Author(s): Scott Campea, MD, Jordan Schroeder, MD, Hetal Patel, MD
Originally published: August 7, 2012 Last updated: May 22, 2025
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Disease/Disorder

See Part 1

Essentials of Assessment

See Part 1

Rehabilitation Management and Treatments

Available or current treatment guidelines

The Paralyzed Veterans of America (PVA) have sponsored the development of clinical practice guidelines for the management of those with spinal cord injury (SCI). Entitled the Consortium for Spinal Cord Medicine, they are based on literature reviews and expert panel consensus.1-12

The Spinal Cord Injury Rehabilitation Evidence (SCIRE) project is a compilation of the research evidence underlying rehabilitation interventions for people with SCI.13

At different disease stages

New onset/acute

  • Management of persons with new onset or acute SCI typically takes place in the acute hospital setting.
  • Key components of early acute management include immobilization of the spine during transportation and initial hospitalization, monitoring of respiratory status, ensuring adequate blood pressure (mean arterial pressure goal of 85-90mmHg), heart rate, and temperature, and recognition and treatment of neurogenic shock and other associated injuries.1
  • Surgical spinal stabilization and decompression may be indicated. Closed or open reduction should be done as soon as feasible with bilateral cervical facet dislocation in incomplete SCI.1
  • Anticoagulation for venous thromboembolism (VTE) prophylaxis should be initiated within 72 hours of injury unless contraindicated. In these cases, mechanical VTE prophylaxis should be initiated until it is safe to begin anticoagulation.1,2
  • Oxygen saturation and arterial blood gas monitoring should occur in the initial days following injury, in order to monitor for declining oxygen saturation and carbon dioxide retention. This may herald the need for mechanical ventilation. Early tracheostomy may be indicated in high tetraplegia if weaning cannot occur in the acute period.1
  • Positioning, range of motion, skin integrity, and bladder and bowel management should be addressed from the onset of hospitalization in order to minimize complications, such as joint contractures and pressure ulcers.1
  • Neurogenic bladder is initially managed with an indwelling catheter.1 Discontinuation of the indwelling catheter and initiation of timed void can be considered with the emergence of bladder reflexes seen on physical exam (i.e., the bulbocavernosus reflex or the anal wink). While there are no specific agreed upon thresholds, bladder scans can evaluate for incomplete bladder emptying (such as a post-void residual greater than 300cc) and prompt intermittent catheterization.

Subacute

  • Management of persons with subacute SCI typically takes place the acute inpatient rehabilitation setting, although hospitalization may be needed for medical complications such as urosepsis, pneumonia, or worsening pressure injuries.
  • The primary goals during the subacute period are to educate the person and family about SCI, prevent secondary complications, improve function, and prepare the person for integration into the community. Taking into account the neurologic level, completeness of injury, individual factors, and coexisting conditions, functional goals can be established.3 Acute inpatient rehabilitation goals include improving independence with functional mobility, self-care activities and bladder and bowel management.
  • Indwelling bladder catheters should be discontinued if still present. Timed voiding trials, or if needed, intermittent catheterization, can be initiated. The goal volume per catheterization should be under 500 mL in order to prevent bladder overdistention and elevated intra-detrusor pressure. Urodynamic studies may be necessary in order to evaluate the underlying bladder dysfunction and for planning long-term bladder management.4
  • Goals of a bowel program are complete and regular bowel movements without episodes of incontinence between planned evacuations. An upper motor neuron, or hyperreflexic, bowel responds well to nightly suppositories and digital rectal stimulation along with oral stool softeners (such as docusate sodium) and pro-kinetic agents (such as senna glycoside). Lower motor neuron, or areflexic, bowel management usually requires manual evacuation or enemas.5
  • Pressure ulcer prevention includes turning in bed every 2 hours, teaching weight-shifting strategies, and optimizing nutritional status. Weight shifting strategies can include using a tilt-in-space feature on a wheelchair or physical movements such as flexing forward or leaning side-to-side.6
  • Autonomic dysfunction can cause significant morbidity and mortality. Orthostatic hypotension can be initially managed with abdominal binders and elastic bandage wrapping of the lower extremities. Autonomic dysreflexia (AD) is a medical emergency occurring in patients with a level of injury T6 or higher. Signs of AD include blood pressure greater higher than 20 mm Hg above baseline, often with bradycardia, headache, flushing, sweating, and piloerection above the level of injury. Bladder and bowel distention are the most common precipitating factors for AD. Management includes sitting the patient upright, loosening clothing, inspection of the body for noxious stimulants (e.g., pressure ulcer or ingrown toenails), and immediate bladder catheterization. If symptoms persist, a rectal exam should be performed and the rectal vault emptied of stool. If blood pressure is elevated at or above 150 mmHg systolic, consider using an antihypertensive agent such as nitropaste.7 An algorithm for the treatment of AD for both children and adults is available from the Dana and Christopher Reeve Foundation at no expense.14 Education on recognizing signs and symptoms should be provided.21
  • Most new venous thromboembolism cases have been found to occur in the first two weeks after injury. The risk for deep venous thrombosis (DVT) is substantially decreased eight weeks following injury. VTE prophylaxis should be administered for at least eight weeks after injury in persons with SCI with limited mobility. Low-molecular-weight heparin and direct oral anticoagulants are the preferred agents to use.2
  • Spasticity, a component to upper motor neuron syndrome, may emerge during the subacute phase. Spasticity may assist with function in some patients, such as leg spasticity helping with transfers. Range of motion exercises can help prevent complications related to spasticity. The higher the level of SCI, the greater the risk of pulmonary complications. Secretion management and prevention of atelectasis are critical to minimize risk of pneumonia. Weaning from the ventilator may be attempted using progressive ventilator-free breathing, usually once vital capacity is consistently over 1L.8 Diaphragmatic pacing systems provide electric stimulation to those with intact phrenic nerves and can help some candidates wean off mechanical ventilation.15
  • Heterotopic ossification, the formation of extraosseous lamellar bone in the soft tissue surrounding peripheral joints, most commonly develops around the anteromedial hip in persons with SCI, usually between 3 and 12 weeks after injury. Treatments include NSAIDS, bisphosphonates, radiation therapy and surgical excision16

