What is the treatment for spinal shock?

From the Guidelines

Spinal shock treatment should prioritize stabilizing the patient and preventing secondary injury, with a focus on maintaining adequate blood pressure and preventing complications, as the most recent and highest quality study recommends emergency surgical decompression within 24 hours of neurological deficit to improve long-term neurological recovery 1.

Key Components of Treatment

• Maintaining adequate blood pressure with IV fluids (crystalloids like normal saline) and vasopressors (norepinephrine 0.1-0.5 mcg/kg/min or phenylephrine 10-200 mcg/min) to achieve a mean arterial pressure of 85-90 mmHg for the first 7 days post-injury
• Respiratory support with supplemental oxygen and possibly mechanical ventilation
• DVT prophylaxis with low molecular weight heparin (enoxaparin 30-40 mg subcutaneously daily) and compression stockings
• Bladder management typically requires intermittent catheterization every 4-6 hours or an indwelling catheter
• Bowel regimens with stool softeners (docusate sodium 100 mg twice daily) and scheduled suppositories to prevent complications
• Early physical therapy and range-of-motion exercises should begin as soon as the patient is stable to prevent contractures and muscle atrophy

Considerations

• High-dose methylprednisolone (30 mg/kg IV bolus followed by 5.4 mg/kg/hr for 23 hours) may be considered if started within 8 hours of injury, though its use remains controversial
• The evidence for blood pressure restoration in neurogenic and spinal shock is uncertain, and hypertonic saline administration does not improve mortality in shock states 1
• Surgical intervention may be recommended in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy 1

Outcome

Spinal shock typically resolves within 4-12 weeks as reflex activity returns, though the underlying spinal cord injury may result in permanent neurological deficits depending on the severity and location of the injury. The goal of treatment is to minimize morbidity, mortality, and improve quality of life, and the most recent and highest quality study supports emergency surgical decompression within 24 hours of neurological deficit to achieve this goal 1.

From the Research

Treatment for Spinal Shock

The treatment for spinal shock involves several key components, including:

• Stabilization of vital signs, following the Advanced Trauma Life Support (ATLS) algorithm for ensuring stability of airway, breathing, and circulation, as well as disability (neurologic evaluation) and exposure 2
• Spinal stabilization, using cervical collars and long backboards, to prevent movement of a potentially unstable spinal column injury and prevent further injury to the spinal cord and nerve roots 2, 3
• Surgery to stabilize the spine, undertaken after life-threatening injuries are addressed 2, 4
• Intensive care unit (ICU) admission for patients with high spinal cord injury or hemodynamic instability 2, 4
• Avoidance of hypotension and hypoxia to minimize secondary neurologic injury, with consideration of elevating the mean arterial pressure above 85 mmHg for 7 days to allow for spinal cord perfusion 2
• Use of intravenous steroids, such as methylprednisolone, although the effectiveness of this treatment is controversial 2, 5
• Early tracheostomy in patients with lesions above C5 to reduce the number of ventilator days and the incidence of ventilator-associated pneumonia 2
• Aggressive measures, including CoughAssist and Intermittent Positive Pressure Breaths (IPPB), to maintain lung recruitment and aid in the mobilization of secretions 2
• Early mobilization of patients and a multidisciplinary approach to care, including respiratory therapists, nutritional experts, physical therapists, and occupational therapists, to streamline care and improve long-term outcomes 2

Pharmacologic Therapy

High-dose methylprednisolone steroid therapy has been shown to be effective in improving neurologic outcome when administered within eight hours of injury, with a dose regimen of bolus 30mg/kg over 15 minutes, followed by maintenance infusion of 5.4 mg/kg per hour for 23 hours 5. Extending the maintenance dose to 48 hours may provide additional benefit if treatment is delayed to between three and eight hours after injury 5.

Pre-Hospital Care

Pre-hospital care providers should immobilize patients with potential spinal cord injuries using a cervical collar, head immobilization, and a spinal board, and transfer patients off of spine boards as soon as feasible 3. Manual in-line cervical spine traction should be used for airway management in patients requiring intubation in the pre-hospital setting 3. Patients with acute traumatic spinal cord injury should be transported to the definitive hospital center for care within 24 hours of injury 3.