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The principles of the advanced trauma life support (ATLS) framework in

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SPINAL INJURIES
The principles of the
advanced trauma life
support (ATLS) framework
in spinal trauma
Surya Gandham
Prokopis Annis
Abstract
Spinal injuries occur frequently in the polytrauma patient making the
evaluation and management of these potentially catastrophic injuries
very important. In the immediate moments following these injuries,
steps can be taken to prevent further injury and promote neurological
recovery. The use of damage control orthopaedics (DCO) over the past
30 years has improved the management of the polytrauma33 patient
and spinal injuries. The advanced trauma life support (ATLS) poly-
trauma algorithm does include the management of the injured spine
but only in general terms. This article reviews the current evidence
on assessment and initial management of spinal injuries in the poly-
trauma setting. A thorough appreciation of these principles and how
they relate to the ATLS framework is essential in the treatment of
these injuries.
Keywords ATLS; polytrauma; spinal injury; spinal trauma
Background
In the UK, approximately 500e600 people per year sustain a
traumatic spinal cord injury (SCI).1 This involves a traumatic
fracture or derangement of the vertebral column which can lead
to a spinal cord injury (SCI). These represent a group of high-
risk patients who need careful management to prevent deterio-
ration or further injury causing paraplegia, tetraplegia or death.
Motor vehicle accidents followed by falls, violence and sports
account for the majority of SCIs.2 Despite traumatic injuries of
the spinal column representing only a minority of all fractures,
they contribute to disability with long-term morbidity and asso-
ciated health-related costs. Studies have shown that up to 80% of
patients with an SCI suffer multisystem trauma and require
special consideration.3 Management of spinal trauma within the
field of general damage control orthopaedics has been conten-
tious as it is difficult to apply the treatment of musculoskeletal
trauma care to spine due to several factors.
Surya Gandham MBChB BSc Hons MRCSEd, Orthopaedic Specialist
Registrar, Department of Orthopaedic and Spinal Surgery, The Royal
Liverpool University Hospital, UK. Conflicts of interest: none
declared.
Prokopis Annis MD FRCS-EQ FAOSNA, Spinal Consultant, Department
of Orthopaedic and Spinal Surgery, The Royal Liverpool University
Hospital, UK. Conflicts of interest: none declared.
ORTHOPAEDICS AND TRAUMA 34:5
1. Secondary cord injury due to hypoperfusion and hypoxia
may alter management strategies.
2. Serious SCIs are associated with life-threatening thoracic and
abdominal trauma, which can complicate decision-making
and preferred treatment algorithms.
3. In neurologically intact patients, the decision between
operative and non-operative management remains debatable
and surgical fixation methods and implant technology offer
the surgeon multiple avenues for decompression and
stabilization.
This review explores the current best practices and recom-
mendations for the evaluation and management of polytrauma
patients with SCI utilising advanced trauma life support (ATLS)
principles.
Prehospital transport and immobilization
In the 1960s, it was first hypothesized that immobilizing patients
with a rigid cervical collar and a hard backboard may prevent
secondary SCIs. This was adopted by many trauma courses
despite the lack of high-quality evidence.4 Hauswald et al.
compared the neurological outcomes of two university hospitals
where one employed rigid spinal immobilization whilst the other
transported patients without. The study suggested that there
were fewer neurological complications in the cohort with no
immobilization and there was less than a 2% chance that spinal
immobilization had any beneficial effect on neurological out-
comes in patients with blunt SCI.5
In 2010, Haut et al. reviewed over 45,000 American patients
with penetrating injuries. Thirty (0.01%) patients had spinal
injuries requiring surgical intervention. The number needed to
treat (NNT) with spinal stabilization to potentially benefit one
patient was 1032. Conversely, the number needed to harm
(NNH) with spinal stabilization to potentially contribute to one
death was 66. The authors concluded that pre-hospital spinal
stabilization was associated with a higher mortality risk in pa-
tients with penetrating trauma and therefore should not be
routinely used in patients with penetrating trauma.6
Other lower GRADE (Grading of Recommendations Assess-
ment, Development and Evaluation) evidence has shown the
possible detrimental effect of spinal immobilization on patients.
Issues such as pressure ulcers, prolonged hospital stays, elevated
intracranial pressure and difficulty in intubation have all been
highlighted.7
Maschmann et al. reviewed the available literature and came
to the conclusion that there is insufficient evidence supporting
the use of hard backboards but favours the use of soft surface
stretched systems such as vacuum mattresses.8 They also pub-
lished ten recommendations which are shown in Table 1.
Airway management and the cervical spine
The ATLSÒ algorithm places an importance on assessing and
optimizing cardiorespiratory function. This in turn helps to
decrease secondary spinal cord injuries. The algorithm starts
with airway maintenance with restriction of cervical spine mo-
tion. While assessing and managing a patient’s airway, it is
important to prevent excessive movement of the cervical spine.
Also, based on the mechanism of trauma, one must assume that
a spinal injury exists. Based on the UK trauma registry, Trauma
305 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
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SPINAL INJURIES
Summary of main recommendations for spinal
stabilization from a Danish interdisciplinary working
group, including the Danish Society for Emergency
