syphilis. prevention vehicle-related sci is prevented with measures including societal and individual efforts to reduce driving under the influence of drugs or alcohol, distracted driving, and drowsy driving. other efforts include increasing road safety (such as marking hazards and adding lighting) and vehicle safety, both to prevent accidents (such as routine maintenance and antilock brakes) and to mitigate the damage of crashes (such as head restraints, air bags, seat belts, and child safety seats). falls can be prevented by making changes to the environment, such as nonslip materials and grab bars in bathtubs and showers, railings for stairs, child and safety gates for windows. gun-related injuries can be prevented with conflict resolution training, gun safety education campaigns, and changes to the technology of guns (such as trigger locks) to improve their safety. sports injuries can be prevented with changes to sports rules and equipment to increase safety, and education campaigns to reduce risky practices such as diving into water of unknown depth or head-first tackling in association football. diagnosis x-rays (left) are more available, but can miss details like herniated disks that mris can show (right). a person's presentation in context of trauma or non-traumatic background determines suspicion for a spinal cord injury. the features are namely paralysis, sensory loss, or both at any level. other symptoms may include incontinence. a radiographic evaluation using an x-ray, ct scan, or mri can determine if there is damage to the spinal column and where it is located. x-rays are commonly available and can detect instability or misalignment of the spinal column, but do not give very detailed images and can miss injuries to the spinal cord or displacement of ligaments or disks that do not have accompanying spinal column damage. thus when x-ray findings are normal but sci is still suspected due to pain or sci symptoms, ct or mri scans are used. ct gives greater detail than x-rays, but exposes the patient to more radiation, and it still does not give images of the spinal cord or ligaments; mri shows body structures in the greatest detail. thus it is the standard for anyone who has neurological deficits found in sci or is thought to have an unstable spinal column injury. neurological evaluations to help determine the degree of impairment are performed initially and repeatedly in the early stages of treatment; this determines the rate of improvement or deterioration and informs treatment and prognosis. the asia impairment scale outlined above is used to determine the level and severity of injury. management prehospital treatment spine motion restriction with a long spine board the first stage in the management of a suspected spinal cord injury is geared toward basic life support and preventing further injury: maintaining airway, breathing, and circulation and restricting further motion of the spine. in the emergency setting, most people who has been subjected to forces strong enough to cause sci are treated as though they have instability in the spinal column and have spinal motion restricted to prevent damage to the spinal cord. injuries or fractures in the head, neck, or pelvis as well as penetrating trauma near the spine and falls from heights are assumed to be associated with an unstable spinal column until it is ruled out in the hospital. high-speed vehicle crashes, sports injuries involving the head or neck, and diving injuries are other mechanisms that indicate a high sci risk. since head and spinal trauma frequently coexist, anyone who is unconscious or has a lowered level of consciousness as a result of a head injury is spinal motion restricted. a rigid cervical collar is applied to the neck, and the head is held with blocks on either side and the person is strapped to a backboard. extrication devices are used to move people without excessively moving the spine if they are still inside a vehicle or other confined space. the use of a cervical collar has been shown to increase mortality in people with penetrating trauma and is thus not routinely recommended in this group. modern trauma care includes a step called clearing the cervical spine, ruling out spinal cord injury if the patient is fully conscious and not under the influence of drugs or alcohol, displays no neurological deficits, has no pain in the middle of the neck and no other painful injuries that could distract from neck pain. if these are all absent, no spinal motion restriction is necessary. if an unstable spinal column injury is moved, damage may occur to the spinal cord. between 3 and 25% of scis occur not at the time of the initial trauma but later during treatment or transport. while some of this is due to the nature of the injury itself, particularly in the case of multiple or massive trauma, some of it reflects the failure to adequately restrict motion of the spine. sci can impair the body's ability to keep warm, so warming blankets may be needed. early hospital treatment initial care in the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and spinal motion restriction. imaging of the spine to determine the presence of a sci may need to wait if emergency surgery is needed to stabilize other life-threatening injuries. acute sci merits treatment in an intensive care unit, especially injuries to the cervical spinal cord. people with sci need repeated neurological assessments and treatment by neurosurgeons. people should be removed from the spine board as rapidly as possible to prevent complications from its use. if the systolic blood pressure falls below 90 mmhg within days of the injury, blood supply to the spinal cord may be reduced, resulting in further damage. thus it is important to maintain the blood pressure which may be done using intravenous fluids and vasopressors. vasopressors used include phenylephrine, dopamine, or norepinephrine. mean arterial blood pressure is measured and kept at 85 to 90 mmhg for seven days after injury. the camper trial led by dr kwon and subsequent studies by the ucsf track-sci group (dhall) have shown that spinal cord perfusion pressure (scpp) goals are more closely associated with better neurologic recovery than map goals. some institutions have adopted these scpp goals and lumbar csf drain placement as a standard of care. the treatment for shock from blood