Spinal Shock & Neurogenic Shock

Both follow spinal cord injury, both cause hypotension — but one is a temporary reflex silence and the other is a life-threatening cardiovascular crisis. Confusing them changes your entire intervention.

Spinal shock and neurogenic shock are two distinct phenomena that can coexist after acute spinal cord injury. Spinal shock is the temporary loss of all reflex activity below the level of injury — flaccid paralysis, absent deep tendon reflexes, loss of bladder and bowel tone. It is not a hemodynamic emergency; it is a neurological phenomenon that resolves over days to weeks. Return of the bulbocavernosus reflex signals its resolution. Neurogenic shock is a distributive shock caused by loss of sympathetic tone, typically from injuries at T6 or above. The hallmark triad is hypotension, bradycardia, and warm/dry skin below the injury — the opposite of hypovolemic shock's cold, clammy, tachycardic presentation. Without sympathetic vasoconstriction, blood pools in peripheral vessels. Treatment targets volume resuscitation first, then vasopressors (phenylephrine or norepinephrine) if fluid alone fails. Atropine may be needed for symptomatic bradycardia. Mean arterial pressure (MAP) is maintained at 85–90 mmHg for the first 7 days to preserve spinal cord perfusion.

Key Distinctions

Don't confuse neurogenic shock (bradycardia, warm skin, vasodilation) with hypovolemic shock (tachycardia, cold skin, vasoconstriction) — trauma patients can have both simultaneously, so persistent hypotension after adequate fluids should raise suspicion for neurogenic cause. Students mix up spinal shock (loss of reflexes, not a cardiovascular emergency) with neurogenic shock (loss of vascular tone, a true shock state). Autonomic dysreflexia is a late complication after spinal shock resolves — it belongs in a different time frame entirely.

Clinical Pearl

Bradycardia plus hypotension plus warm skin after spinal cord injury = neurogenic shock. If the patient is tachycardic, keep looking for bleeding — that's hypovolemic shock hiding underneath.