not mean that the treatment is ineffective; rather, some treatments have not been entered into clinical trials to examine efficacy.

Acute care begins at the scene of an injury, continues through transport of the patient, and ends with early evaluation and care at a trauma center. The complex medical challenges faced in treating patients who suffer a spinal cord injury begin at the injury scene where often the patient not only needs to be immobilized because of concerns about a spinal cord injury but also requires immediate attention for other urgent and life-threatening problems: significant blood loss, blocked respiratory pathways, major head or body system trauma, or a dramatic drop in blood pressure. One indicator of the progress that has been made in acute care is that patients increasingly arrive at the emergency department with less severe injuries. Most patients (55 percent) in the 1970s came to regional centers with complete spinal cord injuries, whereas today approximately 39 percent arrive with complete injuries (AANS/CNS, 2002a). The transformation to less severe injury is most likely the result of improved emergency medical services (EMS) at the accident scene and more careful handling and patient care during transport (Garfin et al., 1989). Apart from immobilization at the accident scene, few therapies for acute spinal cord injuries have been proven to be effective and safe.

At the scene of the injury, the primary considerations related to the spinal cord injury are to stabilize the spine and to ensure rapid transport to the nearest acute-care facility. These goals are vital to preventing further injury, considering that it has been estimated that in the past between 3 and 25 percent of spinal cord injuries took place after the initial trauma, either during transport or early in the course of patient evaluation (Hachen, 1974). In the United States, the practice of immobilizing the neck and spine of all trauma patients at the scene has become nearly universal. Immobilization at the scene is supported by clinical experience and by biomechanical evidence that it reduces the pathological motion of the spinal column.

A major improvement in EMS arrival and transport times has led in recent decades to striking decreases in rates of mortality, injury severity, complications, and lengths of hospital stays (Hachen, 1974; Tator et al., 1993). In the mid-1990s, a large clinical trial conducted in multiple states noted the rapid times of EMS arrival at the scene (e.g., 4 minutes for 25 percent of cases) and arrival to the first emergency department in about 1 hour (Geisler et al., 2001). The elapsed time from the injury to the arrival at