Clinical Recommendations for the Acute Care of Patients With Traumatic Spinal Cord Injury

Background: Acute traumatic spinal cord injury (tSCI) is among the more complex challenges in modern medicine and has far-reaching implications for the affected patients’ quality of life. A practical summary for treating physicians of the currently recommended clinical measures for the acute care of patients with tSCI is needed as an evidence-based guide to treatment.

Methods: This narrative review is based on pertinent publications (1984–2024) retrieved by a search in the PubMed, Cochrane, and EMBASE databases, with particular attention to the updated clinical practice guideline on acute spinal cord trauma issued by AO Spine in 2024. The abstracts were examined for relevance, and the full text of selected articles was studied.

Results: The evidence base for the management of tSCI includes only a small number of randomized controlled trials. As a result, the evidence underlying many of the recommendations is on a moderate or low level. Early surgical decompression (within 24 hours) is associated with a significantly better neurological outcome: it more than doubles the likelihood of an improvement of ≥ 2 points on the ASIA Impairment Scale (AIS) (RR: 2.76, 95% confidence interval [1,60; 4,98]; moderate evidence level). Maintaining an adequate mean arterial blood pressure is considered to be essential, despite the absence of robust evidence for any specific protocol (very low evidence level). The use of corticosteroids remains controversial because of conflicting evidence.

Conclusion: The treatment of tSCI requires a multidisciplinary, evidence-based approach including early surgery and patient-oriented hemodynamic management.

Cite this as: Krueckel J, Kerschbaum M, Alt V, Lang S: Clinical recommendations for the acute care of patients with traumatic spinal cord injury. Dtsch Arztebl Int 2025; 122: 611–6. DOI: 10.3238/arztebl.m2025.0148

Acute traumatic spinal cord injury (tSCI) is a serious condition that significantly impairs sensory, motor, and autonomic functions. It has a substantial impact on both the physical and psychological well-being of patients. Primary spinal cord injury results from mechanical forces that lead to microhemorrhages, axonal lesions, and cell death. This results in damage to blood vessels, neurons, and the blood–spinal cord barrier. Secondary processes such as ischemia and hypoxia further exacerbate the extent of the injury. Early interventions are considered crucial to limit secondary damage and promote neurological recovery (1, 2).

The aim of this narrative review is to provide a clear overview of current developments in the acute care of patients with tSCI and to critically evaluate established measures based on the available evidence. The review focuses on acute care strategies over the first hours and days following injury. The article is intended to serve as a practical guide and to provide a basis for decision-making aimed at ensuring the best possible care. The figures included in this article are intended as schematic guides to clinical practice.

Epidemiology

The incidence of traumatic spinal cord injury in Germany is 15.7 cases per million inhabitants per year. Of these, approximately one-third (5.2 per million) are complete and two-thirds (10.5 per million) are incomplete lesions. Although the risk of injury increases with age, the likelihood of a complete injury decreases. In Germany, 58.7% of injuries involve the cervical spine, 30.8% the thoracic spine, and 10.4% the lumbar spine (3). In 2019, approximately 0.9 million new cases of tSCI and 20.6 million existing cases were registered worldwide, and 6.2 million healthy life years were lost due to disability (years lived with disability, YLDs). Men were affected more frequently than women, and despite a growing proportion of older tSCI patients, long-term trends in incidence and YLD rates have remained largely stable in recent years (4, 5). First-year costs of up to 1.16 million US dollars following injury highlight the considerable socioeconomic impact of these injuries (6). The main causes of tSCI include motor vehicle accidents and falls. Global projections up to 2030 predict rising age-specific incidence rates for both sexes alongside a similar trend in age-standardized YLD rates (7).

Pathophysiology

tSCI begins with a primary injury that causes microhemorrhages in the white and gray matter, as well as damage to axons and cell membranes (8). The severity of the primary injury is determined by the type and intensity of the trauma. The initial tissue injury and subsequent disruption of the blood–spinal cord barrier trigger a secondary injury cascade that may lead to irreversible structural disintegration (9, 10, 11, 12). The rapid increase in proinflammatory factors contributes to an excessive inflammatory response and swelling, ultimately resulting in additional mechanical compression of the spinal cord (9, 10). Minutes to weeks following the trauma, vasoconstriction and hypoxia occur (11). The resulting ion imbalance impairs cellular function and exacerbates neuronal dysfunction. At the same time, the lesion becomes a focus of inflammation, characterized by immune cell infiltration and proinflammatory mediator release. These processes promote local tissue destruction and systemic sequelae (12).

