Spine, Neurologic, and Neurovascular Considerations
Spine and cord injury
Injury level is defined by the lowest intact segment; ASIA scoring documents motor and sensory level and separates complete from incomplete injury. Spinal shock is the transient loss of reflexes with flaccid paralysis below the lesion. Neurogenic shock is different and hemodynamic: hypotension with bradycardia from loss of sympathetic tone, seen at T6 or above. Treat neurogenic shock with fluids, then vasopressors, and atropine for symptomatic bradycardia.
Autonomic dysreflexia
An emergency in lesions at T6 or above: severe hypertension, pounding headache, bradycardia, flushing and sweating above the lesion, pallor below. Sit the patient upright immediately, loosen clothing, and search for the trigger - most often bladder distention from a kinked or blocked catheter, then bowel impaction or a skin lesion. Treat persistent hypertension with a rapid-acting agent.
Cauda equina
Saddle anesthesia, new urinary retention or incontinence, bilateral leg pain or weakness, and reduced rectal tone are surgical emergencies requiring immediate MRI, not a routine follow-up.
Neurovascular assessment
Document color, temperature, capillary refill, pulses, sensation, and motor function. Classic nerve-to-fracture pairs: radial nerve with humeral shaft (wrist drop), axillary nerve with shoulder dislocation (deltoid weakness, numb patch), peroneal nerve with fibular neck or knee injury (foot drop), median and anterior interosseous nerve with supracondylar fracture, sciatic nerve with posterior hip dislocation.
Rule of thumb
Pulses often remain present in compartment syndrome and in many nerve injuries; sensory and motor change is the earlier signal to act on.