Medicine
Recommendation 1 Victims with potential spinal injury should
have spinal stabilization
Recommendation 2 A minimal handling strategy should be
observed
Recommendation 3 Spinal stabilization should never delay or
preclude life-saving intervention in the
critically injured trauma victim
Recommendation 4 Victims of isolated penetrating injury should
not be immobilized
Recommendation 5 Triaging tools based on clinical findings
should be implemented
Recommendation 6 Cervical stabilization may be achieved using
manual in-line stabilization, head-blocks, a
rigid collar or combinations thereof
Recommendation 7 Transfer from the ground or between
stretchers systems should be achieved using a
scoop stretcher
Recommendation 8 Patients with potential spinal injury should be
transported strapped supine on a vacuum
mattress or on an ambulance stretcher system
Recommendation 9 Hard surface stretcher systems may be used
for transports of shorter duration only
Recommendation 10 Patients should under some circumstances be
invited to self-extricate from vehicles
Table 1
Audit and Research Network (TARN), the incidence of spinal
fractures/dislocation in patients with polytrauma is 9.58%.9 In
this group, 24.5% of spinal fractures involved the cervical spine
while 45.42% of spinal cord injuries occurred at the cervical
level. It is therefore important to protect the cervical spine
initially with a collar and clear it once the initial assessment is
complete.
High cervical spine injuries (C1eC5) can lead to respiratory
depression and CO2 retention due to an impairment of diaphrag-
matic function. More than 20% of patients with these injuries
require a tracheostomy for chronic respiratory dysfunction and
tracheostomy rates are higher in complete spinal cord injuries.10
Another mechanism that can contribute to problematic
ventilation is spinal shock resulting in flaccid paralysis of the
muscles below the level of injury, which lasts for a period of
weeks to months.11 Flaccid paralysis of the intercostal muscles
creates an unstable chest wall such that during inspiration, the
negative intrathoracic pressure causes paradoxical inward
depression of the ribs.12 This mechanical imbalance and disad-
vantage result in less efficient ventilation, increased work of
breathing, and a tendency towards distal airway collapse and
microatelectasis.
Circulation and spinal cord perfusion
After securing the airway and adequately protecting the cervical
spine, adequate oxygenation and perfusion should be assessed.
ORTHOPAEDICS AND TRAUMA 34:5
Polytrauma patients with SCI are often complicated by systemic
hypotension due to haemorrhagic and/or neurogenic shock.13
This needs to be treated with aggressive fluid resuscitation aim-
ing to achieve a blood pressure of 90e100 mmHg, heart rate of 60
e100 beats/minute, urine output of 30 ml/hour and normo-
thermia.14 The joint guidelines of the American Association of
Neurological Surgeons (AANS) and the Congress of Neurological
Surgeons (CNS) for cervical spine injury management recom-
mend mean arterial pressure (MAP) greater than 85 mmHg and
avoidance of systolic blood pressure less than 90 mmHg for the
first 5e7 days after SCI.15 Hawryluk et al. also provides support
for the notion of MAP thresholds in SCI recovery, and the highest
MAP values correlated with the greatest degree of neurological
recovery and are appropriate after acute cervical SCI.16
More recent guidance by the AANS and CNS on the treatment
of patients with thoracolumbar spine trauma, states there is
insufficient evidence to recommend for or against the use of
active maintenance with inotropes of arterial blood pressure after
thoracolumbar spinal cord injury.17 Most of these data are
extrapolated from cervical spine injuries and therefore cannot be
fully applied to the thoracolumbar region. However, in light of
published data from pooled (cervical and thoracolumbar) spinal
cord injury patient populations, clinicians may choose to main-
tain mean arterial blood pressures over 85 mmHg in an attempt
to improve neurological outcomes.18
Imaging
In accordance with the ATLS protocol, imaging would come
under the remit of the secondary survey. This protocol advocates
the use of clinical screening decision tools such as the Canadian
C-Spine Rule (CCR) and the National Emergency X-radiography
Utilization Study (NEXUS), c-spine collars and blocks may be
discontinued in many of these patients without the need for
radiologic imaging.19,20 Whole body CT (WBCT) scans have been
advocated as the primary investigation in the management of
polytrauma patients without a firm evidence base.21
Currently across the UK, there are no universal guidelines for
the use of WBCT in major trauma. Several authorities, including
the Royal College of Radiologists (RCR) and the National Institute
for Health and Care Excellence, have proposed guidelines for
WBCT in trauma, but these have not been validated and are not
used by all trauma-receiving hospitals.22,23 However, there is a
body of evidence which suggests plain radiographs can miss
spinal injuries and that WBCT is the screening modality of choice
to detect not only injuries to the spine, but also head and visceral
injuries.24,25 We therefore advocate the use of WBCT as a
screening tool in adult polytrauma as the advantage of a trauma
scan outweighs the negatives of increased ionizing radiation.
With regards to the paediatric population, there is a difficulty
in interpreting CTs of the spine in the immature skeleton with a
higher incidence of isolated soft tissue rather than bone injuries
compared with adults. This is due to decreased muscle strength
and increased ligament laxity which are better visualized with an
MRI scan.26
MRI in the setting of acute SCI has potential benefits over CT.
MRI can identify ongoing spinal cord compression; depict soft
tissue structures that are responsible for compression, including
disc herniation, epidural hematoma, intramedullary hematoma,
306 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES

