TRAUMA OF THE SPINE DIAGNOSIS = Get 

radiographs of entire spine (concomitant spine Fx in

EX: 33 yo F involved in MVA where she was rear-ended in slow moving traffic <10 MPH. PT 20%)
presents to ER w/ localized neck stiffness & pain. On PE she has paraspinal tenderness in the  CT
scan indications
cervical region. She has limited motion secondary to pain. Her motor, sensory, & reflex exam are
normal in UE & LE. Radiographs show normal cervical spine AP & lateral radiographs. Fracture on plain film OR Inadequate plain films

Neurologic deficit in lower extremity

All trauma patients have a cervical spine injury until proven otherwise!!  MRI useful to evaluate for
 Cervical clearance can be performed with PE + radiographically  Injury to anterior & posterior ligament complex
 Initial imaging (trauma centers): CT to bottom of 1st thoracic vertebra   Spinal cord compression by disk or osseous material
 Removal of cervical collar WITHOUT radiographic studies is allowed  Cord edema or hemorrhage
if patient is awake, alert, & not intoxicated
 AND has no neck pain, tenderness, or neurologic deficits TREATMENT
 AND has no distracting injuries Most thoracic and thoracolumbar fractures (burst and compression) can
be treated nonoperatively when PT is neurologically intact
Fractures at level of spinal cord (above L1/2) = much more vulnerable to  Treat in orthosis for 6 - 12 weeks depending on degree of instability
neurologic injury than injuries below & require a more urgent Tx  Indications for surgery include progressive neurologic deficits:
 Myelomalacia seen on MRI and/or Gross spinal instability
Thoracic spine (T2-T10)
 Fractures from T2-T10 are RARE d/t increased stability of thoracic spine
 = vascular watershed area so vascular injury  lead to cord ischemia
 Burst fracture
 Osteoporotic compression fracture
 Fracture dislocation (rare but leads to paralysis in 80%)

Thoracolumbar region (T11 to L2)

 More commonly affected by spine trauma due to fulcrum of motion
(intersection between stiff thoracic spine and  motion of lumbar spine)
 > 50% of all thoracic and lumbar fractures occur in this region

Lumbar region (L3 to S1)

 Spinal cord ends and cauda equina begins at level of L1/L2
 Injuries below L1 have a better Px because nerve roots (cauda equina &
nerve roots within thecal sac) are affected as opposed to the spinal cord

Magerl classification (of thoracic spine injuries)

 Type A = Compression caused by axial loading
 Type B
 B1: ligamentous distraction injury posterior
 B2: osteoligamentous distraction injury posterior
 Type C = Multi directional injuries, often fracture dislocations
 Very unstable with high likelihood of neurologic injury

AO classification (of thoracolumbar spinal fracture) of injuries:

Type A: Compression Type B: Distraction Type C: Torsional injury
  NSAIDs, corticosteroids, PT/OT, pain management
 Antidepressants and anticonvulsants (gabapentin, Neurontin)
Complex Regional Pain Syndrome  Regional nerve block and spinal cord stimulators
EX: a 36 yo sustained a minor trauma to his L lower leg, months later he presents w/
chronic pain that is greater than would be expected given his injury. You notice swelling of
affected extremity, change in skin color from red to cyanotic, temp changes, and INC hair &
nail growth. On palpation, PT has significant pain to light touch.

PEARLS:
Non-dermatomal limb pain following trauma or surgery.
Upper / lower limb pain, swelling, ROM, skin ’s, & bone demineralization
PAIN IS DISPROPORTIONATE TO INJURY 
WITH continuing pain that is disproportionate to any inciting event
 Autonomic and vasomotor dysfunction in the extremities
 Does not follow one peripheral nerve distribution
 No systemic symptoms
One reported symptom in 3 / 4 following categories:
 Sensory: hyperalgesia and/or allodynia
 Vasomotor: skin, temperature, color asymmetry
 Sudomotor/edema: edema, sweating changes, or sweating asymmetry
 Motor/trophic: ROM or motor dysfunction &/or trophic ’s (hair, nail, skin)

DIAGNOSIS:
The Budapest consensus criteria for the clinical Dx is:
 Continuing pain, which is disproportionate to any inciting event

For clinical Dx, PT must REPORT at least 1 symptom in 3 of the 4 categories (more

stringent research criteria require 1 symptom in all 4 categories):
 Sensory: hyperesthesia and/or allodynia
 Vasomotor: temperature asymmetry &/or skin color changes/asymmetry
 Sudomotor/edema: edema &/or sweating changes/asymmetry
 Motor/trophic: decreased range of motion &/or motor dysfunction (weakness,
tremor, dystonia) &/or trophic changes (hair, nail, skin)

For the clinical Dx, pt must DISPLAY at least 1 sign at time of eval in 2 of 4
categories (more stringent research criteria require 1 sign in 3 of the 4 categories):
 Sensory: Evidence of hyperalgesia (to pinprick) &/or allodynia (to light touch
&/or temperature sensation &/or deep somatic pressure &/or joint movement)
 Vasomotor: Evidence of temperature asymmetry (>1°C) and/or skin color ’s
and/or asymmetry
 Sudomotor/edema: Evidence of edema &/or sweating ’s &/or asymmetry
 Motor/trophic: Evidence of decreased ROM &/or motor dysfunction (weakness,
tremor, dystonia) &/or trophic changes (hair, nail, skin)
 There is no other DX that better explains Signs & SXs

TREATMENT
Early mobilization can help prevent CRPS - early intervention is best!