Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

progressive neurologic deficit

1st line – urgent assessment ± surgical decompression

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ACUTE
|
progressive neurologic deficit
1st line – 

urgent assessment ± surgical decompression

Progressive neurologic deficit does not necessarily relate to the original spinal cord injury (SCI) - it may indicate cord compression by metastases, primary spinal cord tumors, extradural hematoma or abscess, or intervertebral disk prolapse, and requires investigation. If any of these conditions are diagnosed, timely surgical decompression and stabilization of the involved spinal column is required.[14]

Patients require reassessment of their neurologic function postsurgery, and require rehabilitation if there is any residual neurologic deficit.

If progressive neurologic deficit indicates secondary ischemia or inflammation following the acute injury, there is no role for surgery.

Plus – treatment of underlying cause

Back
ACUTE
|
progressive neurologic deficit
|
with autonomic dysreflexia
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Autonomic dysreflexia can occur in patients with a lesion affecting T6 or higher.[104][105] It is caused by an excessive autonomic response to stimuli below the level of the lesion, such as a fecal impaction or blocked catheter. The abnormal response produces autonomic imbalance with sympathetic overactivity.

Addressing the underlying cause is first-line treatment. Bladder distension should be excluded first.[104] If the patient has a catheter, the tubing should be checked for blockage or kinking, and replaced if needed. If there is no catheter but clinical signs of urinary retention, catheterization is indicated.

If there is no bladder distension, a rectal exam should be performed to check for and remove rectal fecal impaction.

Other noxious stimuli such as pressure ulcers or an ingrowing toenail are rarer causes.

Consider – vasodilator

Back
ACUTE
|
progressive neurologic deficit
|
with autonomic dysreflexia
Consider – 

vasodilator

Treatment recommended for SOME patients in selected patient group

If symptoms persist despite treatment of the underlying cause, or no cause is identified, patients should be treated with sublingual nifedipine or nitroglycerin to lower their blood pressure.[104][107]

If the response remains inadequate after 2 doses, an intravenous hypotensive agent (e.g., hydralazine, diazoxide, or nitroprusside) should be given.[107][108][109][110]

Blood pressure should be monitored regularly, and efforts to find the underlying cause should be continued.

Primary options

nifedipine: consult specialist for guidance on dose

OR

nitroglycerin: consult specialist for guidance on dose

Secondary options

hydralazine: consult specialist for guidance on dose

OR

diazoxide: consult specialist for guidance on dose

OR

nitroprusside: consult specialist for guidance on dose

stable neurologic status

1st line – therapeutic interventions

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ACUTE
|
stable neurologic status
1st line – 

therapeutic interventions

The goal for any rehabilitation program for spinal cord injury (SCI)-related paralysis is to maximize day-to-day functioning to achieve levels similar to before the injury through compensatory and restorative approaches. Compensatory approaches involve maximizing the strength and functionality of the intact, nonaffected parts of the body, while restorative approaches aim to improve mobility and daily activities by optimizing neuro-recovery.[50][51][52][53]

Physical therapy is used to maintain joint range of motion (ROM) and mobility. This stimulates circulation and aims to prevent deformities, muscle and secondary joint contractures, and osteoporosis.[54] Activity-based therapies can promote neurologic recovery and thus enhance sensory-motor and autonomic function.[55][56][57][58][59]

Specific components of rehabilitation include the following.

Mobility and transfers: techniques are taught in order to facilitate position changes for pressure relief, dressing, daily self-care activities, sleeping, and transfers to and from a wheelchair. Different sitting mechanisms, supports, and methods of rising from the supine to the upright position are explored and taught.[60]

Wheelchair mobility: effective use of power or manual wheelchairs requires training. A variety of different options are available, and control can be customized based on the level of functioning of the patient. Chin, mouth, and hand controls are available for power wheelchairs; power-assisted technology can be used to improve ability to navigate different spaces using manual wheelchairs.[61][62] Advanced maneuvering techniques can be taught to enable patients to turn in tight spaces and negotiate ramps, slopes, and curbs.

Walking: there are multiple interventions that can be used to enable a patient with SCI-related paralysis to practice gait, but neurologic status is the primary predictor of the ability of the patient to walk over ground independently. Patients with at least full ROM of the lower limbs with gravity eliminated are more likely to be able to walk with aids. Locomotor training uses interventions such as treadmill body weight-supported walking or robot-assisted walking.[63][64] Orthoses for joint support or a reciprocating gait orthosis can be used for aiding ambulation. In patients with more severe motor involvement, standing may be possible with a tilt table, frames, upright wheelchairs, or parallel bars. Walking may be difficult if there is concomitant upper limb paralysis, lack of pelvic control, loss of proprioception, obesity, joint contracture, or spasticity.[53][65]

Hand function: the aim is to improve function using neuro-restorative and/or compensatory interventions.[66][67] The compensatory rehabilitative model builds on available function using training and orthoses to maximize dexterity. Splints hold joints in functional positions and can be adapted depending on the function required. Regular hand therapy can be performed out of the splint to maintain flexibility and full passive ROM. The tenodesis effect (passive finger flexion in response to wrist extension) can be taught to some patients to allow them to use the basic pinch, grasp, and 3-point grips. The activity-based therapy model utilizes task-specific training and massed practice in order to improve upper limb function.[68][69] Surgical reconstructions using arthrodesis, tenodesis, and tendon and nerve transfers may be considered in suitable patients.

