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968 Spine Trauma

59 Spine Injuries – General Information, Neurologic

Assessment, Whiplash and Sports-Related Injuries,
Pediatric Spine Injuries

59.1 Introduction
20% of patients with a major spine injury will have a second spinal injury at another level, which
may be noncontiguous. These patients often have simultaneous but unrelated injuries (e.g. chest
trauma, TBI…). Injuries directly associated with spinal cord injuries include arterial dissections (car-
otid and/or vertebral arteries).

59.2 Terminology
59.2.1 Spinal stability
Many definitions have been proposed. A conceptual definition of clinical stability from White and
Panjabi1: the ability of the spine under physiologic loads to limit displacement so as to prevent
injury or irritation of the spinal cord and nerve roots (including cauda equina), and to prevent inca-
pacitating deformity or pain due to structural changes.
Biomechanical stability refers to the ability of the spine ex vivo to resist forces.
Predicting spinal stability is often difficult, and to this end various models have been developed,
none of which is perfect. See models of stability for cervical spine injuries (p. 1027) and thoracolum-
bar fractures (p. 1041).

59.2.2 Level of injury

There is disagreement over what should be defined as “the level” of a spinal cord injury. Some define
the “level” of a spinal cord injury as the lowest level of completely normal function (thus a patient
would be termed a C5 quadriplegic even with minor C6 motor function). However, most sources
define the “level” as the most caudal segment with motor function that is at least 3 out of 5 and if
pain and temperature sensation is present.

59.2.3 Completeness of lesion

Categorization is important for treatment decisions and prognostication.

Incomplete lesion
Definition: any residual motor or sensory function more than 3 segments below the level of the
injury.2 Look for signs of preserved long-tract function.
Signs of incomplete lesion:
1. sensation (including position sense) or voluntary movement in the LEs in the presence of a cervi-
cal or thoracic spinal cord injury
2. “sacral sparing”: preserved sensation around the anus, voluntary rectal sphincter contraction, or
voluntary toe flexion
3. an injury does not qualify as incomplete with preserved sacral reflexes alone (e.g.
bulbocavernosus)

59 Types of incomplete lesion:

1. central cord syndrome (p. 982)
2. Brown-Séquard syndrome (cord hemisection) (p. 984)
3. anterior cord syndrome (p. 984)
4. posterior cord syndrome (p. 985): rare

Complete lesion
No preservation of any motor and/or sensory function more than 3 segments below the level of the
injury in the absence of spinal shock. About 3% of patients with complete injuries on initial exam will
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Spine Injuries 969

develop some recovery within 24 hours. Recovery is essentially zero if the spinal cord injury remains
complete beyond 72 hours.

Spinal shock
This term is often used in two completely different senses:
● 1st SENSE: hypotension (shock) that follows spinal cord injury (SBP usually ≈ 80 mm Hg). See
Hypotension (p. 988) for treatment. Caused by multiple factors:
a) interruption of sympathetics: implies spinal cord injury above T1
○ loss of vasoconstrictors → vasodilatation (loss of vascular tone) below the level of injury
○ leaves parasympathetics relatively unopposed causing bradycardia
b) loss of muscle tone due to skeletal muscle paralysis below level of injury results in venous
pooling and thus a relative hypovolemia
c) blood loss from associated wounds → true hypovolemia
● 2nd SENSE: transient loss of all neurologic function (including segmental and polysynaptic reflex
activity and autonomic function) below the level of the SCI3,4 → flaccid paralysis and areflexia
a) duration: may abate in as little as 72 hours, but typically persists 1–2 weeks, occasionally sev-
eral months
b) accompanied by loss of the bulbocavernosus reflex
c) spinal cord reflexes immediately above the injury may also be depressed on the basis of the
Schiff-Sherrington phenomenon (primarily described in animal models)
d) when spinal shock resolves, there will be spasticity below the level of the lesion and return of
the bulbocavernosus reflex
e) a poor prognostic sign

59.3 Whiplash-associated disorders

59.3 .1 General information
“Whiplash” was initially a lay term, which is currently defined as a traumatic injury to the soft tissue
structures in the region of the cervical spine (including: cervical muscles, ligaments, intervertebral
discs, facet joints…) due to hyperflexion, hyperextension, or rotational injury to the neck in the
absence of fractures, dislocations, or intervertebral disc herniation.5 It is the most common non-fatal
automobile injury.6 Symptoms may start immediately, but more commonly are delayed several
hours or days. In addition to symptoms related to the cervical spine, common associated complaints
include headaches, cognitive impairment, and low back pain.

59.3 .2 Clinical grading

A proposed clinical classification system of WAD is shown in ▶ Table 59.1.7

59.3 .3 Evaluation and treatment

A consensus8 regarding diagnosis and management of these injuries is shown in ▶ Table 59.2 and
▶ Table 59.3. Keep in mind that conditions such as occipital neuralgia may occasionally follow whip-
lash-type injuries and should be treated appropriately (▶ Table 59.3).

Table 59.1 Clinical grading of WAD severity

Grade Description
0 no complaints, no signsa
1 neck pain or stiffness or tenderness, no signs 59
Whip-
2 above symptoms with reduced range of motion or point tenderness
lash
3 above symptoms with weakness, sensory deficit, or absent deep tendon reflexes
4 above symptoms with fracture or dislocationa
athe definition of whiplash excludes these patients5