What initial assessments should I perform for a patient with suspected spinal cord injury in the acute setting?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 22 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

For a patient with suspected spinal cord injury in the acute setting, initial assessments should follow a prioritising sequence, such as ABCDE . This sequence includes assessing for catastrophic haemorrhage, airway with in-line spinal immobilisation, breathing, circulation, disability (neurological), and exposure and environment .

  • General Spinal Injury Assessment:

    At all stages, protect the cervical spine with manual in-line spinal immobilisation, especially during airway interventions, and avoid moving the rest of the spine . Assess the patient for spinal injury by checking for:

    • Any significant distracting injuries .
    • Influence of drugs or alcohol .
    • Confusion or uncooperativeness .
    • Reduced level of consciousness .
    • Any spinal pain .
    • Hand or foot weakness (motor assessment) .
    • Altered or absent sensation in the hands or feet (sensory assessment) .
    • Priapism (in unconscious or exposed males) .
    • A history of past spinal problems, including previous spinal surgery or conditions predisposing to spinal instability .

    Full in-line spinal immobilisation should be carried out or maintained if any of these factors are present or if the assessment cannot be completed .

  • Cervical Spine Injury Assessment:

    Assess for cervical spine injury using the Canadian C-spine rule . A patient is considered at high risk if they have at least one of the following:

    • Age 65 years or older .
    • Dangerous mechanism of injury (e.g., fall from >1 metre or 5 steps, axial load to the head, high-speed motor vehicle collision, rollover accident, ejection from vehicle, motorised recreational vehicle accident, bicycle collision, horse riding accidents) .
    • Paraesthesia in the upper or lower limbs .

    A patient is considered at low risk if they have at least one of the following:

    • Involved in a minor rear-end motor vehicle collision .
    • Comfortable in a sitting position .
    • Ambulatory at any time since the injury .
    • No midline cervical spine tenderness .
    • Delayed onset of neck pain .

    If low-risk factors are present and there are no high-risk factors, assess if the patient is able to actively rotate their neck 45 degrees to the left and right . If they have low-risk factors and can actively rotate their neck 45 degrees left and right, they are considered to have no risk . Note that applying the Canadian C-spine rule to children can be difficult and their developmental stage should be considered .

  • Thoracic or Lumbosacral Spine Injury Assessment:

    Assess for thoracic or lumbosacral spine injury using these factors:

    • Age 65 years or older with reported pain in the thoracic or lumbosacral spine .
    • Dangerous mechanism of injury (e.g., fall from >3 metres, axial load to the head or base of the spine, high-speed motor vehicle collision, rollover accident, lap belt restraint only, ejection from vehicle, motorised recreational vehicle accident, bicycle collision, horse riding accidents) .
    • Pre-existing spinal pathology, or known or at risk of osteoporosis (e.g., steroid use) .
    • Suspected spinal fracture in another region of the spine .
    • Abnormal neurological symptoms (paraesthesia, weakness, or numbness) .
    • On examination: abnormal neurological signs (motor or sensory deficit), new deformity or bony midline tenderness (on palpation), bony midline tenderness (on percussion), midline or spinal pain (on coughing) .
    • On mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs) .

    Similar to cervical spine assessment, assessing children for thoracic or lumbosacral spine injury is difficult and their developmental stage should be considered .

  • When to Carry Out or Maintain Full In-line Spinal Immobilisation and Request Imaging:

    Full in-line spinal immobilisation and imaging should be carried out or maintained if a high-risk factor for cervical spine injury is identified by the Canadian C-spine rule, or if a low-risk factor is identified and the patient is unable to actively rotate their neck 45 degrees left and right, or if indicated by one or more of the factors for thoracic or lumbosacral spine injury .

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Educational content only. Always verify information and use clinical judgement.