Neurogenic Shock vs. Spinal Shock

Understanding Spinal Cord Injury Shocks

This article discusses the two types of shock associated with spinal cord injuries:

1. Neurogenic shock
2. Spinal shock

Both neurogenic shock and spinal shock can occur in patients who have experienced a spinal cord injury. However, these are two distinct conditions.

The two conditions can be easily distinguished because neurogenic shock affects the entire nervous system, whereas spinal shock only affects the spinal cord. These conditions are discussed in detail below.

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What Do You Do for a Spinal Injury?

This video reviews immediate priorities after a suspected spinal injury, including spinal precautions, early assessment focus, and what to watch for during the initial period after injury. Watch the video below to review the fundamentals, then compare neurogenic shock and spinal shock.

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Neurogenic Shock is a High-Level Injury

With neurogenic shock, the spinal cord injury is typically a very high-level injury, usually above the thoracic 6 (T6) level. T6 is the “magic number” that places spinal cord injury patients at risk for complications.

T6 is located in the thoracic vertebrae.

The spinal cord is the body’s information highway. It relays messages and input from the periphery to the brain, and then sends a response from the brain back to the muscles and tissues in the periphery.

In neurogenic shock, there is a disruption of the sympathetic nervous system (SNS) messages being relayed from T1 to L2.

Essentially, there is a loss of SNS stimulation. That loss of stimulation includes the loss of the fight or flight hormones, such as epinephrine and norepinephrine, which are also known as catecholamines.

Epinephrine and norepinephrine are catecholamines that increase heart rate and blood pressure.

The catecholamines are powerful vasoconstrictors and have positive chronotropic effects, meaning they increase the heart rate. When epinephrine and norepinephrine are lost, patients will experience:

• Significant bradycardia or decreased heart rate.
• Hypotension due to vasodilation.

Bradycardia and hypotension are the two primary symptoms of neurogenic shock.

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Read: The Neurological Assessment

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Spinal Shock Affects the Spinal Cord

It is important to understand how the two types of spinal injuries affect the spinal cord, keeping in mind that in spinal shock, only the spinal cord is affected. 

When a patient presents with a spinal cord injury, regardless of the location along the spinal cord, there will likely be bleeding and inflammation at the site of the injury. That bleeding and inflammation impacts surrounding tissue, and that damaged tissue releases chemical mediators. Those chemical mediators cause potent vasoconstriction.

The tissue damage, inflammation, and vasoconstriction result in spinal cord ischemia and hypoxia. A spinal cord that is not receiving blood flow and is not oxygenated is not going to do its job properly. That results in paralysis and loss of sensation below the level of the injury.

Tissue damage, inflammation, and vasoconstriction are present in a spinal cord injury.

Depending on the type of spinal cord injury, the patient may regain movement and sensation. If the patient had an injury involving a complete transection of the spinal cord, they will unfortunately not regain movement and sensation. However, if the patient had a compression of the spinal cord, they will regain movement and sensation below the level of injury once the inflammation and bleeding are controlled.

There are two types of spinal cord injuries, which impact the patient in distinct ways. In neurogenic shock, the entire nervous system is affected, whereas, in spinal shock, only the spinal cord is affected. The provider needs to distinguish between these types of injuries to determine the best course of action.

Nursing Assessments and Clinical Management for Spinal Cord Injuries

With neurogenic shock, the provider’s priority is to maintain the airway, breathing, and circulation (ABCs). The provider must focus on maintaining blood pressure because these patients will experience massive vasodilation and bradycardia. 

Bradycardia is treated with atropine, while hypotension is treated with fluids. For patients with spinal cord injury, a goal of care is to maintain the mean arterial pressure (MAP) above 80–85 mm Hg. In addition, the provider needs to be aware of cervical spine precautions.

Spinal cord injury care starts with airway, breathing, and circulation support plus strict spinal precautions. After initial stabilization, ongoing assessments help separate neurogenic shock vs spinal shock and guide treatment priorities. Trend vital signs, perfusion indicators, temperature regulation, pain, and neurologic findings using consistent documentation and repeat exams.

