What is the management of spinal shock?

Management of Spinal Shock

Spinal shock requires immediate spinal immobilization, aggressive hemodynamic support targeting MAP ≥70 mmHg, early airway management for high cervical injuries, and prompt initiation of rehabilitation once stabilized. 1

Immediate Prehospital Stabilization

• Apply manual in-line stabilization (MILS) immediately combined with a rigid cervical collar to prevent onset or worsening of neurological deficit 1, 2
• Transport on a rigid backboard with vacuum mattress while maintaining head-neck-chest stabilization throughout transport 1
• Delaying immobilization leads to worsening neurological outcomes and must be avoided 1, 2

Airway Management for Cervical Injuries

• Remove only the anterior portion of the cervical collar during intubation to improve mouth opening and glottic exposure while maintaining posterior stabilization 1, 2
• Perform rapid sequence induction with direct laryngoscopy 1, 2
• Use a gum elastic bougie to increase first-attempt success rate 1, 2
• 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 causes life-threatening hyperkalemia due to denervation hypersensitivity 1, 2
• For high cervical cord injuries (C2-C5), immediate intubation is mandatory 1, 2

Hemodynamic Management

The critical priority is maintaining adequate spinal cord perfusion to prevent secondary injury:

• Maintain systolic blood pressure >110 mmHg before injury assessment to reduce mortality 1
• Target mean arterial pressure ≥70 mmHg during the first 7 days to limit worsening of neurological deficit 1
• Evidence shows reverse correlation between time spent with MAP <65-70 mmHg and neurological improvement 1
• Inadequate blood pressure support below target thresholds increases secondary injury 1

Note: While one research study suggests MAP >85 mmHg 3, the most recent guideline-level evidence establishes MAP ≥70 mmHg as the target 1, which represents the current standard of care.

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 1, 2
• Implement comprehensive respiratory bundle including abdominal contention belt during spontaneous breathing, active physiotherapy with mechanically-assisted insufflation/exsufflation device to remove bronchial secretions, and aerosol therapy combining beta-2 mimetics and anticholinergics 2

For lower cervical injuries (C6-C7):

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

Pharmacologic Therapy

• No evidence-based recommendations for pathomechanistically targeted therapies are currently available 1
• This represents a significant gap in management options for the acute phase

Prevention of Secondary Complications

Pressure injury prevention:

• Implement aggressive prevention from the acute phase with early mobilization once spine is stabilized 1, 2
• Perform visual and tactile checks of all at-risk areas at least once daily 1, 2
• Reposition every 2-4 hours 1, 2

Urological management:

• Initiate intermittent urinary catheterization as soon as daily diuresis volume is adequate 1, 2
• Self-intermittent urethral catheterization is the gold standard 1, 2
• Remove indwelling catheters as soon as the patient is medically stable to minimize urological risks 2

Pain Management

Acute phase:

• Use multimodal analgesia approach combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids 1, 2

Neuropathic pain:

• Prescribe oral gabapentinoids for more than 6 months 1, 2
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2

Early Rehabilitation

• Begin rehabilitation immediately after stabilization to maximize neurological recovery 1, 2
• Implement physical exercise to enhance central nervous system regeneration through neurotrophic factors 1, 2
• Apply stretching techniques for at least 20 minutes per zone 1, 2
• For incomplete injuries, use gravity-assisted ambulation or body weight support with treadmill training 2
• Neglecting early rehabilitation results in preventable complications and poorer functional outcomes 1, 2

Critical Pitfalls to Avoid

• Using succinylcholine after 48 hours post-injury risks life-threatening hyperkalemia 1, 2
• Delaying immobilization in suspected spinal cord injury leads to worsening neurological outcomes 1, 2
• Inadequate blood pressure support below MAP ≥70 mmHg increases secondary injury 1
• Failing to implement pressure ulcer prevention strategies leads to significant morbidity 2