Chronic/stable

  • Management of persons with chronic, stable SCI typically takes place in an outpatient setting.
  • Periodic genitourinary evaluation is performed to ensure adequate voiding and to prevent complications. Changes in voiding warrants a urinalysis and culture to evaluate for a urinary tract infection. Patients with neurogenic bladder are often colonized and should only be treated if symptomatic. Many surgical options exist, including suprapubic tubes, bladder augmentation and continent and incontinent diversions.4 Intradetrusor botulinum toxin is safe and effective in treating patients with neurogenic overactivity.17
  • A bowel program should be designed to minimize the occurrence of unplanned or difficult evacuations, to be completed at regular, predictable times within 60 minutes of initiation of the program and to minimize gastrointestinal complications. A bowel program can consist of several aspects including: 1.) timing (30 minutes after a meal to take advantage of the gastrocolic reflex), 2.) the consistency of stool (which can be influenced by fiber, fluids, diet and stool softeners, 3.) medications and 4.) manual interventions (such as digital stimulation or manual evacuation).5
  • SCI has been associated with obstructive sleep apnea, and a sleep study should be considered if symptomatic. Pneumococcal and influenza immunization and tobacco cessation counseling are important, as are ongoing measures to prevent cardiovascular disease.8
  • Spasticity may impair function and can cause complications such as contractures, pain, or skin breakdown. Generalized spasticity can be treated with oral anti-spasticity medications. Localized spasticity can be treated with chemodenervation, such as botulinum toxin or alcohol injections. The impact of these interventions can be enhanced with skilled rehabilitation interventions such as splinting, stretching, electric stimulation, and other modalities. Intrathecal baclofen pumps may be considered for those whose spasticity is not effectively treated or who cannot tolerate the side effects of oral or injectable medications.18
  • Persons with SCI are at risk for the development of osteoporosis, most commonly at the distal femur proximal tibia. These areas are more prone to risk of fracture with minimal trauma.19
  • Persons with SCI who use a manual wheelchair as their primary means of mobility are at risk for developing upper limb pain and overuse injuries. Upper limb function, mobility and equipment use should be routinely assessed. Many prevention and treatment options exist.9
  • Sexual and reproductive health should be addressed in a supportive, respectful, and nonjudgmental manner.10
  • Depression, anxiety, PTSD, suicide risk, and substance abuse, which are more common in SCI than in the general public, require careful recurrent assessment and appropriate management.11
  • Given that persons with SCI typically have decreased physical activity, reduced muscle mass, and increased body fat as compared to those without SCI, they should be screened for diabetes at least every three years.12
  • Asymptomatic posttraumatic syringomyelia (PTS) is estimated to occur in about 30% of individuals with SCI, and progressive myelopathy due to PTS may occur in about 5%. Diagnosis is confirmed with magnetic resonance imaging.120
  • Pain in a person with SCI can be either nociceptive or neuropathic, similar to other patient populations, and should be treated accordingly. The CanPain SCI Clinical Practice Guidelines recommend provides a tiered approach to neuropathic pain treatments.21
  • Functional electric stimulation (FES) uses intact neuromuscular systems to provide therapeutic exercise and allow for functional restoration. Many FES devices exist, including those that can restore upper and lower extremity function, trunk control, respiratory muscle function, bladder control and gait.22