Figure 1 International standard for neurological classification of spinal cord injury. American Spinal Injury Association Impairment Scale (AIS).

and preexisting canal stenosis; detect ligamentous instability at MRI protocols to prognosticate neurological outcome in the
the level of injury or at other spinal levels; and identify vertebral acute SCI setting.
artery injury.27 Furthermore, MRI can estimate the degree of
tissue injury and can help predict neurological and functional Classification
outcomes following spinal injury.28
The international gold standard and ATLS method for classifying
Despite the possible clinical need for MRI scans, it is a time-
SCI is the American Spinal Injury Association Impairment Scale
consuming and traumatic event for an intubated patient and the
(AIS).31 Since its inception, the AIS has been revised multiple
risks may outweigh the benefits.29 As MRI is only suitable for
times as its authors continue to refine the steps of the neurologic
those who are haemodynamically stable, this can present a
examination and details of the classification grades. These re-
challenge in the patient with polytrauma. The prognostic ability
visions have improved reproducibility of the AIS and allowed for
of fat-suppressed T2-weighted MRI to detect acute changes seen
better understanding of the scale’s therapeutic implications
in ligamentous injury decreases with time following trauma. As
(Figure 1).32
oedema expands with time, the ability of serial T2-weighted
In order to assess the prognosis following SCI, researchers
sagittal MRI to accurately assess lesion severity decreases
have analysed T2 weighted sagittal MRI scans. The Brain and
accordingly.30
Spinal Injury Center (BASIC) score was developed in 2015, and it
MRI does not play a part in initial damage control ortho-
is an ordinal scale ranging from 0 to 4, classifying the extent of
paedics as the optimization of the cardiorespiratory systems
transverse injury following blunt cervical SCI. This scale showed
and stablising of intra-abdominal injuries and long bone frac-
strong correlations with AIS grade both at admission and at
tures should take priority. However, based on moderate evi-
discharge, with high interobserver reliability (kappa 0.81
dence, an MRI can be done in the acute period following a
e0.83).33 Mabray et al. have also shown convergent validity,
spinal cord injury for prognostication. It is also strongly rec-
construct validity, and clinical predictive validity for the use of
ommended that the sagittal T2 MRI sequence be included in all

