 2003;20(5):477–82.
52. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice
computed tomography versus plain radiographic cervical spine clear-
ance in trauma patients. J Trauma. 2007;62(6):1427–31.
53. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radio-
graphs as the initial screening test in patients at high, moderate, and
low risk for blunt cervical spine injury: a prospective comparison. J
Trauma. 2009;66(6):1605–9.
54. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines
for identification of cervical spine injuries following trauma: update
from the eastern association for the surgery of trauma practice man-
agement guidelines committee. J Trauma. 2009;67(3):651–9.
55. Ryken TC, Hadley MN, Walters BC, et al. Radiographic assessment. Neu-
rosurgery. 2013;72(Suppl 2):54–72.
56. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a
set of clinical criteria to rule out injury to the cervical spine in patients
 with blunt trauma. National Emergency X-Radiography Utilization
Study Group. N Engl J Med. 2000;343(2):94–9.
57. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule
versus the NEXUS low-risk criteria in patients with trauma. N Engl J
Med. 2003;349(26):2510–8.
58. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine
rule for radiography in alert and stable trauma patients. JAMA.
2001;286(15):1841–8.
59. Anderson PA, Muchow RD, Munoz A, Tontz WL, Resnick DK. Clearance
of the asymptomatic cervical spine: a meta-analysis. J Orthop Trauma.
2010;24(2):100–6.
60. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the
cervical spine in head-injured patients with dynamic fluoroscopy: a
reappraisal. J Trauma. 2001;50(6):1044–7.
61. Pollack CV, Hendey GW, Martin DR, Hoffman JR, Mower WR. NEXUS
Group. Use of flexion-extension radiographs of the cervical spine in
blunt trauma. Ann Emerg Med. 2001;38(1):8–11.
62. Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, Dalinka MK. Utility
of flexion and extension radiographs of the cervical spine in the acute
evaluation of blunt trauma. J Trauma. 2002;53(3):426–9.
63. Duane TM, Cross J, Scarcella N, et al. Flexion-extension cervical spine
plain films compared with MRI in the diagnosis of ligamentous injury.
Am Surg. 2010;76(6):595–8.
64. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging
is not needed to clear cervical spines in blunt trauma patients with
normal computed tomographic results and no motor deficits. Arch
Surg. 2005;140(8):762–6.
65. Hennessy D, Widder S, Zygun D, Hurlbert RJ, Burrowes P, Kortbeek JB.
Cervical spine clearance in obtunded blunt trauma patients: a prospec-
tive study. J Trauma. 2010;68(3):576–82.
66. Padayachee L, Cooper DJ, Irons S, et al. Cervical spine clearance in
unconscious traumatic brain injury patients: dynamic flexion-extension
fluoroscopy versus computed tomography with three-dimensional
reconstruction. J Trauma. 2006;60(2):341–5.
67. Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the use
of electrophysiological monitoring for surgery of the human spinal
column and spinal cord. Neurosurgery. 2017;81(5):713–32.
68. Hadley MN, Fitzpatrick BC, Sonntag VK, Browner CM. Facet fracture-dis-
location injuries of the cervical spine. Neurosurgery. 1992;30(5):661–6.
69. Evans D. Reduction of cervical dislocations. J Bone Jt Surg Br.
1961;43(3):552–5.
70. Burke DC, Berryman D. The place of closed manipulation in the man-
agement of flexion-rotation dislocations of the cervical spine. J Bone
Joint Surg Br. 1971;53(2):165–82.
71. Sonntag VK. Management of bilateral locked facets of the cervical
spine. Neurosurgery. 1981;8(2):150–2.
72. Maiman DJ, Barolat G, Larson SJ. Management of bilateral locked facets
of the cervical spine. Neurosurgery. 1986;18(5):542–7.
73. Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R. Immediate
closed reduction of cervical spine dislocations using traction. Spine.
1990;15(10):1068–72.
74. O’Conner P, McCormack O, Noel J, McCormack D, O’Byrne J. Anterior
displacement correlates with neurological impairment in cervical facet
dislocations. Int Orthop. 2003;27(3):190–3.
75. Cowan JA, McGillicuddy JE. Images in clinical medicine: reversal
of traumatic quadriplegia after closed reduction. N Engl J Med.
2008;359(20):2154.
76. Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler
JM. Magnetic resonance evaluation of the intervertebral disc, spinal
ligaments, and spinal cord before and after closed traction reduction of
cervical spine dislocations. Spine. 1999;24(12):1210–7.
77. Doran SE, Papadopoulos SM, Ducker TB, Lillehei KO. Magnetic reso-
nance imaging documentation of coexistent traumatic locked facets of
the cervical spine and disc herniation. J Neurosurg. 1993;79(3):341–5.
78. Rizzolo SJ, Vaccaro AR, Cotler JM. Cervical spine trauma. Spine.
1994;19(20):2288–98.
79. Grant GA, Mirza SK, Chapman JR, et al. Risk of early closed reduction in
cervical spine subluxation injuries. J Neurosurg. 1999;90(1 Suppl):13–8.
80. Darsaut TE, Ashforth R, Bhargava R, et al. A pilot study of magnetic
resonance imaging-guided closed reduction of cervical spine fractures.
Spine. 2006;31(18):2085–90.
81. Brunette DD, Rockswold GL. Neurologic recovery following rapid
spinal realignment for complete cervical spinal cord injury. J Trauma.
1987;27(4):445–7.
82. Greg Anderson D, Voets C, Ropiak R, et al. Analysis of patient variables
affecting neurologic outcome after traumatic cervical facet dislocation.
Spine J Off J North Am Spine Soc. 2004;4(5):506–12.
83. Gelb DE, Hadley MN, Aarabi B, et al. Initial closed reduction of cervi-
cal spinal fracture-dislocation injuries. Neurosurgery. 2013;72(Suppl
2):73–83.
84. Lehmann KG, Lane JG, Piepmeier JM, Batsford WP. Cardiovascular
abnormalities accompanying acute spinal cord injury in humans:
incidence, time course and severity. J Am Coll Cardiol. 1987;10(1):46–52.
85. Grossman RG, Frankowski RF, Burau KD, et al. Incidence and severity
of acute complications after spinal cord injury. J Neurosurg Spine.
2012;17(1 Suppl):119–28.
86. Hassid VJ, Schinco MA, Tepas JJ, et al. Definitive establishment of airway
control is critical for optimal outcome in lower cervical spinal cord
injury. J Trauma. 2008;65(6):1328–32.
87. Berney S, Bragge P, Granger C, Opdam H, Denehy L. The acute respira-
tory management of cervical spinal cord injury in the first 6 weeks after
injury: a systematic review. Spinal Cord. 2011;49(1):17–29.
88. Ledsome JR, Sharp JM. Pulmonary function in acute cervical cord injury.
Am Rev Respir Dis. 1981;124(1):41–4.
89. Grande CM, Barton CR, Stene JK. Appropriate techniques for airway
management of emergency patients with suspected spinal cord injury.
Anesth Analg. 1988;67(7):714–5.
90. Shatney CH, Brunner RD, Nguyen TQ. The safety of orotracheal intuba-
tion in patients with unstable cervical spine fracture or high spinal cord
injury. Am J Surg. 1995;170(6):676–9.
91. Hindman BJ, From RP, Fontes RB, et al. Intubation biomechanics:
laryngoscope force and cervical spine motion during intubation in
cadavers-cadavers versus patients, the effect of repeated intubations,
and the effect of type II odontoid fracture on C1–C2 motion. Anesthesi-
ology. 2015;123(5):1042–58.
92. Hindman BJ, Fontes RB, From RP, et al. Intubation biomechanics:
laryngoscope force and cervical spine motion during intubation in
cadavers-effect of severe distractive-flexion injury on C3-4 motion. J
Neurosurg Spine. 2016;1–11.
93. Harrop JS, Sharan AD, Scheid EH, Vaccaro AR, Przybylski GJ. Tracheos-
tomy placement in patients with complete cervical spinal cord injuries:
American Spinal Injury Association Grade A. J Neurosurg. 2004;100(1
Suppl Spine):20–3.
94. Berney SC, Gordon IR, Opdam HI, Denehy L. A classification and regres-
sion tree to assist clinical decision making in airway management for
patients with cervical spinal cord injury. Spinal Cord. 2011;49(2):244–50.
95. Leelapattana P, Fleming JC, Gurr KR, Bailey SI, Parry N, Bailey CS. Predict-
ing the need for tracheostomy in patients with cervical spinal cord
injury. J Trauma Acute Care Surg. 2012;73(4):880–4.