Prognosis

Neurological recovery following tSCI typically occurs within the first 6 months, although improvements may still be observed up to 5 years post-injury (13). The key prognostic factor for functional outcome is the completeness of the injury. The American Spinal Injury Association (ASIA) Impairment Scale (AIS) classifies neurological function according to severity, ranging from A (complete injury, no sensorimotor function) to E (normal, fully preserved sensorimotor function) (14). While approximately 10–20% of initially clinically complete injuries show partial recovery in the first year, motor recovery in AIS-A injuries generally remains severely limited. In the case of incomplete injuries (AIS B–D), around 20–75% of patients regain some ability to walk within 1 year, depending on the baseline injury severity (15). To assess individual prospects of recovery, datasets from tSCI patients are available through the European Multicenter Study about Spinal Cord Injury (EMSCI). These enable more detailed statements on patient-specific prognosis, particularly with respect to future walking ability, based on neurological findings recorded at an early post-injury stage (16, 17, 18).

Since prognosis in the early phase following tSCI is difficult to assess due to limited diagnostic reliability, early prognostic statements should be avoided. Structured informational discussions with patients are also essential in non-specialized centers. In this context, the timing of discussions as well as an empathic style of communication are considered essential for affected individuals. Further details can be found in the current clinical practice guideline of the German Neurological Society (Deutsche Gesellschaft für Neurologie, DGN) and the German-Speaking Medical Society for Paraplegiology (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie, DMGP) (19).

Methods

This narrative review is based on a literature search of studies published between 1984 and 2024 in the PubMed, Cochrane, and EMBASE databases, with particular attention given to the updated clinical practice guideline on acute spinal cord trauma issued by AO Spine in 2024. The abstracts were examined for relevance, and the full text of selected articles was studied. Artificial intelligence–based translation tools (DeepL, ChatGPT) were used to support the preparation of this article. The authors are solely responsible for the final content and wording.

Clinical management

Basic principles and proven strategies

The acute management of traumatic spinal cord injuries requires tailored decision-making based on patient-specific factors. For structured orientation, we present a flowchart of diagnosis and initial management in the emergency department (Figure 1), as well as a timeline showing key interventional steps following confirmation of the tSCI diagnosis (Figure 2).

Figure 1

Algorithmic flowchart for the structured initial management of suspected traumatic spinal cord injury (tSCI) in the emergency department. Developed as a practical decision-making aid for the emergency department and trauma room.

Figure 2

Timeline for the management of confirmed traumatic spinal cord injury (tSCI). Recommended measures and critical interventions requiring different levels of urgency are shown.

Hemodynamic management

Maintaining adequate organ perfusion is of central importance to prevent hypoxia and insufficient blood supply to the spinal cord, thereby minimizing secondary damage (20). Earlier guidelines recommended maintaining a mean arterial pressure (MAP) of 85–90 mm Hg during the first week following tSCI (16, 17, 18, 19). Recommendations on blood pressure regulation remained unchanged for a long time, as their effects are difficult to assess in isolation. Moreover, only around 25% of MAP values during the first days following tSCI are within the recommended target range of 85–90 mm Hg, underscoring the challenge of maintaining stable blood pressure control (21). At present, maintaining blood pressure is regarded as a key treatment principle, but this recommendation is based solely on observational studies. To date, no randomized controlled trials or prospective comparisons of different MAP target ranges are available. Existing works predominantly report associations between neurological recovery and MAP targets in the range of 70–95 mm Hg (1, 22, 23). In a recent systematic review, Kwon et al. identified possible MAP target ranges for tSCI and, albeit based on very low-quality evidence, issued a weak recommendation for maintaining MAP values between 75–80 mm Hg and 90–95 mm Hg (23). There is no clear recommendation on the selection of vasoactive drug. Retrospective studies found that dopamine, compared with phenylephrine, was associated with a higher rate of adverse events, without any significant neurological benefit being observed (1).

Furthermore, spinal cord perfusion pressure (SCPP), derived from the difference between MAP and intraspinal pressure, can be used as a targeted method to measure perfusion. Maintaining SCPP at approximately 60–65 mm Hg may be associated with improved neurological recovery (24, 25). However, practical implementation beyond individual case studies has not yet been achieved (26).