ORTHOPAEDICS AND TRAUMA 34:5 307 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES
the BASIC score when applied to acute thoracic and thor-
acolumbar SCI.34
The 2005 Thoracolumbar Injury Classification and Severity
(TLICS) score and the 2007 Subaxial Cervical Spine Injury Clas-
sification (SLIC) score systems have been widely adopted to
guide surgical decision-making.35,36 They are both based on
fracture morphology, neurologic involvement and the integrity of
the posterior elements (Figures 2 and 3).
TLICS and SLIC sum the patient score in each category, and
the final score determines the next treatment step. A score less
than 4 suggests non-operative management, 4 is borderline, and
higher than 4 is an indication for operative management.
This standardized treatment protocol but has been criticized
for its ‘one-size-fits-all’ approach, which critics have accused of
promoting the treatment biases of its creators.37,38 Furthermore,
TLICS relies heavily on the evaluation of the posterolateral
ligamentous complex (PLC), which is most commonly performed
with MRI.
The AOSpine Thoracolumbar Injury Classification System
(ATLICS) was introduced by Vaccaro et al. in 2013, as a
comprehensive classification system that could be universally
utilised.39 ATLICS employs the features of two previous
classification systems: the Magerl system and TLICS.40 This
system consists of a morphological classification of the frac-
ture based on a revision of the original Magerl system. In
addition, two key improvements of the AOSpine system
compared to prior classification schemes are: (I) inclusion of
an assessment of the neurological status of the patient; and
(II) inclusion of a description of clinically relevant patient-
specific modifiers, such as osteoporosis and rheumatologic
disease (Figures 4 and 5).
TLICS 3 Independent Predictors
1 Morphology • Compression
Immediate stability • Burst
• Translation/rotation
• Distraction
2 Integrity of PLC • Intact
Long-term stability • Suspected
• Injured
3 Neurological • Intact
Status • Nerve root
• Complete cord
• Incomplete cord
• Cauda equina
Predicts need for surgery
Figure 2 Thoracolumbar Injury Classification and Severity (TLICS) score system.
ORTHOPAEDICS AND TRAUMA 34:5 308
Overall, ATLICS demonstrated better reliability than TLICS in
stratifying these injuries.41,42 However, there are still reserva-
tions when using both these classifications in guiding surgical
management and a robust, multicentred trial is required to
establish solid guidance.
The use of pharmacological agents after SCI
Methylprednisolone (MP) was initially advocated in the use of
SCI over 30 years ago. Pre-clinical studies have shown MP can
prevent the loss of spinal cord neuro-filament proteins, facilitate
neuronal excitability and impulse conduction, improve blood
flow, enhance NaþKþ-ATPase activity, and preserve the cord
structure by decreasing lipid peroxidation and preventing
ischemia-induced tissue damage.43
The National Acute Spinal Cord Injury Studies trial II (NASCIS
II) has been a driving force in the use of MP. It has shown that
patients treated with a 30 mg/kg bolus at hospital admission
followed by 5.4 mg/kg/hour for the next 23 hours starting before
8 hours of contusion showed a slight improvement in light touch
and pinprick sensation and a very subtle motor improvement.44
However, this article has been criticized for the reliance on
subgroup analysis, the small reported effect size for neurological
improvement and the potential or serious adverse effects.
Further, well-designed randomized control trials have not been
done in order to validate the results of NASCIS II which limits the
ability to draw any concrete conclusions. Evaniuew et al. per-
formed a meta-analysis on the use of MP in SCI patients and
showed it was not associated with an increase in long-term motor
score recovery and suggests it may be associated with increased
gastrointestinal bleeding.45
1
2
3 Radiographs
4 CT
0
2
3 MRI
0
2
2 Physical
3 examination
3
0–3 Non-surgical
4 Surgeon’s
choice
>4 Surgical
Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES

