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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Assume spine injury in high-risk trauma until cleared clinically or radiographically.
- Primary goals: prevent secondary cord injury, maintain oxygenation/perfusion, immobilize appropriately, and obtain urgent imaging.
- Neurogenic shock = hypotension + bradycardia from loss of sympathetic tone, usually cervical or high thoracic injury.
- Spinal shock = transient flaccid paralysis and areflexia below lesion, not the same as neurogenic shock.
- High-dose steroids are not routine standard emergency treatment for acute traumatic spinal cord injury.
Overview
Spinal cord injury may result from fracture, dislocation, ligamentous injury, penetrating trauma, epidural hematoma, or disc herniation after trauma. Cervical injuries are especially dangerous because they can impair ventilation, cause neurogenic shock, and produce tetraplegia. Emergency care focuses on spinal motion restriction, neurologic documentation, avoidance of hypoxia/hypotension, and urgent spine consultation.
Epidemiology
Traumatic spinal cord injury is most commonly caused by motor vehicle collisions, falls, violence, and sports injuries. Young men and older adults are disproportionately affected. Morbidity includes permanent motor impairment, respiratory failure, autonomic dysfunction, pressure injuries, bladder/bowel dysfunction, and chronic pain.
Clinical Features
Symptoms
Neck or back pain after trauma, especially midline pain
Weakness, numbness, paresthesia, or paralysis below a level
Dyspnea or weak cough suggesting high cervical injury
Urinary retention, priapism, or loss of bowel/bladder control
Electric shock sensation down spine with neck movement may suggest cervical cord involvement
Signs
Motor deficit, sensory level, decreased rectal tone, or absent bulbocavernosus reflex early after injury
Hypotension with bradycardia and warm skin suggests neurogenic shock
Central cord syndrome: upper extremity weakness greater than lower extremity after hyperextension
Brown-Sequard syndrome: ipsilateral motor/proprioception loss with contralateral pain/temperature loss
Anterior cord syndrome: motor and pain/temperature loss with preserved vibration/proprioception
Investigations
First-line
Neurologic examinationDocument motor strength, sensation, reflexes, rectal tone, perianal sensation, and sacral sparing; repeat serially.
CT cervical spineFirst-line imaging for adult blunt trauma when imaging is indicated; evaluates fracture and alignment.
CT thoracic/lumbar spineIndicated with back pain, neurologic deficit, high-energy mechanism, altered mental status, or distracting injury.
Second-line
MRI spineBest for cord edema, ligamentous injury, epidural hematoma, disc herniation, and persistent neurologic deficit despite CT.
Trauma CT / CTAEvaluate associated head, chest, abdominal, pelvic, or vascular injury based on mechanism and exam.
Respiratory monitoringSerial vital capacity and negative inspiratory force in cervical/high thoracic injuries.
Specialist
Spine surgery consultationUrgent for neurologic deficit, unstable fracture/dislocation, cord compression, epidural hematoma, penetrating injury, or progressive symptoms.
1
Immediate management
- Maintain spinal motion restriction during airway, breathing, and circulation management.
- Airway with in-line stabilization if intubation needed.
- Avoid hypoxia and hypotension; maintain spinal cord perfusion.
- Treat associated hemorrhage first if hypotension could be hemorrhagic rather than neurogenic.
- Remove from hard backboard as soon as safe to prevent pressure injury while maintaining immobilization.
2
Neurogenic shock
- Recognize hypotension + bradycardia after high cord injury.
- Initial cautious crystalloid if volume status uncertain, then vasopressor support.
- Norepinephrine is commonly used because it supports vascular tone and cardiac output.
- Atropine, epinephrine, or pacing may be needed for severe symptomatic bradycardia.
3
Definitive spine care
- Urgent MRI and decompression/stabilization when cord compression, unstable injury, or progressive deficit is present.
- Maintain MAP targets per institutional spine protocol, often 85-90 mmHg for several days.
- High-dose methylprednisolone is not routinely recommended.
- DVT prophylaxis when bleeding risk allows; pressure injury prevention and bladder management.
4
Clearance and disposition
- Use NEXUS or Canadian C-Spine Rule for low-risk alert patients when appropriate.
- Do not clinically clear intoxicated, obtunded, neurologically abnormal, or unreliable patients.
- Transfer to trauma/spine center if unstable injury or neurologic deficit exceeds local capability.
Complications
- Respiratory failure: High cervical injury can impair diaphragm and accessory muscles
- Neurogenic shock: Loss of sympathetic tone causes hypotension and bradycardia
- Autonomic dysreflexia: Later complication of lesions above T6
- DVT/PE: Immobility and paralysis increase risk
- Pressure injuries and infections: Long-term morbidity from immobility and neurogenic bladder
USMLE Step 2 CK Exam Tips
- 1Neurogenic shock = hypotension with bradycardia; hemorrhagic shock usually causes tachycardia.
- 2Spinal shock = flaccid areflexia below lesion; not the same as neurogenic shock.
- 3Central cord syndrome = arms weaker than legs after hyperextension in older patient.
- 4Brown-Sequard = ipsilateral motor/proprioception loss + contralateral pain/temp loss.
- 5CT is first-line cervical spine imaging in adult trauma when imaging is indicated.
- 6MRI is needed for neurologic deficit with suspected cord/ligament/disc/epidural hematoma pathology.
- 7High-dose steroids are not the routine best answer for acute traumatic SCI.
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