What is your diagnosis?

Spinal shock, which is a temporary loss of spinal cord function and reflexes below the level of injury. 

• Pearl: Spinal injuries can be classified as complete or incomplete. Complete injuries result in total loss of motor and sensation below the level of injury, while partial loss is defined as incomplete. Classifying the injury during spinal shock can initially be difficult as it can cause total loss below the injury, resembling complete spinal injury, despite the possibility of it being incomplete, as mentioned in the prompt. Because of this, classification of injury cannot be done until spinal shock has resolved [1,2].

What physical exam findings are expected?

Flaccid and areflexic paralysis as well as loss of sensation below the lesion. Bradycardia and hypotension can occur secondary to the loss of sympathetic tone [2,3].

What is the expected time course?

Spinal shock can occur from onset of injury to up to 1-2 days. It tends to improve within 48 hours from injury and resolves completely in weeks or sometimes months [2]. As motor and sensation return, spasticity, hyperreflexia, and clonus can progress over days to weeks. The end of spinal shock is determined by the return of the bulbocavernosus reflex and/or plantar reflexes [2,3,4].

• Pearl: The bulbocavernous reflex is anal sphincter contraction in response to squeezing the glans penis/clitoris or tugging on an indwelling foley.

What is the pathophysiology/etiology of this condition?

Much study and research has been performed on spinal shock but at this time, the entirety of its pathophysiology or etiology is not completely known. It is thought to be a result of neurons becoming hyperpolarized during the injury which then become unresponsive to brain stimuli [2,4,5].

What is your initial management?

A patient with a suspected spinal cord injury, including spinal shock, needs to be immobilized and placed in a c-collar. If injury occurs on the sideline, leave helmet and shoulder pads in place until removal with enough medical personnel can ensure spinal stability throughout, ideally at a trauma facility. ATLS should be initiated and followed [1,5].

• Pearl: If the patient has respiratory depression and concurrent spinal trauma, suspect a high c-spine injury as nerves C3, C4, C5 innervate the diaphragm.