Pre-terminal or end of life care

  • Unique clinical and ethical issues may need to be addressed when caring for a person with SCI, such as consideration of withdrawing ventilator support at the request of a newly injured individual.

Coordination of care

A team approach is necessary in the rehabilitation person with SCI. Team meetings and communications are critical for coordination of care. Inclusion of the patient in goal setting is essential.

Patient & Family education

Literature focused on education and expected outcomes for persons with SCI is available from the PVA in a series called Consumer Guidelines.23 The Yes You Can!: Guide to Self-Care for Persons with Spinal Cord Injury provides educational material on a variety of subjects for newly injury patients.24 The Christopher & Dana Reeve Foundation also offers many consumer-oriented resources.25

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Spinal Cord Injury Medicine is a subspecialty with the American Board of Physical Medicine and Rehabilitation. Physicians specializing in SCI Medicine often function as primary care providers for persons with SCI. Advocacy and education within the health care system is important to ensure optimal care for persons with SCI.

Cutting Edge/Emerging and Unique Concepts and Practice

Research into possible neuroprotective or restorative therapies for acute SCI are ongoing. Recently, the neuroprotective effects of riluzole, an antiglutamatergic sodium channel blocker typically used for amyotrophic lateral sclerosis, has been confirmed.26

Numerous neurostimulation strategies exist, such as spinal cord stimulation and repetitive transcranial magnetic stimulation, that can address pain, autonomic dysregulation and bladder and bowel function.27 For people living with chronic cervical SCI, externally applied electrical stimulation over the cervical spine can improve the strength and function of the upper limbs.28

Robotic exoskeletons can allow persons with SCI with a variety of levels of injury to safely ambulate or exercise. Feasibility, cost, and setting realistic expectations are important considerations when considering the use of an exoskeleton.29

Gaps in the Evidence-Based Knowledge

There are no precise guidelines regarding the timing of surgical decompression following acute SCI except for cervical SCI. There is growing evidence to support that spinal decompression following cervical injury within 24 hours of injury is associated with positive outcomes, though uniform consensus about specific situations when early surgical intervention is indicated is still lacking.30,31 While current practice guidelines recommend high tidal volume ventilation in people with SCI, optimal ventilator settings to facilitate early weaning and prevention of pneumonia have not been established.32