SLIC 3 Independent Predictors

1 Morphology • Compression 1
Immediate stability • Burst 2
• Translation/rotat 3 Radiographs
ion 4 CT
• Distraction
2 Discoligamentous • Intact 0
Complex • Suspected 1
Longterm stability • Injured 2 MRI

3 Neurological • Intact 0
status • Nerve root 1
• Complete cord 2 Physical
• Incomplete cord 3 examination
• Incomplete cord 4
Injury with
ongoing
cord compression

3 Non-surgical

Predicts need for surgery Surgeon’s

4 choice

Surgical
>5
Figure 3 Subaxial Cervical Spine Injury Classification (SLIC) score system.

In 2013, the AANS/CNS developed guidelines to resolve the
controversy in the literature surrounding the use of MP. This
produced a conflicting level 1 recommendation against the use of
MP based on the following reasons: 1. MP is not Food and Drug
Administration approved for this application, 2. there is no class I
or II evidence supporting the clinical benefit of MP, and 3. class I,
II, and III evidence exist that high-dose steroids are associated
with harmful side effects, including death.46 This led to
increasing debate and confusion within the medical community
and put the treating physician in a difficult position when
deciding for or against the use of MP in the acutely injured pa-
tient. Based on the current body of literature, the guideline
development group agreed it was necessary to distinguish be-
tween the following groups: 1. a 24- versus a 48-hour adminis-
tration of MP and 2. administration of MP within versus after 8
hours of injury. Fehlings et al. performed a systematic review
and meta-analysis which stated a high dose of MPSS given within
8 hours of injury confers a small positive benefit on long-term
motor recovery and should be considered a treatment option
for patients with SCI.47
The National Institute for Health and Care Excellence (NICE)
has recommended against the use of medications, aimed at
providing neuroprotection and prevention of secondary deterio-
ration, in the acute stage after acute traumatic spinal cord injury
based on a review of 10 papers.1 This recommendation is not
based on a sufficiently large evidence base.
Recently published literature has outlined the use of riluzole,
a glutamatergic modulator, for neuroprotection after SCI. Rilu-
zole acts by blocking the pathological influx of sodium and in-
hibits abnormal glutamatergic neurotransmission in damaged
neurons.48 While still relatively new, animal and in-vitro human
studies have shown promising results and should pave the way
for clinical trials in the future.49
The type and timing of anticoagulation prophylaxis
The incidence of asymptomatic or symptomatic deep vein
thrombosis (DVT) in untreated SCI patients ranges from 50% to
100%.50 This decreases to 10e20% in patients receiving
thromboprophylaxis.51 Pulmonary embolism (PE) is the third
most common cause of mortality in these patients after respira-
tory and heart disease, with an incidence of autopsy-proven fatal
PE of up to 5%.52 Therefore, it is vital for this high-risk group to
receive thromboprophylaxis.
Low-molecular-weight heparin (LMWH) is the most used
anticoagulant for patients with acute SCI.53 Randomized control
trials that have compared the efficacy and safety of LMWH with
no prophylaxis or low-dose unfractionated heparin (LDUH) for

ORTHOPAEDICS AND TRAUMA 34:5 309 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES

Figure 4 AO Spine subaxial cervical spine injury classification system. Reproduced with permission from the AO Foundation. Ó AO Foundation,
Switzerland (www.aospine.org/classification).63

ORTHOPAEDICS AND TRAUMA 34:5 310 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES

Figure 5 AO Spine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Reproduced with
permission from the AO Foundation. Ó AO Foundation, Switzerland (www.aospine.org/classification).39

ORTHOPAEDICS AND TRAUMA 34:5 311 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
 Author's Personal Copy
SPINAL INJURIES
prevention of VTE after acute SCI, show LMWH was more
effective in the prevention of VTE compared with LDUH.54,55
Guidance from AOSpine also advocates the use of LMWH as
thromboprophylaxis in the acute-care phase following SCI once
there is no evidence of active bleeding.56
Despite a number of societies (American College of Chest
Physicians, The North American Spine Society and NICE)
advising on the use of thromboprophylaxis in SCI, only AOSpine
has released guidance on the optimal timing of starting LMWH.
They recommend commencing anticoagulant thromboprophy-
laxis within the first 72 hours after injury, if possible, in order to
minimize the risk of venous thromboembolic complications
during the period of acute hospitalization.56 However, the actual
decision should be made on a clinical basis, balancing VTE
versus bleeding risk. This decision is often complicated by a
combination of active bleeding, epidural/spinal haematomas, the
requirement for surgical intervention and multiple fractures with
a very high VTE risk.
There is still a lack of evidence examining the complications
due to thromboprophylaxis, duration of treatment, optimal dose
and cost-effectiveness. This should represent future areas of
research.
Timing of surgical interventions
By utilising ATLS principles we aim to prevent secondary injuries
to the spinal cord. This approach has been termed ‘balanced,’
‘haemostatic,’ or ‘damage-control’ resuscitation. Simultaneous
efforts to rapidly control bleeding and reduce the detrimental
effects of coagulopathy, hypothermia, and acidosis in these pa-
tients are extremely important.57 It is therefore imperative to
optimize these parameters by either resuscitative or surgical
means prior to any primary spinal surgery. There is little to no
evidence in the current literature supporting early total care with
regards to spinal trauma in the setting of a polytrauma patient.
Most authors will agree that there are no cut-off parameters to
separate patients into early or staged surgery and the decision
making has to be done on an individual basis taking into account
other injuries.58
Pre-clinical studies have suggested that persistent compres-
sion of the spinal cord after the primary injury represents a
reversible form of secondary injury, which, if decompressed in
an expeditious fashion, may lead to reduced neural tissue injury
and improved outcomes.59 The Surgical Timing in Acute Spinal
Cord Injury Study: STASCIS has shown decompression prior to
24 hours after SCI can be performed safely and is associated with
improved neurologic outcome, defined as at least a two-grade
AIS improvement at 6 months follow-up. Wilson et al. performed
a meta-analysis which also partially supported this evidence
showing improved neurological recovery among cervical SCI
patients undergoing early surgery (<24 hours); however, evi-
dence regarding remaining SCI populations and clinical out-
comes was inconsistent.60 There is a growing body of evidence
which favours early decompression following SCI as it has
proven to be clinically safe and feasible, however, there is still no
definite proof that early decompression leads to improved clin-
ical outcomes.61,62
This evidence, suggests early decompression and stabilization
to be done only after safe optimization of the patient using the
ORTHOPAEDICS AND TRAUMA 34:5
ATLS principles as a guide. We also recommend a more robust
clinical trial investigating the mid to long-term clinical outcomes
of patients treated with either early or staged surgery.
Conclusion
The complete evaluation and management of the polytrauma
patient with spinal injuries begins at the scene of the accident and
transporting the patient. It is often a challenge diagnosing, clas-
sifying and initiating treatment to prevent further neurological
deterioration. Precise guidelines outlining these issues do not exist
as the evidence base is lacking and the heterogenicity of these
injuries makes it difficult. The surgeon involved with the care of
these patients must have detailed knowledge of the classification
and when and how these spinal injuries should be treated. Other
members of the trauma team should be well trained in measures to
prevent additional injuries and maximising neurological recovery.
The evidence provided in this article hopes to allow physicians
initially treating spinal injury patients with polytrauma the tools to
manage these complex patients. A
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