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Spinal Shock

- See:
      - Fluids and Electrolytes in the Head/Spine Injured Pt:
      - Incomplete Spinal Injury:

- Discussion:
    - spinal shock involves a spinal cord concussion which usually invovles 24-72 hour period of paralysis, hypotonia, & areflexia, and
           at its conclusion there may be hyperreflexia, hypertonicity, and clonus;
           - return of reflex activity below level of injury (such as bulbocavernosus) indicates end of spinal shock;
           - note that spinal shock does not apply to lesions that occur below the cord, and therefore, low lumbar burst frx should not
                  cause spinal shock (and in this situation, absence of the bulbocaveronsus reflex indicates that there
                  is a cauda equina injury);
                  - persistent loss of the bulbocavernosus reflex may be a result of a conus medullaris injury (eg from an L1 burst frx);
    - return of the bulbocavernosus reflex (anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley)
           signifies the end of spinal shock, and for complete injuries, further neurologic improvement will be minimal;
           - bulbocavernosus reflex involves the S1, S2, S3 neurve roots and is spinal cord mediated reflex;
           - its presence signals the end of spinal shock, and rarely will spinal shock last beyond 48 hrs;
    - complete absence of distal motor function (EHL - S1) or perirectal sensation, together with recovery of the bulbocavernosus
           reflex, indicates a complete cord injury, and in such cases it is highly unlikely that significant neurologic damage will return;
           - if bulbocavernous reflex is present 48 hours following injury, it can be assumed that the patient is out of spinal cord shock;
    - if no motor or sensory recovery below the level of the fracture is present, the patient has a complete spinal cord injury and no
           further distal recovery of motor function can be expected;
           - in contrast, any spared motor or sensory function below level of injury is considered an incomplete spinal cord injury;

- Diff Dx:
    - spinal shock (2nd to loss of sympathetic tone) can be differentiated from hypovolemic shock based on the presence
           of relative bradycardia in neurogenic shock, as opposed to tachycardia and hypotension with hypovolemic shock;
    - Swanz Ganz catheter monitoring is helpful

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