Spinal Shock

Ziu E, Mesfin FB.

Introduction
Spinal shock is a result of severe spinal cord injury. It usually requires high-impact, direct trauma that leads to of spinal cord
injury and spinal shock. The initial encounter with a patient that has spinal shock is usually under trauma scenario. Ischemia
of the spinal cord can also produce a spinal shock, for example, a hypotensive patient in the medical intensive care unit (ICU)
or a post-angiography patient with thrombotic occlusion of arteries that supply cervical spine. Treatment of ischemic type
spinal shock is different. The outcome expectations are also different from spinal shock achieved from a traumatic event.
Spinal shock after a traumatic event affects mostly young; the average age is 29.  It is more common in men (80%) than in
women. Cord injury is often associated with fracture-dislocation, tearing of ligaments, rotational distraction, as well as tearing
of the disc space. If the spinal shock is not associated with significant injury of the spinal column itself, then the prognosis for
this patients is more favorable than when the fracture is present. Overall treatment of patients with significant spinal shock
and injury presents a big challenge due to poor outcome, especially in patients that are in the prime of their youth. Two
common mechanisms lead to spinal shock. Regarding the treatment of spinal cord injury, the best treatment for the primary
spinal cord injury is prevention. The injury associated with the primary event is irreversible. However, secondary injuries
such as hypotension and hypoxia are preventable. Aggressive medical management can reduce its effect on the overall
functionality of the patient.  This chapter review is designed to provide a concise introduction to the care of these patients.[1]

Etiology
Spinal shock has been described initially in a patient with transected spinal cord and difficult to treat hypotension as a result
of decreased sympathetic tone throughout the body and especially in the arterial wall. Initially, this process was described as
permanent as the majority of these patients progressed to death. As clinical care started to improve, and the understanding of
the pathologic mechanisms involved in the progression of deficits increased, survival also improved. Unfortunately, deficits
after shock are still permanent, and we yet have to achieve the goal of improving those deficits. There are several definitions
in the literature pertaining to spinal shock. Some definitions include the presence of hypotension, and some include the
absence of reflexes below the level of the lesion with and without hypotension. Having unique definition is important but
what is more important is understanding the care of these patients. In this review, we will not argue about which definition is
more accurate.

Epidemiology
Young men in their second decades of life are prone to spinal cord injury and clinical diagnosis of spinal shock. Among cases
of spinal shock, 45% are due to motor vehicle accidents (MVA), 34% domestic accidents such as falls, 15% sporting accidents,
6% self-harm. Intoxication due to alcohol or other drugs plays a major role, and often the initial neurological exam is not
accurate due to intoxicant levels being very high. As one can imagine, the events before and after the event are very tragic for
the patient, family, and the society. The cost of care for these patients has spiraled out of control since they do require long-
term care, which most often families are not equipped to provide.

Pathophysiology
Despite the fact that spinal shock has been described for many years, professionals continue to identify its pathophysiology.
Animal models have been used to study the pathophysiology detail of spinal shock. From these studies, researchers have
learned that at the point of initial injury, the spinal cord appears normal, and no gross pathology can be identified. Within the
first four hours of the initial injury, hemorrhagic foci appear more pronounced in the gray matter. In the first 24 hours, there
is significant protein accumulation in the gray matter. Edema ensues and peaks at three to six days post-injury. On MRI, edema
can be visualized up to two weeks after injury. The slow process of central cord necrosis and vacuolization ensues from this
point on and continues for about two months. The characteristically thin rim of white matter surrounding the central core of
necrosis remains intact throughout this process. Often it is observed that patient starts losing neurologic function above the
level of injury, which brings anxiety to an inexperienced provider prompting more imaging of the patient's spinal cord. Loss of
function that happens several days post-injury above the level of the injury is mostly due to spinal cord pathways
rearrangement. Once this process abates, the function above the injury returns to normal, although the exact time needed for
this process is not precisely defined and could last from weeks to months. If a patient survives the initial injury but
remains immobile, the area fills with gliotic tissue.[2]

