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The European Trauma Course Manual

Edition 4.0
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9.
Trauma to the vertebral column and spinal cord
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QAssessing and managing vertebral column and spinal cord injuries

QAssessing and managing neurogenic shock

QNeurological examination in patients with suspected spinal injury

QClinical clearance of the cervical spine

QSafe log rolling and removal from a long spinal board

QInterpretation of spinal imaging

Introduction head trauma will have a spinal cord injury. Moreover,

In all major trauma patients, there should be a high
index of suspicion of vertebral column injury (VCI)
and spinal cord injury (SCI). Recent studies are not
consistent and suggest that 2-15% of polytrauma
patients may sustain SCI with a corresponding high
chance of life-long morbidity. Many victims are young
individuals and these injuries have a major impact on
society as a whole.
SCI occur in 20-35% of patients with multiple injuries.
Of particular concern is the combination with
abdominal and thoracic trauma. When associated
with severe haemorrhage, the fatality rate is greater
than either injury alone. Therefore, the pre-hospital
and early in-hospital management of patients with
severe injuries should always be conducted bearing in
mind the possibility of, and need for, management of
vertebral column and spinal cord injuries.

Epidemiology of vertebral Assessment and management

column and spinal cord injury
The aetiology of vertebral column and spinal cord
injury varies worldwide, but overall, the most frequent
cause in all age groups is road traffic collisions (RTCs),
Pre-hospital principles
The following principles are applied to reduce morbidity
and mortality in trauma patients with VCI or SCI:
Qawareness of the mechanism of injury;

accounting for approximately 40-50% of all victims. In Qtriage to facilities with SCI expertise;

an RTC, the exact nature of the injury varies according Qpre-warning to the receiving hospital of a patient

to a number of factors including driver or pedestrian, with either a spinal, head or multiple injuries;
type of vehicle, the direction and the speed of the Qfull spinal immobilization, including semi-rigid

vehicle at impact, the victim’s position and the
presence or absence of seat belts and airbags. The
next most common causes are falls, acts of violence,
and sports-related injuries. Children have a higher
percentage of spinal cord injury compared to adults
due to sports and water recreational activities.
Up to 60% of patients suffering from spinal cord trauma
will have other injuries; 25-50% will have an associated
head injury and conversely, 5-10% of patients with
collars, spinal boards and vacuum mattresses have
been the standard of care for decades. However,
there is no evidence to support this practice, and
procedures around immobilisation have become
less rigid as explained below.
Initial reception
The goal of in-hospital management of VCI and SCI is
to preserve neurological function while maximising the
chances of recovery. This requires:

CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 117

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Qa primary survey and resuscitation with appropriate
patient immobilization and a minimal handling
strategy.
Qa secondary survey, including physical evaluation
of the patient and radiological examination.
Qtreatment of hypotension to maintain spinal cord
perfusion.
Qearly surgical decompression particularly in
incomplete SCI
Subsequently, the patient will require definitive care
e.g. ICU, surgery.
Transfer of the patient on arrival in hospital
Most patients in whom VCI or SCI is suspected will
arrive at hospital fully immobilised. However, for those
patients who are not, there are two ways of transferring
the patient onto an Emergency Department trolley:
QAn ambulance scoop-stretcher can be inserted
beneath the patient, the head and neck immobilised
manually and then the patient lifted over.
QManual transfer of the patient. This requires a team
of five people, all fully trained in the procedure.
One person stabilizes the patient’s head and
cervical spine using his hands and forearms and
also controls the transfer, three other members
position themselves for lifting; one for the thoracic
spine, one for the lumbar spine and pelvis and one
for the legs (figure 9.1). On the controller’s command
all four gently lift the patient and the fifth member
removes the trolley. At no time during the course of
this manoeuvre should the patient be subjected to
a bending or twisting force.
Figure 9.1 Manual transfer of a trauma patient
Primary survey and resuscitation
Spinal cord injury is frequently suspected early,
often before arrival in the Emergency Department.
Acknowledging this information, the team should
not be distracted from the routine of the primary
survey and the team leader must ensure that the same
system of assessment and resuscitation is followed as
described in chapter 2 to prevent deterioration due to
other trauma.
118 | EUROPEAN TRAUMA COURSE
Once the team leader has completed the 5-second
round and the team have initiated the primary survey,
information about the mechanism of the incident
should be sought from the patient and/or the pre-
hospital team to identify the potential for spinal trauma
and cord injury.
TABLE 9.1
Mechanism of Injury
Q fall from height
Q high speed RTC (motorbike)
Signs and symptoms
Q unconsciousness
Q intoxication
Q neck and/or back pain
Q neurological deficit
Q severe facial injury
Q polytrauma
Q distracting injuries
Pre-existing medical conditions
Q cervical spondylosis (old age!)
Q previous vertebral column surgery
Q dementia
In all these groups, the presence of an underlying vertebral
and/or spinal cord injury should be assumed until positively
excluded by both clinical and radiological examination.
Moreover, it is vital for the team leader to ensure that these
patients are moved in a manner such that secondary injury
to the spinal cord is prevented.
The team leader must ensure that all team
members are aware of the potential for spinal
injury.
Airway and cervical spine control
If the airway needs to be secured, the neck should be
stabilised in a neutral position, without any distracting
force being applied.
No patient should have their head or neck
forced into a neutral spine position. No
deformity should be reduced.
If the spine has not been stabilised, this is best achieved
initially by asking the patient to keep his head in neutral
position. In the unconscious patient manual in-line
stabilisation (MILS) should be applied. If the victim is
still wearing a motorcycle crash helmet, two skilled
operators should remove it; one expands the helmet
laterally and gradually ‘rocks’ the helmet off the head
until it can be rotated free, while the other person
immobilises the cervical spine from below. As soon
as appropriate, MILS should be replaced with head
blocks and tapes or a vacuum mattress according to
local policy. If, for whatever reason, the patient cannot
tolerate this, MILS should be continued. If at any time it
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becomes necessary to remove the collar and blocks then
im MILS should be reapplied. Although immobilization
devices as semi rigid collars are generally effective in
limiting motion they can be associated with significant
morbidity including patient discomfort, pressure sores,
raised intracranial pressure, risk of aspiration and
restriction of ventilation. Therefore, immobilization
devices should be removed as soon as any lesion of
the vertebral column and/or the spinal cord is excluded
with certainty.
The effect of spinal immobilisation on
mortality, neurological injury, spinal stability
and adverse effects in trauma patients remains
uncertain. Airway obstruction is a major cause
of preventable death in trauma patients, and
immobilisation, particularly of the cervical
spine, can cause airway compromise, the
possibility that immobilisation may increase
mortality and morbidity cannot be excluded
Conscious patients suspected of having spinal injury
but who are confused, restless, and agitated and refuse
to lie down can present a problem. On no account
should such patients be forcibly restrained, but rather
reassured and allowed the freedom to move. The
muscle spasms associated with spinal injury result in
the conscious person instinctively holding the head
and neck still and avoiding movement. It is therefore
unusual for these patients to worsen spinal injury by
their own voluntary movement. The team must try to
identify and to treat the cause of the restlessness; this
is commonly due to pain, fear, a full bladder, or not
understanding the language.
Three groups of patients with spinal injuries require
urgent tracheal intubation.
1. Unconscious patients. These develop a paralytic
ileus rapidly and an incompetent gastroesophageal
sphincter. This combination, with a potentially full
stomach, puts them at a high risk of regurgitation
and aspiration.
2. Patients with signs of a high cervical cord injury.
Complete injury above the C3 level leads to apnoeic
respiratory arrest and death unless immediate
ventilatory assistance is provided.
3. Patients with associated major injuries. This will
include head, chest and abdominal injuries.
Intubation in these individuals is more difficult
because of the need to maintain absolute neck
immobilization. Uncontrolled attempts at intubation
resulting in hyperflexion and/or hyperextension of
the cervical spine can cause or exacerbate vertebral
