What is the management of spinal shock?

Management of Spinal Shock

Spinal shock requires immediate spinal immobilization, aggressive hemodynamic support targeting systolic blood pressure >110 mmHg initially and mean arterial pressure ≥70 mmHg for the first week, careful airway management with manual in-line stabilization, and early surgical decompression when indicated, while avoiding methylprednisolone due to serious complications without proven benefit. 1, 2, 3

Immediate Prehospital Stabilization

Early spinal immobilization is the first priority to prevent onset or worsening of neurological deficit in any patient with suspected spinal cord injury. 1, 2, 4

Spinal Immobilization Protocol:

• Apply manual in-line stabilization (MILS) immediately combined with a rigid cervical collar 1, 2, 4
• Transport on a rigid backboard with vacuum mattress 1
• Maintain head-neck-chest stabilization throughout transport 1

Airway Management in Cervical Injuries

For patients requiring intubation with suspected cervical spinal cord injury, use a specific technique to minimize cervical spine movement while maximizing success:

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining posterior stabilization 1, 2, 4
• Perform rapid sequence induction with direct laryngoscopy 1, 2, 4
• Use a gum elastic bougie to increase first-attempt success rate 1, 2, 4
• Maintain cervical spine in neutral axis without Sellick maneuver 1, 2
• Succinylcholine can be safely used only within the first 48 hours after spinal cord injury; after 48 hours it risks life-threatening hyperkalemia due to denervation hypersensitivity 2

Videolaryngoscopy cannot be recommended as first-line in the prehospital setting based on prospective randomized data. 1

Hemodynamic Management

Blood Pressure Targets:

Prehospital/Initial Phase:

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1
• Hypotension (SBP <110 mmHg) at hospital admission is an independent mortality factor 1

First Week Post-Injury:

• Target mean arterial pressure ≥70 mmHg during the first 7 days to limit worsening of neurological deficit 1
• The French guidelines suggest MAP ≥70 mmHg based on evidence showing reverse correlation between time spent with MAP <65-70 mmHg and neurological improvement 1
• While some recommend targeting MAP >85 mmHg, this is based on uncontrolled studies without comparison groups 1

Vasopressor Selection:

• Phenylephrine is preferred over dopamine due to lower complication rates in complete and incomplete spinal cord injury 5
• Norepinephrine provides comparable spinal cord perfusion pressure benefits 5
• Dopamine has higher rates of complications, particularly in elderly patients 5
• Vasopressors should be combined with fluid resuscitation, though avoid fluid overload 4, 6

Respiratory Management

For high cervical injuries (C2-C5):

• Perform early tracheostomy within the first 7 days to accelerate ventilatory weaning and reduce ICU hospitalization times 2, 4
• Immediate intubation is mandatory for high cervical cord injuries 2

For lower cervical injuries (C6-C7):

• Perform tracheostomy only after one or more tracheal extubation failures 2

Respiratory Bundle:

• Apply abdominal contention belt during spontaneous breathing or raising procedures 2
• Active physiotherapy with mechanically-assisted insufflation/exsufflation device to remove bronchial secretions 2
• Aerosol therapy combining beta-2 mimetics and anticholinergics 2

Pharmacologic Therapy

Methylprednisolone is NOT recommended. Subsequent analysis of NASCIS II and III trials demonstrated potentially serious complications with limited benefit. 3 There are currently no evidence-based recommendations for pathomechanistically targeted therapies. 3

Surgical Timing

Evidence since the STASCIS trial demonstrates potential functional outcome benefit with ultra-early surgical intervention ≤8 hours post-injury when decompression is indicated. 3 Early decompression is recommended for incomplete deficit seen in the first 6 hours. 6

Prevention of Secondary Complications

Pressure Ulcer Prevention:

• Implement aggressive prevention from the acute phase with early mobilization once spine is stabilized 2, 4
• Visual and tactile checks of all at-risk areas at least once daily 2, 4
• Repositioning every 2-4 hours 2, 4

Urological Management:

• Intermittent urinary catheterization is recommended as soon as daily diuresis volume is adequate 2, 4
• Self-intermittent urethral catheterization is the gold standard 2, 4
• Remove indwelling catheters as soon as the patient is medically stable 2, 4

Pain Management

Multimodal analgesia approach:

• Combine non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute management 2, 4
• For neuropathic pain: oral gabapentinoids for more than 6 months 2, 4
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2, 4

Early Rehabilitation

Begin immediately after stabilization to maximize neurological recovery. 2, 4

Key components:

• Physical exercise to enhance central nervous system regeneration through neurotrophic factors 2, 4
• Stretching techniques for at least 20 minutes per zone 2, 4
• For incomplete injuries: gravity-assisted ambulation or body weight support with treadmill training 2, 4

Critical Pitfalls to Avoid

• Delaying immobilization in suspected spinal cord injury leads to worsening neurological outcomes 2, 4
• Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia 2
• Inadequate blood pressure support below target thresholds increases secondary injury 1
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 2, 4
• Using methylprednisolone causes serious complications without proven benefit 3