Acute spinal cord injury: contemporary management and novel therapies

Acute spinal cord injury (SCI) remains a life-threatening condition associated with substantial morbidity, mortality, and long-term disability. Despite the advances in trauma systems, surgical techniques, and critical care, the optimal management strategies for acute SCI continue to improve, and clinical practice remains heterogeneous across institutions. The pathophysiology of acute SCI involves an irreversible primary mechanical insult, followed by a dynamic secondary injury cascade characterized by ischemia, inflammation, excitotoxicity, and apoptotic cell death. Early neurological assessments using standardized clinical scales, along with advanced imaging, particularly magnetic resonance imaging, play a crucial role in injury characterization, prognostication, and treatment planning. The contemporary acute management of this condition focuses on the prevention of secondary injury through hemodynamic optimization, early stabilization, and timely surgical decompression. Growing evidence has supported early decompressive surgery, particularly within 24 hours after injury, to improve neurological outcomes. However, the optimal timing, surgical strategy, and patient selection process remain areas of ongoing debate. Pharmacologic neuroprotection, including high-dose methylprednisolone, has become increasingly controversial, while novel agents such as riluzole and minocycline have shown promising but inconclusive results in clinical trials. Beyond conventional management, novel therapeutic approaches-including cell-based therapies, biologics targeting neuroregeneration, neuromodulation, and advanced rehabilitation technologies-have been actively investigated. In parallel, advances in artificial intelligence and predictive modeling are beginning to influence early prognostication and individualized treatment strategies. This review aimed to synthesize current evidence regarding the assessment and management of acute SCI, highlight key controversies, and discuss novel therapies that may shape future clinical practice.