# Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg. On day 3 his arms and legs are flaccid, with no reflexes below the injury, including the bulbocavernosus reflex. His mother asks whether this means he will never move again. Which statement BEST describes what these findings mean?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630032  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg.

On day 3 his arms and legs are flaccid, with no reflexes below the injury, including the bulbocavernosus reflex. His mother asks whether this means he will never move again. Which statement BEST describes what these findings mean?

## 보기

1. They show a complete cord injury, so no motor recovery is expected
2. They are caused by his sedation and will clear when it is stopped
3. They show rising pressure in the brain compressing the brainstem
4. They reflect spinal shock, so the full extent cannot yet be judged **✔ 정답**

**정답: 4**

## 해설

Spinal shock is a temporary loss of all reflexes with flaccid paralysis below the injury, lasting days to weeks. Whether the injury is complete cannot be decided until spinal shock ends, which is marked by the return of reflexes such as the bulbocavernosus reflex.

## 심화 해설

Core concept: spinal shock versus permanent cord injury

The clinical picture here is flaccid paralysis with areflexia below the C6 lesion, including loss of the bulbocavernosus reflex. This is the classic presentation of spinal shock, not a reliable sign that the cord has been permanently destroyed.

Spinal shock is a temporary neurophysiologic state that follows acute spinal cord injury. It reflects a sudden loss of supraspinal excitatory input to the spinal cord below the lesion, which produces a transient depression of all reflex activity. The result is flaccid paralysis, loss of deep tendon reflexes, and absence of the bulbocavernosus reflex — findings that cannot yet be used to predict final motor outcome.

The bulbocavernosus reflex is a sacral cord–mediated reflex (S2–S4). Its return is traditionally used as a clinical marker that spinal shock is resolving. Only after reflexes begin to reappear can the examiner reliably determine whether the injury is complete or incomplete using the ASIA Impairment Scale. On day 3, with the reflex still absent, the patient remains in the spinal shock phase.

Watch out! A flaccid, areflexic picture in the first days after injury does not equal a complete cord lesion. Recovery of reflex activity — including the bulbocavernosus reflex — marks the end of spinal shock and is the earliest point at which completeness can be judged.

Why the other options are not correct

| Option | Why it is incorrect |
| --- | --- |
| 1. Complete cord injury, no motor recovery expected | This conclusion is premature. During spinal shock, even an incomplete injury can present with flaccid paralysis and absent reflexes. Prognosis cannot be established until spinal shock resolves. |
| 2. Caused by sedation and will clear when stopped | Sedation can depress neurologic exam findings, but the pattern here — flaccid paralysis with loss of the bulbocavernosus reflex below a known C6 injury — is attributable to spinal shock, not simply to sedative medication. |
| 3. Rising ICP compressing the brainstem | Brainstem compression from elevated ICP would produce cranial nerve dysfunction, pupillary changes, or posturing, not isolated flaccid paralysis below a cervical cord level. The findings localize to the spinal cord, not the brainstem. |
| 4. Spinal shock; full extent cannot yet be judged | Correct. The areflexia and flaccid paralysis are temporary features of spinal shock, and the completeness of injury cannot be determined until reflex activity returns. |

How spinal shock fits into the broader recovery trajectory

The acute phase after traumatic spinal cord injury involves two overlapping pathophysiologic processes. The primary injury is the immediate mechanical damage to the cord from the trauma itself, which is largely irreversible. The secondary injury cascade — ischemia, inflammation, excitotoxicity, and electrolyte shifts — evolves over minutes to days and can extend the damage. Spinal shock is a functional consequence of this acute disruption, not a structural measure of how many axons were severed.

Recovery after spinal cord injury follows a variable and nonlinear course. Neurological improvement is not a single event but a trajectory that unfolds over weeks to months. During the spinal shock phase, motor and sensory scores are at their lowest and do not reflect the eventual neurologic plateau. This is why prognostication must be deferred until spinal shock has resolved and serial examinations can be compared.

Key point! The end of spinal shock is signaled by the return of reflexes, most commonly the bulbocavernosus reflex. Only after that point can the ASIA Impairment Scale be applied with confidence to classify the injury as complete or incomplete.

What this means for the mother’s question

The mother is asking a prognostic question: will her son move again? The honest and accurate answer is that it is too early to know. The current flaccid, areflexic state is expected in the acute phase and does not by itself indicate permanent loss of motor function. The care team will monitor for return of the bulbocavernosus reflex and other reflexes, then perform serial motor and sensory examinations to determine the true extent of injury.

Spinal shock typically lasts days to weeks, and its resolution — not its presence — is the first meaningful milestone for prognosis. Until then, the priority remains hemodynamic support, maintenance of spinal cord perfusion, and prevention of secondary injury.

## 임상 시나리오

Spinal Shock vs Permanent Cord InjuryEarly flaccid areflexia does not predict final outcome
Spinal shock is a temporary loss of all reflex activity below an acute cord injury, producing flaccid paralysis and areflexia lasting days to weeks. It reflects sudden loss of supraspinal excitatory input, not irreversible cord destruction.

The bulbocavernosus reflex is mediated by S2-S4. Its return is the traditional clinical marker that spinal shock is resolving. Only after reflexes reappear can the ASIA Impairment Scale reliably classify the injury as complete or incomplete.

CautionDo not tell families that flaccid areflexia in the first days means permanent paralysis. Completeness of injury cannot be judged until spinal shock ends, marked by return of the bulbocavernosus reflex.

## 핵심 개념

- **spinal shock** — Temporary loss of all reflexes with flaccid paralysis below an acute spinal cord injury, lasting days to weeks
- **bulbocavernosus reflex** — Sacral cord-mediated reflex (S2-S4); its return marks the end of spinal shock
- **ASIA Impairment Scale** — Standardized neurologic classification of spinal cord injury; reliable only after spinal shock resolves
- **cerebral perfusion pressure** — Mean arterial pressure minus intracranial pressure; target 60-70 mmHg in severe TBI
- **complete cord injury** — Absence of sensory and motor function in the lowest sacral segments; cannot be confirmed during spinal shock

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