Robin Lester DENT-OBHS 131 January 13, 2009

Spinal Shock

Question: I was studying the reflex arc of the corticospinal tract and I came across a
question that I was hoping you could help me answer. In lecture you had mentioned once
that stroke victims often have no muscle tone and their limbs are like jello. Then when
talking about UMN lesions of stroke you mentioned that sometimes their arms will be
drawn up because of an unchecked reflex/tonus from the LMN. It seems to me like these
are contradictions, but am I missing something? Logically, it would seem to me that a
stroke in the brain would be a lesion of the UMN so the limbs would be hypertoned.
Could you clarify?

Response (from Dr. Baños): Like a lot of things in neuroscience, the answer lies in the
fact that things are a little more complicated in reality. There is a phenomenon called
"spinal shock," which occurs when lower motor neurons suddenly lose their input from
upper motor neurons. As part of this shock, the whole lower motor neuron feedback loop
(for tone and reflexes) temporarily stops functioning. You'll usually hear this mentioned
in the context of spinal cord injury, but you also see it with a stroke (which abruptly
deprives *all* lower motor neurons on the affected side of the cord of their UMN input).
Clinically, you see a flaccid paralysis with absent tone and reflexes (essentially a lower
motor neuron presentation), but within a matter of hours to days tone re-emerges and
reflexes return. Both soon become exaggerated and more consistent with the "classic"
upper motor neuron presentation. In spinal cord injury, you would obviously only see this
in the muscles innervated by LMNs below the level of the lesion. For some stroke cases,
the tone has already re-emerged by the time they make it to the emergency room.
For others, they've still got flaccid paralysis by the time they're here at rehab a week or
two later. Our physical therapists spend a lot of time working to prevent development of
contractures as the tone re-emerges and becomes abnormal.