To guide clinical implementation, the following recommendations currently apply:

• Mean arterial blood pressure should be increased to at least 75–80 mm Hg, but should not be raised above 90–95 mm Hg.
• If necessary, vasopressors should be used to achieve the abovementioned blood pressure targets. Due to the very low quality of evidence, it is currently not possible to recommend a specific vasopressor; selection should therefore be made on a case-by-case basis.

Diagnostic imaging

Traditional x-rays of the cervical and thoracolumbar spine have proved unsuitable for initial diagnostic assessment, as their sensitivity for injuries is insufficient (27). Instead, non-contrast multidetector computed tomography (MDCT) has become established as the gold standard, with slice thicknesses of less than 2 mm recommended (28).

If tSCI is suspected, a whole-body CT scan is recommended (29). This initially includes a non-contrast CT scan of the head, followed by a multislice CT scan with intravenous contrast, which images the region from the circle of Willis to the pelvis (30).

However, since MDCT cannot visualize ligamentous or spinal cord injuries, magnetic resonance imaging (MRI) may be used as an adjunct in specific diagnostic questions. It should be used preoperatively in cases of suspected spinal cord injury or spinal instability, as well as when there are discrepancies between clinical neurological findings and CT imaging, provided that this does not result in a relevant delay in surgical treatment. Both the AO Spine and the DGN and DMGP guidelines unanimously endorse this approach (19, 31). It is not recommended in patients who cannot be clinically or neurologically evaluated, as well as in those with normal CT findings (32, 33).

Methylprednisolone sodium succinate

The use of methylprednisolone within 8 h of tSCI remains controversial. Some guidelines—including that of the AO Spine—regard high-dose intravenous administration (30 mg/kg bolus, followed by 5.4 mg/kg/h over 24 h) as a potential therapeutic option. In contrast, other guidelines—including the recently published German clinical practice guideline of the DGN/DMGP—explicitly advise against this approach (19, 34, 35, 36, 37, 38). This divergence is also reflected in the systematic literature. While Sultan et al. found no significant benefit—but higher complication rates—when excluding the NASCIS-II trial data, Fehlings et al., when including these data, found a moderate but significant improvement in motor function (mean +3.2 motor score after at least 6 months; [0.1; 6.3]) (34, 36). The former analyzed a total of 12 studies, comprising five randomized controlled trials, five retrospective cohort studies, and two prospective cohort studies. The latter included 13 studies in their guideline evaluation: seven systematic review articles, four randomized controlled trials (including NASCIS-I–III), and two prospective cohort studies (34, 36).

Against this backdrop, routine use cannot currently be recommended. In individual cases, methylprednisolone administration can be considered within 8 h of tSCI—provided there are no contraindications, particularly no concomitant traumatic brain injury. Beyond the 8-h time window, however, there is broad consensus that methylprednisolone is not indicated. Potential risks—such as an increased incidence of pneumonia and hyperglycemia, as well as higher mortality in cases of combined traumatic brain injury—should be carefully weighed against the benefits when assessing the indication (35, 36, 39).

Anticoagulation

The risk of deep vein thrombosis (DVT) and pulmonary embolism is high in patients with tSCI. The reported rates range between 5% and 65%, depending on the diagnostic methods and preventive measures used, taking into account immobility, systemic inflammatory reactions, and endothelial damage (40, e1, e2).

The recommendation for the prophylaxis of venous thromboembolism in acute tSCI is based on several randomized controlled trials that, despite the overall low quality of evidence, point to a benefit for early pharmacological intervention (e3). For example, a significant reduction in the DVT rate was observed when enoxaparin was given compared to no prophylaxis (5.2% versus 21.6%; p = 0.041), without a significant increase in major complications such as bleeding, or mortality (e4). Three other randomized controlled trials with comparable levels of evidence found no significant differences in efficacy or safety between different low-molecular-weight heparin (LMWH) preparations, or in the comparison between LMWH and unfractionated heparin (UFH) (e5, e6, e7). The importance of starting anticoagulation early is underscored by a prospective study in which the initiation of prophylaxis within 72 h was associated with a pronounced reduction in DVT incidence (2% versus 26%; relative risk 12.9; [3.2; 51.2]; p < 0.001) (e8).

