A 40 year old male is involved in a head on MVC. There was a reported loss of consciousness prior to EMS arrival and a prolonged extrication. There was witnessed syncope in the field. The trauma team is activated prior to arrival. On exam there are no obvious external injuries. The GCS is 15, the airway is intact, and there are equal breath sounds bilaterally. Patient is hemodynamically stable with regular rate and rhythm. There is tenderness to palpation of the thoracolumbar junction and profound weakness to bilateral lower extremities. His strength is 1/5 in all major muscle groups of the lower extremities, sensation is 0/5 from dermatomes T11 downward. Patient does not sense noxious stimuli to either lower extremity.
CT imaging of the spine is negative for acute traumatic injury.
MRI of the complete spine is negative for any spinal cord lesions or pathology.
Throughout the shift, the patient shows mild improvements on physical exam, with strength improving to 2/5 and sensation improving to sensation of noxious stimuli.
The patient is admitted to Trauma ICR. Neurology is consulted and in agreement with ED for concern of spinal shock. Over three days, the patient continues to improve and ultimately walks out of hospital.
What is Spinal Shock?
Euphemized as “concussion of spinal cord,” spinal shock manifests as transient distal areflexia, lasting from a few hours to weeks. Initially, the patient experiences a flaccid quadriplegia along with areflexia. Segmental reflexes usually start to return within 24 hours as the spinal shock starts to resolve. Bulbocavernosus reflex (S2-S4) is among the first to return. It is important to note that spinal shock may make a incomplete spinal cord lesion seem like it is complete. Thus, final neurological prognosis for spinal cord injuries can not be made in the ED!
Every spinal cord trauma patient presenting to the ED has suffered primary spinal cord injury (injury to bone, blood supply, soft tissue swelling, etc). Our goal in the ED is to prevent secondary injury, which mostly consists of preventing further traumatic injury to the cord as well as preventing hypoxemia and hypotension, physiologic states obviously not beneficial to injured nerve tissues.
This patient warranted a cervical collar due to neurological deficits, altered level of consciousness in field, and concern for head injury. The collar alone is really just a reminder to the provider “to avoid moving the neck.” True c-spine immobilization requires head tape/sandbags etc.
If your spinal injury patient does this…
Begins to vomit - if you have the staff support then perform a concerted effort to log roll. If you are by yourself and patient is about to vomit consider Trendelenburg position to allow gravity to take emesis away from airway.
Becomes tachypneic - With shallow breathing above, have a low threshold to intubate for fear of injury to diaphragm innervation levels (C3-5) or intercostal muscle innervation (T1-12).
Becomes hypotensive - Aggressively search for possible sources of hemorrhage and transfuse blood. After these steps, then consider the presence of neurogenic shock and treat with vasopressors.
Take Away #1
Avoid Secondary Spinal cord injury - Place the patient on supplemental oxygen for a goal Spo2 99-100% and a MAP goal of 65-70. Immobilize the spine. Note that rolling a patient is not a benign maneuver and while you may be holding c-spine during a roll, the unstable injured thoracic and lumbar spine can shift in position.
Take Away #2
Spinal Shock and Neurogenic Shock are two different entities:
Spinal shock is a “concussion” to spinal cord resulting in temporary loss of motor and sensory function below level of lesion.
Neurogenic Shock is hypotension, bradycardia, and peripheral vasodilation secondary to loss of sympathetic tone. It typically occurs with cord lesions T6 and higher. Hypotension in a trauma patient is hemorrhagic until proven otherwise. If certain no hemorrhaging, then treat neurogenic shock with a norepinephrine drip. Be wary of increasing vagal tone with maneuvers such as suctioning or nasogastric tube insertion as these can worsen the neurogenic shock.
Take Away #3
Here's a trick for swapping a hard collar placed by EMS with a Philadelphia collar - Undo the velcro of the hard collar, and attach Velcro of Philadelphia collar back piece to that of hard collar back. Then as you pull out the hard collar to the right you simultaneously pull Philadelphia collar back behind patients neck with minimal motion to the patient.
Sean Boaglio, DO is a current third year resident at Stony Brook Emergency Medicine.
Reference(s):
LITFL Spinal cord Injury: https://litfl.com/trauma-spinal-injury/
Spinal Cord Injury classification: https://www.sci-info-pages.com/levels-and-classification/
Medscape: Cervical Spine Fracture evaluation and clinical presentation https://emedicine.medscape.com/article/824380-clinical#b3
Edited by Bassam Zahid, MD