loss is different from that for neurogenic shock, and could harm people with the latter type, so it is necessary to determine why someone is in shock. however it is also possible for both causes to exist at the same time. another important aspect of care is prevention of insufficient oxygen in the bloodstream, which could deprive the spinal cord of oxygen. people with cervical or high thoracic injuries may experience a dangerously slowed heart rate; treatment to speed it may include atropine. the corticosteroid medication methylprednisolone has been studied for use in sci with the hope of limiting swelling and secondary injury. as there does not appear to be long term benefits and the medication is associated with risks such as gastrointestinal bleeding and infection its use is not recommended as of 2018. its use in traumatic brain injury is also not recommended. surgery may be necessary, e.g. to relieve excess pressure on the cord, to stabilize the spine, or to put vertebrae back in their proper place. in cases involving instability or compression, failing to operate can lead to worsening of the condition. surgery is also necessary when something is pressing on the cord, such as bone fragments, blood, material from ligaments or intervertebral discs, or a lodged object from a penetrating injury. although the ideal timing of surgery is still debated, studies have found that earlier surgical intervention (within 12 hours of injury) is associated with better outcomes. this type of surgery is often referred to as "ultra-early", coined by burke et al. at ucsf. sometimes a patient has too many other injuries to be a surgical candidate this early. surgery is controversial because it has potential complications (such as infection), so in cases where it is not clearly needed (e.g. the cord is being compressed), doctors must decide whether to perform surgery based on aspects of the patient's condition and their own beliefs about its risks and benefits. recent large-scale studies have shown that patients who do undergo earlier surgery (within 12–24 hours) experience significantly lower rates of life-threatening complications and spend less time in hospital and critical care. however, in cases where a more conservative approach is chosen, bed rest, cervical collars, motion restriction devices, and optionally traction are used. surgeons may opt to put traction on the spine to remove pressure from the spinal cord by putting dislocated vertebrae back into alignment, but herniation of intervertebral disks may prevent this technique from relieving pressure. gardner-wells tongs are one tool used to exert spinal traction to reduce a fracture or dislocation and to reduce motion to the affected areas. rehabilitation main article: rehabilitation in spinal cord injury sci patients often require extended treatment in specialized spinal unit or an intensive care unit. the rehabilitation process typically begins in the acute care setting. usually, the inpatient phase lasts 8–12 weeks and then the outpatient rehabilitation phase lasts 3–12 months after that, followed by yearly medical and functional evaluation. physical therapists, occupational therapists, recreational therapists, nurses, social workers, psychologists, and other health care professionals work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the person's condition. an orthopedic device like this also known as a drop foot orthosis has only one functional element for lifting the forefoot in order to compensate for a weakness in the dorsiflexors. if other muscle groups, such as the plantar flexors, are weak, additional functional elements must be taken into account. an ankle-foot orthoses (afo) of the drop foot orthosis type is therefore not suitable for the care of patients with weakness in other muscle groups. in the acute phase physical therapists focus on the patient's respiratory status, prevention of indirect complications (such as pressure ulcers), maintaining range of motion, and keeping available musculature active. for people whose injuries are high enough to interfere with breathing, there is great emphasis on airway clearance during this stage of recovery. weakness of respiratory muscles impairs the ability to cough effectively, allowing secretions to accumulate within the lungs. as sci patients have reduced total lung capacity and tidal volume, physical therapists teach them accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing) that typically are not taught to healthy individuals. physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage, respiratory muscle training, and assisted cough techniques. patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions. the quad cough technique is done lying on the back with the therapist applying pressure on the abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions. manual abdominal compression is another technique used to increase expiratory flow which later improves coughing. other techniques used to manage respiratory dysfunction include respiratory muscle pacing, use of a constricting abdominal binder, ventilator-assisted speech, and mechanical ventilation. the amount of functional recovery and independence achieved in terms of activities of daily living, recreational activities, and employment is affected by the level and severity of injury. the functional independence measure (fim) is an assessment tool that aims to evaluate the function of patients throughout the rehabilitation process following a spinal cord injury or other serious illness or injury. it can track a patient's progress and degree of independence during rehabilitation. people with sci may need to use specialized devices and to make modifications to their environment in order to handle activities of daily living and to function independently. weak joints can be stabilized with devices such as ankle-foot orthoses (afos) or knee-ankle-foot orthoses (kafos), but walking may still require a lot of effort. increasing activity will increase chances of recovery. patient after incomplete paraplegia (lesion height l3) with a knee-ankle-foot orthosis (kafo) with an integrated stance phase control knee joint. for treatment of paralysis levels in the lower thoracic spine or lower, starting therapy with an orthosis is promising from the intermediate phase (2–26 weeks after the incident). in patients with complete