Spinal-cord injury level and neurogenic shock — Rapid

Synopsis

Localise acute spinal-cord injury, distinguish neurogenic from haemorrhagic shock, protect respiratory and cord perfusion, and communicate a reproducible neurological level and completeness assessment.

Protect alignment while prioritising airway and breathing; high cervical injury can retain a normal early saturation despite falling ventilation and ineffective cough.
Document a structured motor and sensory examination, including perianal sensation, deep anal pressure and voluntary anal contraction when clinically appropriate to determine sacral sparing.
The neurological level is the most caudal segment with normal sensory and antigravity motor function under the ISNCSCI method; do not infer it from one weak limb.
Complete injury has no sacral sensory or motor sparing; preserved sacral function defines incomplete injury and carries different prognostic implications.
Neurogenic shock is haemodynamic hypotension from sympathetic loss, often with relative bradycardia and warm skin; spinal shock is transient areflexia and flaccidity below the lesion.
Exclude and control haemorrhage before attributing hypotension to neurogenic physiology; mixed shock is common after high-energy trauma.
Use CT to define bone and alignment, then MRI urgently when neurological abnormality may arise from cord, disc, ligament or epidural pathology.
Avoid methylprednisolone, nimodipine and naloxone for acute traumatic cord neuroprotection under NICE guidance; preserve oxygenation, perfusion, temperature and timely decompression instead.

Key red flags

Diaphragmatic breathing, weak cough, falling vital capacity, hypercapnia or high cervical weakness requires early anaesthetic and critical-care support before oxygen saturation falls.

Hypotension with relative bradycardia and warm peripheries suggests neurogenic shock, but chest, abdominal, pelvic, vascular and long-bone bleeding must be excluded and treated first.

New weakness, sensory level, sacral sensory loss, reduced anal contraction or priapism indicates spinal-cord or cauda equina injury requiring urgent spinal specialist and MRI assessment.

Investigation priorities

First-line structured neurological examinationFirst stepFirst line

Localise level, completeness and change over time.

Preferred CT spinePreferred

Define fracture, translation, canal bone and alignment rapidly.

Management branches

ImmediateProtect cord and ventilation

Trauma produces weakness, sensory level, sacral change or high-risk spinal pain.

Run ABCDE with coordinated spinal protection, give oxygen when required and call anaesthetic support for weak cough, hypoventilation or high cervical injury.
Document a structured motor, sensory and sacral examination before and after transfers or reduction whenever feasible.
Search for and control haemorrhage, correcting hypoxia, hypothermia and inadequate volume before labelling hypotension neurogenic.
Arrange complete CT and urgent spinal-surgeon consultation, followed by MRI for neurological abnormality attributable to the cord.

Key medicines

Noradrenaline infusion for selected neurogenic shockStart only in a monitored critical-care setting after adequate volume and haemorrhage control, using the local standard concentration and titrating the intravenous infusion to the spinal-team perfusion target; there is no single safe fixed trauma dose.Central access is preferred for sustained use; monitor rhythm, limb perfusion, extravasation and lactate, and do not let vasopressor response conceal ongoing haemorrhage.

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