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SPINAL SHOCKBy: Dr Ismah, Ortho department

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Contents

Definition Anatomy Pathophysiology Phases Vs. neurogenic shock Management

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Definition

Immediate temporary loss of total power, sensation and reflexes below the level of injury

+ Loss of bulbo-cavernous reflex Usually recover within 24-48 hrs

-oxford handbook-

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bulbo-cavernous reflex

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Anatomy

http://www.radiologyassistant.nl/

en/p4906c8352d8d2/spine-thoracolumbar-injury.html

Dennis three column-spine stability

6Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

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Pathophysiology

TRAUMA -- > SCI causes a concussion like injury to spinal cord total sensory and motor power loss and loss of all reflexes

for initial some period followed by then gradual recovery of reflexes

Reflexes in the SC caudal to the SCI are depressed (areflexia)

This state of sensory and motor loss along with total loss of reflexes following trauma is known as spinal shock

The 'shock' in spinal shock does not refer to circulatory collapse

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Phases

Phase Time Physical exam findings

Underlying physiological event

1 0-1 days Areflexia Loss of descending facilitation

2 1-3 days Initial reflex return Denervation supersensitivity

3 1-4 weeks Hyperreflexia Axon-supported synapse growth

4 1-12 months

Hyperreflexia, Spasticity

Soma-supported synapse growth

http://www.nature.com/sc/journal/v42/n7/full/3101603a.html

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Phase 1:

A complete loss or weakening of all reflexes below the level of spinal cord injury

Spinal concussion caused the neurons involved in various reflex arcs and the neural input from the brain become hyperpolarized and unresponsive.

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Phase 2

Characterized by the return of some reflexes. The first reflexes to reappear is the bulbocavernosus reflex

The reason reflexes return is the hypersensitivity of reflex muscles following denervation; more receptors for neurotransmitters are expressed and are therefore they are easier to stimulate.

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Phases 3 and 4

Characterized by hyperreflexia

Neurons below the injury attempt to reestablish the synapses

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Spinal vs neurogenic shock

http://www.orthobullets.com/spine/2006/spinal-cord-injuries

Spinal shock Neurogenic shock

Definition Immediate temporary loss of total power, sensation and reflexes below the level of injury

Sudden loss of the sympathetic nervous system signals

BP Hypotension Hypotension

Pulse Bradycardia Bradycardia

Bulbocavernosus reflex

Absent Variable

Motor Flaccid paralysis Variable

Time 48-72 hrs immediate after SCI

Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli

Disruption of autonomic pathways loss of sympathetic tone and vasodilation

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MANAGEMENTImmobilisation-Spinal board

-Cervical collar

1) Monitor neurological status2) Cord/cauda-equina Sx

Methylprednisolone -given as bolus of 30 mg / kg body wt

-followed by infusion at 5.4 mg / kg / hour for 24 hours

Symtomatic medication:-Pain relief

-ConstipationDVT prophylaxis

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The National Spinal Cord Injury Study (NASCIS)

NASCIS 3 USA, 1997

High dose methylprednisolone

Prevent secondary injury of SCI

Rx start within 3 hrs for 24 hrs

Side effects: immunosuppression, GIT bleeding, hyperglycemia and ARDS

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16 Thank you