References

  1. Consortium for Spinal Cord Medicine. Early Acute Management in Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2008.
  2. Consortium for Spinal Cord Medicine. Prevention of Venous Thromboembolism in Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals 3rd Edition Washington, DC: Paralyzed Veterans of America; 2016.
  3. Consortium for Spinal Cord Medicine. Outcomes Following Traumatic Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 1999.
  4. Consortium for Spinal Cord Medicine. Bladder Management for Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2006.
  5. Consortium for Spinal Cord Medicine. Management of Neurogenic Bowel Dysfunction in Adults After Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2020.
  6. Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals 2nd Edition. Washington, DC: Paralyzed Veterans of America; 2014.
  7. Consortium for Spinal Cord Medicine. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Individuals With Spinal Cord Injury Presenting to Health-Care Facilities. Washington, DC: Paralyzed Veterans of America; 2020.
  8. Consortium for Spinal Cord Medicine. Respiratory Management Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2005.
  9. Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2005. 
  10. Consortium for Spinal Cord Medicine. Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2010.
  11. Consortium for Spinal Cord Medicine. Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Washington, DC: Paralyzed Veterans of America; 2020.
  12. Consortium for Spinal Cord Medicine. Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2018.
  13. Spinal Cord Injury Rehabilitation Evidence. Available at: http://www.scireproject.com/. Accessed March 27, 2021.
  14. Christopher and Dana Reeve Foundation AD pamphlets. Available at: https://www.christopherreeve.org/living-with-paralysis/free-resources-and-downloads/wallet-cards. Accessed March 27, 2021.
  15. Dalal K, DiMarco AF. Diaphragmatic pacing in spinal cord injury. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):619-29
  16. Sullivan, M. P., Torres, S. J., Mehta, S., & Ahn, J. (2013). Heterotopic ossification after central nervous system trauma: A current review. Bone & joint research, 2(3), 51–57. 
  17. Vaheb S, Mokary Y, Ghoshouni H, Mirmosayyeb O, Ghaffary EM, Shaygannejad V, Panah MY (2024). Onabotulinum toxin A improves neurogenic detrusor overactivity following spinal cord injury: a systematic review and meta-analysis. Spinal Cord Jun:62(6):285-294.
  18. Stevenson VL (2010). Rehabilitation in practice: Spasticity management. Clin Rehabil. Apr:24(4);293-304.
  19. Cirnigliaro CM, Myslinski MJ, La Fountaine MF, Kirshblum SC, Forrest GF, Bauman WA. Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options. Osteoporos Int. 2017 Mar;28(3):747-765.
  20. Kim, H. G., Oh, H. S., Kim, T. W., & Park, K. H. (2014). Clinical Features of Post-Traumatic Syringomyelia. Korean journal of neurotrauma, 10(2), 66–69. 
  21. Loh E, Mirkowski M, Agudelo AR, Allison DJ, Benton B, Bryce TN, Guilcher S, Jeji T, Kras-Dupuis A, Kreutzwiser D, Lanizi O, Lee-Tai-Fuy G, Middleton JW, Moulin DE, O’Connell C, Orenczuk S, Potter P, Short C, Teasell R, Townson A, Widerstrom-Noga E, Wolfe DL, Xia N, Mehta S (2022). The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update. Spinal Cord. Jun:60(6):548-566.
  22. Ho CH, Triolo RJ, Elias AL, Kilgore KL, DiMarco AF, Bogie K, Vette AH, Audu ML, Kobetic R, Chang SR, Chan KM, Dukelow S, Bourbeau DJ, Brose SW, Gustafson KJ, Kiss ZH, Mushahwar VK. Functional electrical stimulation and spinal cord injury. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):631-54
  23. Paralyzed Veterans of America (PVA) Consumer Guides. Available at: http://pva.org/research-resources/publications/consumer-guides/. Accessed March 30, 2021.
  24. Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury. Fourth edition. Available at: https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/yes-you-can_digital.pdf. Accessed March 31, 2021.
  25. Christopher and Dana Reeve Foundation Consumer Resources. Available at:
    http://www.christopherreeve.org/living-with-paralysis. Accessed March 30, 2021.
  26. Fehlings MG, Moghaddamjou A, Harrop JS, et al. Safety and efficacy of riluzole in acute spinal cord injury study (RISCIS): a multi-center, randomized, placebo-controlled double blinded trial. (2023) Journal of Neurotrauma. 40:1878-1888.
  27. Chari A, Hentall ID, Papadopoulous MC, Pereira EA. Surgical neurostimulation for spinal cord injury. Brain Sci. 2017;7(2):18
  28. Moritz C, Field-Fote EC, Tefertiller C, et al. (2024). Non-invasive spinal cor
  29. Kandilakis C, Sasso-Lance E. Exoskeletons for personal use after spinal cord injury. Archives of Physical Medicine and Rehabilitation. 2021;102(2):331-337
  30. Liu JM, Long XH, Zhou Y, Peng HW, Liu ZL, Huang SH. Is urgent decompression superior to delayed surgery for traumatic spinal cord injury? A meta-analysis. World Neurosurg. 2016 Dec
  31. Mattiassich G, Gollwistzer M, Gaderer F, et al. Functional outcomes in individuals undergoing very early (<5h) and early (5-25h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurologic improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma. 2017 Dec 15;34(24):3362-3371.
  32. Korupolu R, Stampas A, Uhlig-Reche H, et al. (2020). Comparing outcomes of mechanical ventilation with high vs. moderate tidal volumes in tracheostomized patients with spinal cord injury in acute inpatient rehabilitation setting: a retrospective cohort study. Spinal Cord 59:618-625.

Original Version of the Topic

Argyrios Stampas, MD, Joel E Frontera MD. SCI Traumatic: Part 2. 8/7/2012.

Previous Revision(s) of the Topic

Argyrios Stampas, MD, Joel E Frontera MD. SCI Traumatic: Part 2. 5/5/2016.

Scott Campea, MD, Hetal Patel, MD. SCI Traumatic Part Two: Treatment and Practice. 11/8/2021

Author Disclosure

Scott Campea, MD
Nothing to Disclose

Jordan Schroeder, MD
Nothing to Disclose

Hetal Patel, MD
Nothing to Disclose