Spine and Spinal Cord Trauma

Committee on Trauma Presents
Spine and
Spinal Cord
Trauma
Initial Assessment and Management
Objectives
● Describe the evaluation of a patient with

suspected spinal injury.
● Explain the appropriate management of spinal
injury.
● Discuss appropriate patient disposition.
Spinal Injury
When should you suspect a spine injury?

Spinal Injury
When should you suspect a spine injury?
●Mechanism of injury
●Unconscious patient
●Neurologic deficit
●Spine pain / tenderness
Spinal Injury
How do I protect the spine during evaluation and

transport?
Spinal Injury
How do I protect the spine during evaluation and

transport?
●board
Immobilize entire patient on long spine
with proper padding.
●Apply semirigid collar.
Protection is priority; detection is
secondary.
Spinal Injury Screening
●Clinical
● Normal neurologic exam and
● Absence of spinal pain and tenderness
Caution
Drugs, alcohol, and other injuries

can mask spinal injury.
●If patient is
● Conscious
● Cooperative
● Able to concentrate on c-spine
●If no neck or spine pain or tenderness
●If still no pain or tenderness with voluntary
movement
●No further evaluation or x-ray necessary
Clear spine and remove cervical collar.
Altered Consciousness or Symptoms
●Radiographic visualization of entire spine

●Plain films (7 c spine vertebrae and first
thoracic vertebrae)
●CT scan of suspicious or poorly visualized

areas
How do I confirm a spine injury?

How do I confirm a spine injury?
●Clinical signs of neurological deficit

●Radiological investigations
● Plain X-ray / CT / MRI
● Identify bony fracture / subluxation
●Presume spinal instability
●Early spine service consult
Cervical Spine X-rays
●Crosstable lateral film excludes 85% of

fractures
●Addition of AP and odontoid views excludes

most fractures
●Also may require

● Swimmer’s view
● CT scan for bony detail
● MRI
Cervical Spine X-rays
●10% of patients with a c-spine fracture have a

second, associated noncontiguous vertebral
column fracture
●Identify one abnormality? Look for another!

●Radiographic screening of entire spine required
in this situation
Pitfalls
Pitfalls
● Spinal evaluation complicated by altered

sensorium
● Remove spine board as soon as possible and logroll
patient
● Pressure sores occur early in unconscious or
paralyzed patients
Caution
Caution
At least 5% of patients with spinal

cord injuries worsen neurologically
at the hospital.
Neurologic Status
How do I assess the patient’s neurologic status?

Neurologic Status
How do I assess the patient’s neurologic status?
Neurologic level
● Most caudal level of motor / sensory function
● Motor and sensory may not be the same
● Sensory can vary on each side
Bony level
● Site of vertebral column damage
Neurologic Status
Complete Injury
● No motor or sensory function below injury
level
Incomplete Injury
● Any motor or sensory preservation below
injury level
● Sacral sparing may be only residual function

Effects of Spinal Cord Injury
●Neurogenic shock
●Spinal shock
●Other consequences
Fasciculus gracilis
Dorsal column
Fasciculus cuneatus
Lateral corticospinal tract
Spinothalamic
Neurogenic Shock – Direct Effects
●sympathetic
Cardiovascular phenomenon due to loss of
tone
●spine
Associated with cervical / high thoracic
injury
●Hypotension and slow heart rate

●occasional
Treatment includes fluid resuscitation and
atropine and vasopressors
Spinal Shock – Direct Effects
●Neurologic, not hemodynamic phenomenon

●Occurs shortly after cord injury
●Variable duration
●Flaccidity and loss of reflexes
Other Consequences
●Inadequate ventilation
●Abdominal evaluation compromised
●Occult compartment syndrome
Management
How do I manage patients with spinal cord injury and

limit secondary injury?
Management
How do I manage patients with spinal cord injury and

limit secondary injury?
●oxygenation
Ensure adequate ventilation and
●Maintain blood pressure

●Maintain perfusion of spinal cord
Management
Management of Hypotension
●Assess for associated bleeding

●Consider neurogenic shock
●Monitor urinary output
Stop
the
bleeding!
Management
Whom do I transfer?
●Unstable fractures
●Neurologic deficit
Caution
Avoid transfer delay!

Management
Management of Patients Requiring Transfer
●Provide respiratory
support as needed
●Exclude other life-

threatening injury
●Properly immobilize
entire patient
●Avoid hypothermia
Summary
●Treat life-threatening injuries first

●Properly immobilize entire patient
●Obtain appropriate spine films
●Document examination
●Obtain neurosurgical / orthopaedic consult
●Transfer unstable fracture / cord injury

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Committee on Trauma Presents

● Describe the evaluation of a patient with

When should you suspect a spine injury?

When should you suspect a spine injury?

How do I protect the spine during evaluation and

How do I protect the spine during evaluation and

Drugs, alcohol, and other injuries

Altered Consciousness or Symptoms

●Radiographic visualization of entire spine

●CT scan of suspicious or poorly visualized

How do I confirm a spine injury?

How do I confirm a spine injury?

●Clinical signs of neurological deficit

●Crosstable lateral film excludes 85% of

●Addition of AP and odontoid views excludes

●Also may require

●10% of patients with a c-spine fracture have a

●Identify one abnormality? Look for another!

● Spinal evaluation complicated by altered

At least 5% of patients with spinal

How do I assess the patient’s neurologic status?

How do I assess the patient’s neurologic status?

● Sacral sparing may be only residual function

Lateral corticospinal tract

Neurogenic Shock – Direct Effects

●Hypotension and slow heart rate

Spinal Shock – Direct Effects

●Neurologic, not hemodynamic phenomenon

How do I manage patients with spinal cord injury and

How do I manage patients with spinal cord injury and

●Maintain blood pressure

●Assess for associated bleeding

Avoid transfer delay!

Management of Patients Requiring Transfer

●Exclude other life-

●Treat life-threatening injuries first

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