Exercise: a variety of exercise interventions, including passive ROM, strengthening and conditioning, functional electrical stimulation, and electrically stimulated resistance exercise, may improve arterial function and help neuro-recovery in patients with SCI.[70][71][72]

Plus – supportive care

Back
ACUTE
|
stable neurologic status
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Maintenance of good respiratory function is vital. Regular airway clearance techniques and clinical assessment and ongoing monitoring of pulmonary function are recommended to ensure adequate airway clearance.[73] A regular change in position and posture and regular deployment of assisted cough and regular breathing exercises (incentive spirometry) are useful in preventing secondary respiratory problems.[74] In patients requiring ongoing ventilatory support, noninvasive approaches are associated with fewer complications than invasive ventilation.[73] Resistive inspiratory muscle training has been found to have a positive short-term effect on inspiratory muscle function in patients with SCI who have impaired pulmonary function.[75]

Pressure ulcers typically occur under the sacrum (lying supine), ischial tuberosities (sitting), or trochanters (lying on a side). They are prevented by good nursing, regular change in position, padding prominences, maintaining cleanliness, and regular checking of the skin. Surgical management is required in the presence of necrotic tissue.[76] See Pressure ulcer.

Patients at increased risk of thrombosis (e.g., immobilized for bed rest, or admitted for medical illness or surgery) should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[77] Pharmacologic prophylaxis should be used unless contraindicated; nonpharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding. See Venous thromboembolism (VTE) prophylaxis.

Plus – bladder management

Back
ACUTE
|
stable neurologic status
Plus – 

bladder management

Treatment recommended for ALL patients in selected patient group

Most patients with SCI have impairments in bladder function, be it storage, evacuation, or both.[78]

The preferred method of management is intermittent self-catheterization. Use of an indwelling catheter with an external collection system may also be considered; however, this increases the risk of urinary contracture and infection. It is important that the method used maintains a low-pressure system, prevents bladder overdistension, and ensures complete emptying.

Management strategies can be developed based on bladder studies (postvoid ultrasound, urodynamic assessments, and micturition cystourethrogram).[82] Pharmacologic management is aimed at optimizing storage and elimination by using agents that decrease detrusor hyperreflexia, improve bladder compliance, and address detrusor-sphincter dyssynergia (e.g., anticholinergics, beta agonists, alpha-blockers, botulinum toxin injection, and sometimes even cholinergic agents).[83] Consult a specialist for guidance on choice of therapy.

Plus – customized bowel management program

Back
ACUTE
|
stable neurologic status
Plus – 

customized bowel management program

Treatment recommended for ALL patients in selected patient group

A bowel management program should be developed and customized for each patient.[85][86][113]

Dietary management should include consumption of a balanced diet, including fiber and stimulant foods, with fluid intake >2 liters/day.

Regular routine: meals and bowel movements, if possible, should occur at the same time each day; the same location should be used for bowel movements.

Physical maneuvers include stimulation of the gastrocolic reflex by a hot dietary trigger, abdominal massage, and physical activity to promote defecation. The patient should sit on a commode or toilet if possible.

Local triggers for defecation can be used, including digital stimulation, suppositories, or manual evacuation.

Pharmacologic treatments: stool softeners are preferred. Stimulant or osmotic laxatives are only indicated if constipation persists despite optimization of all other components of the bowel management program. Bowel obstruction should be excluded before administration of laxatives.

Plus – management of bone health

Back
ACUTE
|
stable neurologic status
Plus – 

management of bone health

Treatment recommended for ALL patients in selected patient group

Bone loss starts early after paralysis onset and, while most pronounced in the first 12 months, continues for years after SCI.[100] Assessment of bone mineral density should be done as soon as the patient is medically stable after paralysis, and should be repeated after at least 12 months of medical therapy and then at 1- to 2-year intervals.[46]

The low bone density and secondary osteoporosis associated with SCI-related paralysis leads to a high incidence of low impact fractures, which often result in hospitalization.[101][102] Several commonly prescribed medications for patients with SCI (antidepressants, anticonvulsants, opioids, proton-pump inhibitors, anticoagulants) may have a negative effect on bone density.[103]

No therapeutic intervention has been shown to decrease fracture risk, but ambulation, standing, and electrical stimulation may increase bone mineral density in patients with SCI.[47] There is evidence that bisphosphonates, anti-RANKL monoclonal antibodies (e.g., denosumab), and teriparatide (parathyroid hormone analog) can increase bone density of the spine, hip, and knee in patients with SCI.[47] Consult a specialist for guidance on choice of therapy.

