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Anesthesia for adults with acute spinal cord injury

Letha Mathews, MBBS, FFARCS (I)
Lorri A Lee, MD
Section Editor
Jeffrey J Pasternak, MD
Deputy Editor
Marianna Crowley, MD


Spinal cord injury (SCI) is a common, often devastating event, with approximately 12,000 new cases in the United States each year.

This topic will discuss anesthetic management in the operating room (OR) for adults with acute SCI. Diagnosis, emergency department (ED) management, medical therapy, and anesthesia for patients with chronic SCI are discussed separately. (See "Evaluation and acute management of cervical spinal column injuries in adults" and "Acute traumatic spinal cord injury" and "Chronic complications of spinal cord injury and disease" and "Respiratory physiologic changes following spinal cord injury" and "Respiratory complications in the adult patient with chronic spinal cord injury" and "Anesthesia for adults with chronic spinal cord injury".)

For the purpose of this discussion, the acute period will be defined as the first several weeks after the injury.


In addition to neurologic injury, cervical and upper thoracic acute spinal cord injuries (ASCIs) are associated with cardiovascular and pulmonary complications that affect the plan for anesthetic management.

Spinal shock — Spinal shock and neurogenic shock are two distinct entities:


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Literature review current through: Jul 2017. | This topic last updated: Jan 26, 2016.
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  1. Ditunno JF, Little JW, Tessler A, Burns AS. Spinal shock revisited: a four-phase model. Spinal Cord 2004; 42:383.
  2. Nanković V, Snur I, Nanković S, et al. [Spinal shock. Diagnosis and therapy. Problems and dilemmas]. Lijec Vjesn 1995; 117 Suppl 2:30.
  3. Guly HR, Bouamra O, Lecky FE, Trauma Audit and Research Network. The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department. Resuscitation 2008; 76:57.
  4. Furlan JC, Fehlings MG, Shannon P, et al. Descending vasomotor pathways in humans: correlation between axonal preservation and cardiovascular dysfunction after spinal cord injury. J Neurotrauma 2003; 20:1351.
  5. Mathias CJ. Orthostatic hypotension: causes, mechanisms, and influencing factors. Neurology 1995; 45:S6.
  6. 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; 10:46.
  7. Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurg Focus 2008; 25:E13.
  8. Bilello JF, Davis JW, Cunningham MA, et al. Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg 2003; 138:1127.
  9. Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity. J Neurotrauma 2003; 20:707.
  10. Silver JR. Early autonomic dysreflexia. Spinal Cord 2000; 38:229.
  11. Lindan R, Joiner E, Freehafer AA, Hazel C. Incidence and clinical features of autonomic dysreflexia in patients with spinal cord injury. Paraplegia 1980; 18:285.
  12. Lord SA, Boswell WC, Williams JS, et al. Airway control in trauma patients with cervical spine fractures. Prehosp Disaster Med 1994; 9:44.
  13. Robitaille A, Williams SR, Tremblay MH, et al. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg 2008; 106:935.
  14. Gerling MC, Davis DP, Hamilton RS, et al. Effects of cervical spine immobilization technique and laryngoscope blade selection on an unstable cervical spine in a cadaver model of intubation. Ann Emerg Med 2000; 36:293.
  15. Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview EVO2, Glidescope, and Airwayscope laryngoscope use in patients with cervical spine immobilization. Br J Anaesth 2008; 101:723.
  16. Laosuwan P, Earsakul A, Numkarunarunrote N, et al. Randomized cinefluoroscopic comparison of cervical spine motion using McGrath series 5 and Macintosh laryngoscope for intubation with manual in-line stabilization. J Med Assoc Thai 2015; 98 Suppl 1:S63.
  17. Berlly M, Shem K. Respiratory management during the first five days after spinal cord injury. J Spinal Cord Med 2007; 30:309.
  18. Jackson AB, Groomes TE. Incidence of respiratory complications following spinal cord injury. Arch Phys Med Rehabil 1994; 75:270.
  19. Kao CH, Ho YJ, Changlai SP, Ding HJ. Gastric emptying in spinal cord injury patients. Dig Dis Sci 1999; 44:1512.
  20. Karlsson AK. Autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs. Prog Brain Res 2006; 152:1.
  21. Kewalramani LS. Neurogenic gastroduodenal ulceration and bleeding associated with spinal cord injuries. J Trauma 1979; 19:259.
  22. Romero Ganuza FJ, La Banda G, Montalvo R, Mazaira J. Acute acalculous cholecystitis in patients with acute traumatic spinal cord injury. Spinal Cord 1997; 35:124.
  23. Furlan JC, Fehlings MG. Hyponatremia in the acute stage after traumatic cervical spinal cord injury: clinical and neuroanatomic evidence for autonomic dysfunction. Spine (Phila Pa 1976) 2009; 34:501.
  24. Bauman WA, Biering-Sørensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord 2011; 49:1068.
  25. Krassioukov AV, Karlsson AK, Wecht JM, et al. Assessment of autonomic dysfunction following spinal cord injury: rationale for additions to International Standards for Neurological Assessment. J Rehabil Res Dev 2007; 44:103.
  26. Hasler RM, Exadaktylos AK, Bouamra O, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg 2012; 72:975.
  27. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 2009; 37:2642.
  28. Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia 2006; 61:427.
  29. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010; 22:164.
  30. Wimalasena Y, Burns B, Reid C, et al. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015; 65:371.
  31. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006; 104:158.
