As the recovery from neurological deficits depends upon the severity of injury, completeness and level of injury are important factors. Whether the injury is complete or incomplete contributes to future outcomes.

In other words those with ASIA B or D SCIs (incomplete) often show a more substantial recovery than those with ASIA A (complete) injuries.³  The level of injury, defined as the first spinal segment that demonstrates an abnormal neurological deficit, describes the regions of the body that are affected.

With acute and complete SCIs, the greatest level of recovery occurs most frequently in those having cervical injuries. Thoracolumbar injuries, on the other hand, show the least degree of healing.⁴ 

In addition, a patient’s recovery can also be related to the severity of his or her initial neurological deficits: the fewer the deficits at the acute stage regarding to initial level of injury, motor strength and whether the injury is complete or incomplete, the higher the rate of recovery. ^5, 6  

Beside the physical destruction of the spinal cord itself, there are also secondary conditions that can, through cell death, lead to the loss of neurological functioning.⁷  Through mechanisms such as arterial spasms or pressure on veins caused by edema, the interruption of spinal cord blood supply can lead to ischemia and a loss of neurological functions.

Given this fact, the restoration of the blood supply to the spinal cord as soon as possible is essential for recovery.⁸ 

In general, an individual’s recovery can be divided into two phases: early (within hours and days of onset) and late (over weeks and months). The time point of recovery will vary depending upon the type of SCI. For example, mild and incomplete SCIs are frequently associated with earlier recoveries.

In order to best assess the prognosis for recovery from acute spinal cord injuries, a thorough neurological examination is necessary. ^{9, 10}   However, making a determination about the severity of injury as it relates to prognoses shortly after injury is not possible.

The ideal examination time has been defined as seventy-two hours post-injury in order to make the best predictions regarding recovery.^11, 12   In general, the majority of a patient’s overall recovery will occur in 80% of cases within the first three months. However, it is also important to note that improvement of neurological functions can take place up to 18 months after the incident and even beyond. ¹³

Often prognoses are based on outcomes in other SCI patients with similar impairments.¹⁴ Beside the differences in lesion severity, recovery of acute SCI can vary greatly due to the timely and appropriate interventions used, such as those aiming to maintain or restore the spinal cord blood supply. ^{15, 16, 17}  

Choosing the right interventions — contributions to recovery

Twenty-five percent of damage in spinal cord injuries can occur or be aggravated following the initial event. This may occur during transport of the patient or even in the period of early treatment and evaluation.¹⁸

Given this, it cannot be emphasized enough that for traumatic SCI, rehabilitation begins at the scene of the accident. This can mean that the laypersons who are at the scene of the accident may or may not take proper steps (such as minimizing the movement of the patient) to prevent further spinal cord injury.

Emergency first responders, on the other hand, need to exercise expertise in the area of pre-hospital management for SCI and undertake proper immobilization and transport procedures when indicated.^{19, 20, 21}   The transportation of those suspected of having an SCI needs to be undertaken both safely and rapidly. In some instances this can even mean evacuation by helicopter to the nearest spinal cord trauma center.

Pre-hospital management and traumatic SCI ^{22, 23}

Box 1: Aspects of Optimal Pre-Hospital Management

The primary goal of pre-hospital management of patients suffering from trauma is to both minimize the time it takes for the patient to receive care and maximize the chances that he or she reach the hospital alive. Early interventions by emergency first responders intend to save lives and support essential organ functions. For traumatic SCI patients, pre-hospital management is important for both reducing existing neurological deficits and preventing further harm.  In the event that a traumatic SCI is suspected through a fall or other accident, it is essential that critical steps are taken by emergency first responders, as well as anyone administering first aid, to prevent further injury. One emergency first responder offers the guidelines found in Box 1.

Arrival at the trauma center: acute care management

The steps that begin on admission to the hospital or trauma center build on the efforts of the emergency first responders. Ideally, SCI patients should be admitted to a trauma center specializing in spinal cord injuries. Studies have demonstrated that those admitted to specialized centers have a lower rate of subsequent complications and a reduction in the degree of acute care needed and the length of stay.²⁵ 

Following admission, a determination can be made based on MRI technology as to both the type of spinal cord injury present and the adequacy of the blood supply to the spinal cord.²⁶  With this data, an accurate diagnosis as well as a prognosis on recovery can be made. ^{27, 28}  

The accuracy of the diagnosis is critical for making decisions on appropriate courses of treatment and interventions. The acute care management that begins at the trauma center aims to accomplish a specific set of goals: supporting organ function, decompressing the spinal cord and neuroprotection of the spinal cord. ^{29, 30, 31}   For example, whether the SCI be treated conservatively through pharmacological treatment or more aggressively through a surgical intervention.  ^{32, 33, 34, 35} 

The start of early post-acute rehabilitation

In addition to treatment decisions, the appropriate time point for admission to early post-acute rehabilitation must be decided. Studies have shown that rehabilitation started early on can lead to improved recoveries through better functional outcomes.³⁶ 

This will often occur immediately following a patient’s acute care where vital functions are stabilized, in a phase termed early post-acute. Although much depends upon the course of the acute phase, early rehabilitation tends to hasten and promote improvements in the activities of daily living either directly or indirectly and thus should be started as soon as possible.³⁷ 

The physical therapy and exercise involved promote motor recovery, which in turn help synapse growth. Early functional recovery is dependent upon such growth. ^{38, 39}  So while rehabilitation can be thought of as beginning immediately after an accident, the formal, early post-acute care rehabilitation will have an immense impact on recovery and functional outcomes.