96. Romero J, Vari A, Gambarrutta C, Oliviero A. Tracheostomy timing in
traumatic spinal cord injury. Eur Spine J Off Publ Eur Spine Soc Eur
Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2009;18(10):1452–7.
97. O’Keeffe T, Goldman RK, Mayberry JC, Rehm CG, Hart RA. Tracheostomy
after anterior cervical spine fixation. J Trauma. 2004;57(4):855–60.
98. Babu R, Owens TR, Thomas S, et al. Timing of tracheostomy after ante-
rior cervical spine fixation. J Trauma Acute Care Surg. 2013;74(4):961–6.
99. Wolf A, Levi L, Mirvis S, et al. Operative management of bilateral facet
dislocation. J Neurosurg. 1991;75(6):883–90.
100. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with
acute cervical cord trauma: description, intervention, and prediction of
outcome. Neurosurgery. 1993;33(6):1007–16.
101. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgi-
cal 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):239–46.
102. Hawryluk G, Whetstone W, Saigal R, et al. Mean arterial blood pressure
correlates with neurological recovery after human spinal cord injury:
analysis of high frequency physiologic data. J Neurotrauma 2015.
103. Ryken TC, Hurlbert RJ, Hadley MN, et al. The acute cardiopulmonary
management of patients with cervical spinal cord injuries. Neurosur-
gery. 2013;72(Suppl 2):84–92.
 104. Bracken MB, Collins WF, Freeman DF, et al. Efficacy of methylpredniso-
lone in acute spinal cord injury. JAMA. 1984;251(1):45–52.
105. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial
of methylprednisolone or naloxone in the treatment of acute spinal-
cord injury. Results of the Second National Acute Spinal Cord Injury
Study. N Engl J Med. 1990;322(20):1405–11.
106. Bracken MB, Shepard MJ, Holford TR, et al. Methylprednisolone or tirila-
zad 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):699–706.
107. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for
acute spinal cord injury. Neurosurgery. 2013;72(Suppl 2):93–105.
108. Pointillart V, Petitjean ME, Wiart L, et al. Pharmacological therapy of
spinal cord injury during the acute phase. Spinal Cord. 2000;38(2):71–6.
109. Matsumoto T, Tamaki T, Kawakami M, Yoshida M, Ando M, Yamada H.
Early complications of high-dose methylprednisolone sodium suc-
cinate treatment in the follow-up of acute cervical spinal cord injury.
Spine. 2001;26(4):426–30.
110. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of
severe traumatic brain injury. Neurosurgery. 2017;80(1):6–15.
111. Werndle MC, Saadoun S, Phang I, et al. Monitoring of spinal cord
perfusion pressure in acute spinal cord injury: initial findings of
the injured spinal cord pressure evaluation study*. Crit Care Med.
2014;42(3):646–55.
112. Scott DA, Denton MJ. Spinal cord protection in aortic endovascular
surgery. Br J Anaesth. 2016;117(Suppl 2):ii26–31.
113. Khan NR, Smalley Z, Nesvick CL, Lee SL, Michael LM. The use of lumbar
drains in preventing spinal cord injury following thoracoabdominal aor-
tic aneurysm repair: an updated systematic review and meta-analysis. J
Neurosurg Spine. 2016;25(3):383–93.
114. Kwon BK, Curt A, Belanger LM, et al. Intrathecal pressure monitoring
and cerebrospinal fluid drainage in acute spinal cord injury: a prospec-
tive randomized trial. J Neurosurg Spine. 2009;10(3):181–93.
115. Mortazavi MM, Verma K, Tubbs RS, Theodore N. Non-pharmacological
experimental treatments for spinal cord injury: a review. Childs Nerv
Syst ChNS Off J Int Soc Pediatr Neurosurg. 2012;28(12):2041–5.
116. Cerebrospinal Fluid Drainage (CSFD) in Acute Spinal Cord Injury [Inter-
net]. ClinicalTrials.gov. 2015;Available from: https://clinicaltrials.gov/ct2/
show/NCT02495545?term=CSF&cond=Spinal+Cord+Injuries&cntry=
US&rank=5.
117. Thompson S, Zlololow D. Handbook of splinting and casting. Amster-
dam: Elsevier; 2012.
118. Williams K. Campbell’s operative orthopedics. 2013.