For this reason, national and international guidelines recommend initiating pharmacological thromboprophylaxis as early as clinically justifiable, ideally within 72 h of the injury (19, e9). The duration of prophylaxis should be individually tailored and depends on factors such as injury severity, mobility, bleeding risk, and comorbidities (e3, e10). If pharmacological prophylaxis is initially contraindicated, early recourse should be taken to mechanical measures such as intermittent pneumatic compression. Although the two methods are often used in combination, the additive benefit has not been conclusively demonstrated to date; thus, corresponding recommendations should be made with caution (e3, e9, e11).

The timing of decompressive surgery

The timing of surgical decompression is a crucial factor in the management of tSCI. The aim of early surgical decompression is to shorten the ischemic phase, limit secondary damage, and thereby improve neurological recovery (e12, e13). A recent meta-analysis by Fehlings et al. that included two randomized controlled trials and several prospective cohort studies points to moderate evidence that surgical decompression within 24 h of injury results in significantly better neurological outcomes than later interventions. On average, a 4.5-point [1.70; 7.29] improvement was observed in the ASIA Motor Score in favor of early surgery. In addition, the likelihood of an improvement in AIS grade by ≥ 2 was more than doubled (RR = 2.76 [1.60; 4.98]). Only those studies that methodologically controlled for potential biases arising from differences in the baseline neurological status of patients were included. There was no difference in the rate of major complications between patients who underwent early and those who underwent late surgery (2). After 24 h, the effectiveness of decompression declines significantly, indicating a narrow therapeutic window for optimal surgical intervention (e14).

This evidence base is also reflected in the corresponding AO Spine guideline and the German clinical practice guideline of the DGN/DMGP, which recommend surgical management within 24 h of injury, provided the patient’s overall condition permits.

The evidence for ultra-early decompression (for example, within 4, 8, or 12 h) is methodologically heterogeneous and currently of low quality. Due to small case numbers, lack of standardization of time windows, and insufficient adjustment for confounders, no reliable recommendations can be made as yet in this regard (e15, e16, e17, e18).

In summary, the importance of early surgical decompression within 24 h is evident, explaining why the “time is spine” principle has become established.

Despite these insights, the practical and logistical challenges associated with performing early decompression should not be underestimated. Multiple injuries or medical comorbidities may preclude immediate surgery. Furthermore, infrastructural challenges such as patient transfer, diagnostic testing, and surgeries conducted outside regular working hours pose significant hurdles. In their retrospective analysis, Glennie et al. demonstrated that fewer than 50% of tSCI patients treated in Canada underwent surgery within the 24-h window, indicating shortcomings in healthcare infrastructure (e19). These findings highlight the need for optimization, for example, through:

• The establishment of standard operating procedures
• Making use of interdisciplinary collaboration, with clear responsibilities defined for trauma surgery, neurosurgery, neurology, and radiology.
• Integration into regional and supraregional networks (for example, the Trauma Network of the German Society of Trauma Surgery [Traumanetzwerk der Deutschen Gesellschaft für Unfallchirurgie, DGU])
• Treatment in specialized centers.

Following initial acute care, additional key aspects of clinical management come to the fore, including spinal shock, autonomic dysreflexia, spasticity, and bowel and bladder management. The early initiation of rehabilitative measures also plays a crucial role in long-term functional recovery. Figure 2 provides a structured overview of the chronological sequence of these treatment phases and serves as a schematic guide following confirmed tSCI diagnosis. Detailed recommendations on ongoing care can be found in the German clinical practice guideline of the DGN and DMGP.

Below is an overview of the clinical measures for the management of tSCI (Box):

• Hemodynamics: Maintain an MAP of 75–80 mm Hg and 90–95 mm Hg during the first week
• Methylprednisolone: Administration beyond 8 h after trauma is not recommended.
• Anticoagulation: Early chemoprophylaxis for the prevention of thromboembolism
• Decompression: Surgical decompression within 24 h

Box

Surgical decompression techniques

Summary

The acute care of traumatic spinal cord injury requires guideline-based standards and structured care pathways. Whereas early decompression is established, optimal hemodynamic management as well as the importance of methylprednisolone and thromboprophylaxis remain unclear. Key issues that remain open include the control of spinal perfusion, neuroprotective pharmacotherapies such as riluzole, and AI-based decision-making aids. In addition, spinal perfusion pressure monitoring, cell-based regenerative treatments, neuromodulatory techniques, and virtual rehabilitation systems are coming increasingly to the fore.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 23 January 2025, revised version accepted
on 7 August 2025.

Translated from the original German by Christine Rye.

Corresponding author
Dr. med. Jonas Krueckel

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