  32. Yoo KY, Jeong CW, Kim SJ, et al. Cardiovascular and arousal responses to laryngoscopy and tracheal intubation in patients with complete spinal cord injury. Br J Anaesth 2009; 102:69.
  33. Raw DA, Beattie JK, Hunter JM. Anaesthesia for spinal surgery in adults. Br J Anaesth 2003; 91:886.
  34. Donaldson WF 3rd, Towers JD, Doctor A, et al. A methodology to evaluate motion of the unstable spine during intubation techniques. Spine (Phila Pa 1976) 1993; 18:2020.
  35. Lennarson PJ, Smith D, Todd MM, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg 2000; 92:201.
  36. Lennarson PJ, Smith DW, Sawin PD, et al. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg 2001; 94:265.
  37. Kaufman HH, Harris JH Jr, Spencer JA, Kopanisky DR. Danger of traction during radiography for cervical trauma. JAMA 1982; 247:2369.
  38. Bivins HG, Ford S, Bezmalinovic Z, et al. The effect of axial traction during orotracheal intubation of the trauma victim with an unstable cervical spine. Ann Emerg Med 1988; 17:25.
  39. Thiboutot F, Nicole PC, Trépanier CA, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth 2009; 56:412.
  40. Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia 1993; 48:630.
  41. Suderman VS, Crosby ET, Lui A. Elective oral tracheal intubation in cervical spine-injured adults. Can J Anaesth 1991; 38:785.
  42. McCrory C, Blunnie WP, Moriarty DC. Elective tracheal intubation in cervical spine injuries. Ir Med J 1997; 90:234.
  43. Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology 2006; 104:1293.
  44. Meschino A, Devitt JH, Koch JP, et al. The safety of awake tracheal intubation in cervical spine injury. Can J Anaesth 1992; 39:114.
  45. Holley J, Jorden R. Airway management in patients with unstable cervical spine fractures. Ann Emerg Med 1989; 18:1237.
  46. Rhee KJ, Green W, Holcroft JW, Mangili JA. Oral intubation in the multiply injured patient: the risk of exacerbating spinal cord damage. Ann Emerg Med 1990; 19:511.
  47. Scannell G, Waxman K, Tominaga G, et al. Orotracheal intubation in trauma patients with cervical fractures. Arch Surg 1993; 128:903.
  48. Shatney CH, Brunner RD, Nguyen TQ. The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg 1995; 170:676.
  49. Prasarn ML, Horodyski M, Scott NE, et al. Motion generated in the unstable upper cervical spine during head tilt-chin lift and jaw thrust maneuvers. Spine J 2014; 14:609.
  50. Aprahamian C, Thompson BM, Finger WA, Darin JC. Experimental cervical spine injury model: evaluation of airway management and splinting techniques. Ann Emerg Med 1984; 13:584.
  51. Donaldson WF 3rd, Heil BV, Donaldson VP, Silvaggio VJ. The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study. Spine (Phila Pa 1976) 1997; 22:1215.
  52. McGuire G, el-Beheiry H. Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures. Can J Anaesth 1999; 46:176.
  53. The American College of Surgeons. Advanced Trauma Life Support for Doctors (Student Course Manual), 8th ed, American College of Surgeons, Chicago 2008. p.168.
  54. Hauswald M, Sklar DP, Tandberg D, Garcia JF. Cervical spine movement during airway management: cinefluoroscopic appraisal in human cadavers. Am J Emerg Med 1991; 9:535.
  55. Sawin PD, Todd MM, Traynelis VC, et al. Cervical spine motion with direct laryngoscopy and orotracheal intubation. An in vivo cinefluoroscopic study of subjects without cervical abnormality. Anesthesiology 1996; 85:26.
  56. Hastings RH, Vigil AC, Hanna R, et al. Cervical spine movement during laryngoscopy with the Bullard, Macintosh, and Miller laryngoscopes. Anesthesiology 1995; 82:859.
  57. MacIntyre PA, McLeod AD, Hurley R, Peacock C. Cervical spine movements during laryngoscopy. Comparison of the Macintosh and McCoy laryngoscope blades. Anaesthesia 1999; 54:413.
  58. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005; 101:910.
  59. Maruyama K, Yamada T, Kawakami R, Hara K. Randomized cross-over comparison of cervical-spine motion with the AirWay Scope or Macintosh laryngoscope with in-line stabilization: a video-fluoroscopic study. Br J Anaesth 2008; 101:563.
  60. Houde BJ, Williams SR, Cadrin-Chênevert A, et al. A comparison of cervical spine motion during orotracheal intubation with the trachlight(r) or the flexible fiberoptic bronchoscope. Anesth Analg 2009; 108:1638.
  61. Afilalo M, Guttman A, Stern E, et al. Fiberoptic intubation in the emergency department: a case series. J Emerg Med 1993; 11:387.
  62. Amar AP, Levy ML. Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal cord injury. Neurosurgery 1999; 44:1027.
  63. Kobrine AI, Doyle TF, Martins AN. Autoregulation of spinal cord blood flow. Clin Neurosurg 1975; 22:573.
  64. Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. J Neurotrauma 2011; 28:1479.
  65. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical 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; 87:239.
  66. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993; 33:1007.
  67. 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; 32:1958.
  68. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 2013; 60 Suppl 1:82.
  69. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2008; 31:403.
  70. Biais M, Bernard O, Ha JC, et al. Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery. Br J Anaesth 2010; 104:407.
  71. Dijkers M, Bryce T, Zanca J. Prevalence of chronic pain after traumatic spinal cord injury: a systematic review. J Rehabil Res Dev 2009; 46:13.
  72. Michailidou C, Marston L, De Souza LH, Sutherland I. A systematic review of the prevalence of musculoskeletal pain, back and low back pain in people with spinal cord injury. Disabil Rehabil 2014; 36:705.