What is the management of spinal shock?

Management of Spinal Shock

The management of spinal shock should follow a comprehensive protocol including respiratory support, hemodynamic stabilization, prevention of complications, and early rehabilitation measures to reduce morbidity and mortality in patients with spinal cord injury. 1

Definition and Pathophysiology

Spinal shock is characterized by the temporary loss of sensory, motor, and reflex function below the level of spinal cord injury. It occurs immediately after injury and can last from days to weeks, with some symptoms persisting up to 12 weeks 2. It represents the initial phase following spinal cord injury before transitioning to spasticity 3.

Initial Management

Respiratory Management

• For patients with cervical cord injury requiring ventilation:
  • Implement a respiratory weaning bundle combining:
    • Abdominal contention belt during spontaneous breathing
    • Active physiotherapy with mechanically-assisted insufflation/exsufflation devices
    • Aerosol therapy with beta-2 mimetics and anticholinergics 1
  • Consider early tracheostomy (within 7 days) for upper level injuries (C2-C5)
  • For lower cervical injuries (C6-C7), attempt extubation first and consider tracheostomy only after failed attempts 1

Hemodynamic Management

• Monitor and maintain blood pressure (neurogenic shock is common)
• Maintain head elevation 15-30° if risk of aspiration exists
• Provide continuous cardiac monitoring 4

Prevention of Secondary Complications

Pressure Ulcer Prevention

• Implement early mobilization once spine is stabilized
• Perform visual and tactile checks of all risk areas at least once daily
• Reposition patient every 2-4 hours with pressure zone checks
• Use pressure-relieving tools (cushions, foam, pillows)
• Utilize high-level prevention supports (air-loss mattress, dynamic mattress) 1

Urinary Management

• Implement intermittent urinary catheterization as soon as daily diuresis volume is adequate
• Remove indwelling catheters as soon as medically stable to reduce risk of urinary tract infections and urolithiasis
• Maintain a micturition calendar to adapt frequency and schedule of catheterization 1

Rehabilitation Measures

• Begin rehabilitation as soon as the patient is medically stable
• Focus on:
  • Maintaining joint amplitudes
  • Preventing musculotendinous contractions
  • Stretching for at least 20 minutes per zone
  • Using simple posture orthoses
  • Proper bed and chair positioning to prevent deformities 1

Monitoring and Evolution

Spinal shock evolves through phases, transitioning from areflexia to hyperreflexia over time 5. Understanding this evolution helps guide management:

• Initially: Complete loss of reflexes below injury level
• Recovery phase: Gradual return of reflexes in a specific pattern
• Late phase: Development of spasticity requiring specific management 6

Special Considerations

Anesthesia Considerations

• Succinylcholine can be used as a rapid-acting agent for emergency anesthesia induction in the early hours after spinal cord injury
• Avoid succinylcholine after 48 hours post-injury due to risk of hyperkalemia from denervation 1

Spasticity Management

• Monitor for development of spasticity as spinal shock resolves
• Consider appropriate pharmacological interventions when spasticity emerges 3

Common Pitfalls to Avoid

1. Delayed tracheostomy: For high cervical injuries (C2-C5), early tracheostomy (within 7 days) can improve outcomes
2. Prolonged use of indwelling catheters: Switch to intermittent catheterization as soon as possible
3. Inadequate pressure ulcer prevention: Implement comprehensive prevention protocol from day one
4. Delayed mobilization: Begin as soon as spine is stabilized to prevent complications
5. Failure to recognize transition from spinal shock to spasticity: This requires changes in management approach

By following this structured approach to spinal shock management, clinicians can minimize complications and optimize outcomes for patients with spinal cord injury.