History and Physical

Healthcare providers should obtain a detailed history of the accident. Often factors such as a rollover crash, ejection outside
the car, or seat belt usage can give significant information on the severity and type of spinal cord injury that should be
expected to an experienced physician.  The presence of intoxication is important information, as it will confuse physical exam.
It is important to understand that the energy necessary to produce spinal shock and spinal fracture during a traumatic event is
very high, and patients should be thoroughly examined for other tissue and organ injury. It is more appropriate to use the
trauma activation code announced when a patient with spinal shock arrives at the emergency department, that way trauma
team can complete a full workup for the patient. The full spinal examination should include motor, sensory reflexes including
bulbocavernosus reflex and anal wink reflex. Motor activity and strength decrease not only in the skeletal muscles but the
motor activity of internal organs like bowel and bladder. This decrease leads to constipation and urinary retention. It is of
utmost importance to record an ASIA score as prognostic long-term expectations can be made with fair accuracy before any
discussion with family and the patient. While evaluating the patient, assume their spine is unstable and take all the necessary
precautions to keep it stable until final imaging is obtained and stability is established.

Evaluation
Patients with spinal cord injury need to be evaluated in a timely fashion to minimize secondary injuries. Preferably, these
patients should be evaluated at level one trauma centers due to the extent of injuries. After the initial trauma evaluation is
completed, and if the patient is stable enough to undergo imaging, a complete spinal CT should be the initial imaging obtained.
MRI spine imaging is very helpful but should not be the initial imaging modality. Myelogram would be helpful if the spinal
shock is associated with canal compromise after fracture and would be the imaging of choice if the patient cannot obtain an
MRI.

Treatment / Management
Spinal shock patient should be treated in an ICU setting, as many complications should be expected to arise due to the injury.
Methylprednisone treatment is controversial with some trial showing modest benefit and some other showing more negative
side effects than benefits. We recommend, if the patient is young and does not have any underlying diseases that could be
exacerbated by steroid use, a short trial of methylprednisone should be initiated starting with a loading dose of 30 mg/kg
followed by maintenance dose of 5 mg/kg/h for the next 24 hours. Neurogenic shock usually ensues with lesions above T6 level.
Norepinephrine drip and judicious use of atropine for bradycardia should be part of the initial treatment. Eventually, within
few days hypotension improves, and intravenous (IV) drips should be gradually decreased. With high cervical injuries, the
diaphragmatic function will be compromised, and these patients will necessitate early tracheotomy since they will be
ventilator dependent. Deep vein thrombosis is excessively high in these patients. Prophylaxis should be initiated as soon as
possible within days of injury. Long-term management of spinal shock injury patients always requires multidisciplinary team
treatment between different services. Approximately 60% of these patients will require spine stabilization with surgical
intervention, and neurosurgery or orthopedic professionals should be consulted early. Lastly, maintain high suspicion, but
constant movement of the patient on a regular basis should help the patient not to develop a pressure ulcer. [3]

Questions
To access free multiple choice questions on this topic, click here.

References
1. Atkinson PP, Atkinson JL. Spinal shock. Mayo Clin. Proc. 1996 Apr;71(4):384-9. [PubMed: 8637263]
2. Biering-Sørensen F, Biering-Sørensen T, Liu N, Malmqvist L, Wecht JM, Krassioukov A. Alterations in cardiac autonomic
control in spinal cord injury. Auton Neurosci. 2018 Jan;209:4-18. [PubMed: 28228335]
3. Sweis R, Biller J. Systemic Complications of Spinal Cord Injury. Curr Neurol Neurosci Rep. 2017 Feb;17(2):8. [PubMed:
28188542]

Publication Details
Author Information

Authors

Endrit Ziu1; Fassil B. Mesfin2.

Affiliations
1
University of Missouri Columbia
2
MU School of Medicine

Publication History

Last Update: February 19, 2019.

Copyright
Copyright © 2019, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,
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Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Ziu E, Mesfin FB. Spinal Shock. [Updated 2019 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.