Neurogenic Shock

• Assessment focus: hypotension, bradycardia, warm dry skin, altered mentation, weak pulses, reduced urine output
• Monitoring: continuous ECG, frequent BP checks, perfusion checks, and trending response to interventions
• Perfusion goal: many protocols target MAP 80 to 85 mm Hg to support spinal cord perfusion, per provider order

Management overview: Neurogenic shock occurs due to loss of sympathetic tone. Treatment is aimed at restoring perfusion and supporting heart rate. IV fluids may be used based on volume status. Persistent hypotension often requires vasopressors per provider order. Symptomatic bradycardia may be treated with atropine. If bradycardia is severe and not responsive, escalation may include pacing based on clinical judgement and local protocol.

Spinal Shock

• Assessment focus: motor strength, sensation, reflexes, tone, bowel and bladder function, and trends over serial exams
• Safety priorities: immobilization, turning schedules, pressure injury prevention, pulmonary hygiene
• Complication prevention: DVT prevention per protocol, bowel bladder support plans, rehabilitation planning as appropriate

Management overview: Spinal shock is primarily neurologic and does not automatically mean the patient is in circulatory shock. Care focuses on close neurologic monitoring, supportive measures, and prevention of complications while the spinal cord recovers from acute injury. Communicate any new neurologic decline promptly because worsening deficits can indicate evolving injury or compression.

Neurogenic shock and spinal shock differ in their pathophysiology.

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What is the Neurological Assessment?

This video explains a structured neurological assessment and how to document findings clearly over time, including motor and sensory checks and how to trend changes. Check out the video below to help ensure consistent monitoring when neurogenic shock is suspected.

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Resolution Indicators: Recognizing the End of Spinal Shock

Spinal shock is considered resolved when neurological function begins to return below the level of injury. This does not mean full recovery, but it often includes a gradual return of reflex activity and muscle tone. A common teaching point is the return of specific reflexes, such as the bulbocavernosus reflex, as an early indicator that the spinal shock phase is ending. Providers also look for improving motor responses and sensory findings over repeated exams.

• Reflexes: return of deep tendon reflexes or other spinal reflex activity over time
• Tone: increasing muscle tone compared with the earlier flaccid phase
• Motor and sensory trends: improved movement, sensation, or response to stimulation below the lesion
• Documentation: consistent serial neuro checks help recognize meaningful changes

Because recovery varies, focus on trends rather than a fixed timeline. Any sudden deterioration should be escalated promptly.

Comparison: Neurogenic Shock vs Spinal Shock

Use the comparison below for a quick bedside review. It highlights the most useful differences for assessment, documentation, and early management priorities.

Feature	Neurogenic Shock	Spinal Shock
What it is	Distributive shock from loss of sympathetic tone	Neurologic suppression below the injury level
Primary problem	Hemodynamic instability and perfusion risk	Loss of reflexes, motor, and sensory function
Typical onset	Often early after high spinal cord injury	Often early after spinal cord injury
Injury level association	Commonly above T6	Can occur with injuries at various levels
Blood pressure	Low due to vasodilation	May be normal unless another shock state exists
Heart rate	Often low due to unopposed vagal tone	Usually not defined by bradycardia
Skin findings	Often warm and dry from vasodilation	Not a defining feature
Reflexes	Not the defining diagnostic clue	Classically decreased or absent below lesion early
Key features	Hypotension plus bradycardia after spinal cord injury	Flaccid weakness and sensory loss below injury, then gradual return
Primary treatment focus	Support BP and HR, maintain perfusion and MAP goals per order	Serial neuro exams, supportive care, complication prevention
Duration pattern	Variable, depends on recovery of sympathetic pathways	Resolves as reflexes and function return, variable by patient

Quick rule: hypotension plus bradycardia after a high level spinal cord injury points toward neurogenic shock. Absent reflexes and flaccid neurologic findings below the lesion with stable hemodynamics points toward spinal shock.