Consider – pain management

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ACUTE
|
stable neurologic status
Consider – 

pain management

Treatment recommended for SOME patients in selected patient group

Nociceptive pain is amenable to physical therapy and simple analgesia.[87]

Neuropathic pain is difficult to treat.[88][89]​ First-line agents are neurostabilizing anticonvulsants (e.g., gabapentin, pregabalin), serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine), and tricyclic antidepressants (e.g., amitriptyline).[91][92]​ Opioid analgesics such as tramadol or oxycodone may be considered as a last resort once other options have been tried, but only if expected benefits outweigh risks and after a full discussion with the patient.[93][94]​​[95]

Neuromodulation therapies for treating pain, such as transcutaneous electrical stimulation, spinal cord stimulation, and brain stimulation, have mixed outcomes.[96][97][98] Patients with nerve root compression should be considered for surgical decompression.

The efficacy of psychological interventions in the treatment of chronic neuropathic pain has been insufficiently studied.

Primary options

gabapentin: 300 mg orally once daily on day 1, followed by 300 mg twice daily on day 2, followed by 300 mg three times daily on day 3, then increase gradually according to response, maximum 3600 mg/day

OR

pregabalin: 75-150 mg orally twice daily

OR

duloxetine: 60 mg orally once daily

OR

amitriptyline: 25-50 mg orally once daily at night

Secondary options

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) twice daily when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Consider – management of spasticity

Back
ACUTE
|
stable neurologic status
Consider – 

management of spasticity

Treatment recommended for SOME patients in selected patient group

Spasticity management may involve both pharmacologic agents (e.g., oral baclofen and tizanidine; some neuropathic pain medications such as gabapentin; dopaminergic drugs such as levodopa/carbidopa; chemodenervation with botulinum toxin or phenol/alcohol; intrathecal baclofen) and surgical procedures (orthopedic contracture release; nerve transfer; dorsal rhizotomy).[48] Consult a specialist for guidance on choice of therapy.

Evidence for the effectiveness of non-pharmacological interventions (such as electro-neuromuscular stimulation, stretching, splinting, repetitive magnetic stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, vibration therapy) is limited.[99]

Consider – management of psychological comorbidities

Back
ACUTE
|
stable neurologic status
Consider – 

management of psychological comorbidities

Treatment recommended for SOME patients in selected patient group

Patients with SCI who screen positive for a psychological or substance use disorder should be referred to a mental health professional for further assessment, and initiation of treatment if indicated. Pharmacologic and/or nonpharmacologic interventions should be considered, with treatment decisions based on clinical considerations and patient preference.[40]

Consider – management of sexual dysfunction, fertility, pregnancy, and birth

Back
ACUTE
|
stable neurologic status
Consider – 

management of sexual dysfunction, fertility, pregnancy, and birth

Treatment recommended for SOME patients in selected patient group

Patients with sexual dysfunction should be provided with information, and offered nonpharmacologic and pharmacologic treatments as appropriate.[111]

Assisted fertility treatments should be offered as required.[37][38]

Pregnancy, labor, and birth for female patients living with SCI require specialty care by a multidisciplinary team. Patients considering pregnancy should have a prepregnancy evaluation. Autonomic dysreflexia can mimic preeclampsia, and labor can trigger severe autonomic dysreflexia; neuraxial anesthesia is preferred to reduce the risk of autonomic dysreflexia.[37] Women with SCIs can give birth vaginally. For cesarean birth, spinal or epidural anesthesia is preferred. Clinicians should be aware that patients with SCI may have delayed wound healing.[112]​​

Plus – treatment of underlying cause

Back
ACUTE
|
stable neurologic status
|
with autonomic dysreflexia
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Autonomic dysreflexia can occur in patients with a lesion affecting T6 or higher.[104][105] It is caused by an excessive autonomic response to stimuli below the level of the lesion, such as a fecal impaction or blocked catheter. The abnormal response produces autonomic imbalance with sympathetic overactivity.

Addressing the underlying cause is first-line treatment. Bladder distension should be excluded first.[104] If the patient has a catheter, the tubing should be checked for blockage or kinking, and replaced if needed. If there is no catheter but clinical signs of urinary retention, catheterization is indicated.

If there is no bladder distension, a rectal exam should be performed to check for and remove rectal fecal impaction.

Other noxious stimuli such as pressure ulcers or an ingrowing toenail are rarer causes.

Consider – vasodilator

Back
ACUTE
|
stable neurologic status
|
with autonomic dysreflexia
Consider – 

vasodilator

Treatment recommended for SOME patients in selected patient group

If symptoms persist despite treatment of the underlying cause, or no cause is identified, patients should be treated with sublingual nifedipine or nitroglycerin to lower their blood pressure.[104][107]

If the response remains inadequate after 2 doses, an intravenous hypotensive agent (e.g., hydralazine, diazoxide, or nitroprusside) should be given.[107][108][109][110]

Blood pressure should be monitored regularly, and efforts to find the underlying cause should be continued.

Primary options

nifedipine: consult specialist for guidance on dose

OR

nitroglycerin: consult specialist for guidance on dose

Secondary options

hydralazine: consult specialist for guidance on dose

OR

diazoxide: consult specialist for guidance on dose

OR

nitroprusside: consult specialist for guidance on dose

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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