column or spinal cord injuries and even lead to the
death of the patient. To reduce these risks intubation
must be carried out by an experienced anaesthetist
proficient in using specialized equipment for example
a fibreoptic laryngoscope. The use of hypnotics and
neuromuscular blocking drugs to facilitate intubation
of the trachea in these patients by trained staff is
the technique of choice. The specific neuromuscular
blocking drug used will depend on local policy
and individual preferences; however the use of
succinylcholine in patients with spinal cord injury
soon after injury may cause a profound bradycardia,
and after 48 hours it may also cause profound
hyperkalaemia and cardiac arrest.
Emergency drug assisted tracheal intubation should
be performed with the semi-rigid collar released and
replaced with MILS; this requires a team approach,
usually under the direction of the airway doctor. After
successful intubation of the trachea, the cervical collar
should be re-fastened. Supraglottic airway devices are
useful alternatives for airway management, particularly
in the case of difficulty with intubation. Therefore these
devices, according to local protocol, should always be
available when intubation is attempted.
Breathing and ventilation
Immediately life-threatening thoracic injuries need
to be identified and treated as described in chapter
4. Depending on the level of spinal cord injury the
accessory muscles of respiration, intercostals and
abdominal muscles may be paralysed; a lesion in the
upper cervical region (C3-C5) will result in loss of most
respiratory muscle activity causing acute respiratory
failure and hypoxia due to hypoventilation. Injuries
below this level, sparing the diaphragm but paralysing
the intercostals and abdominal muscles will result
in diaphragmatic breathing (paradoxical chest and
abdominal movement on spontaneous ventilation);
this may be the first clue to a significant injury of the
cervical spinal cord. In addition there will be:
Qinadequate coughing;
Qa decrease in vital capacity;
Qreduced functional residual capacity;
Qloss of active expiration.
Frequent re-evaluation of breathing and ventilation
is necessary since it might deteriorate over time. Early
considerations must be given to arterial blood gas analysis
to assess the adequacy of oxygenation and ventilation.
Circulation and control of haemorrhage
Assessment and management are as described in
chapter 5; external haemorrhage should be controlled
by direct pressure, IV access obtained and bloods taken
for crossmatching and appropriate investigations.
Hypotension may be the result of neurogenic shock,
however haemorrhagic shock needs to be excluded.
It may be possible to distinguish between the two but
remember they may co-exist and severe haemorrhage
from co-existing injuries can complicate and
exacerbate the degree of hypotension. Furthermore,
the inability to perceive pain can mask potentially
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life-threatening injuries e.g. pelvic or intra-peritoneal
trauma as they are unnoticed by the patient. Whatever
the cause, resuscitation will be required using
the principles already described; hypotension is a
potential cause of secondary neurological injury of
the spinal cord and therefore, it is essential that it is
identified and treated rapidly.
Neurogenic shock
This is defined as vascular hypotension associated
with a bradycardia as a result of spinal cord injury. It
occurs following injury to the spinal cord above T6 and
results in a progressive loss of sympathetic outflow
and vasomotor tone with ascending level of the lesion.
This leads to hypotension secondary to arteriolar and
venous vasodilatation of the peripheral vasculature
and the splanchnic vascular beds. The higher the
lesion, the greater will be the loss of vasomotor tone
and peripheral vasodilatation. When the lesion is
above T2, there will also be a bradycardia and a reduced
stroke volume secondary to loss of the sympathetic
innervation of the heart. These pathophysiological
changes cause pooling of blood in the extremities and
reduction of central venous return. Thus, neurogenic
shock may be associated with a SBP below 70mmHg
and a bradycardia below 60 beats/min in the presence
of normovolaemia. Moreover, such a patient cannot
mount a normal response to hypovolaemia caused
by other injuries Neurogenic Shock is not be confused
with Spinal Shock, which is a reversible combination
of areflexia/hyporeflexia and autonomic dysfunction
that accompanies spinal cord injury.
In an unconscious patient these findings may be the
only indication of a significant SCI. Furthermore the
lack of any sympathetic activity may be unmasked
as profound parasympathetic reflexes such as severe
bradycardia during laryngoscopy. Atropine should
be reserved for patients with severe symptomatic
bradycardia due to the profound effect on heart rate
and widespread side effects.
These patients may require intravenous vasopressors
and/or positive chronotropic agents; a central venous
line should be inserted early to help monitor and guide
the response to fluid challenges. Although elevation of
the patient’s legs can be used to counteract peripheral
venous pooling, it will not be possible in the presence
of pelvic, lower limb or lumbar spine injuries.
In patients suffering from spinal cord injury, care is
required to ensure optimal fluid resuscitation. Too little
and tissue ischaemia will increase whereas too much
may precipitate pulmonary oedema. The aim should
be to maintain a MAP of >90mmHg and any episode of
hypotension avoided. Neurogenic shock needs to be
considered in those patients who respond inadequately
to fluid resuscitation and remain bradycardic.
120 | EUROPEAN TRAUMA COURSE
For fluid resuscitation, crystalloids or colloids can be
given according to local protocols. Furthermore, it
is not yet clear whether hypertonic solutions as part
of a ‘small volume resuscitation’ technique provide
a clinical benefit in the management of patients
suffering from spinal cord injury. Extrapolating from
the findings in patients with traumatic brain injury
implies these solutions may be justified in patients in
whom hypotension or multiple trauma is combined
with spinal cord injury. However, controlled clinical
trials are still lacking. Whichever regimen is used, fluids
containing glucose should not be given for two reasons:
Qrapid metabolism of glucose results in ‘free water’
which supports oedema formation;
Qthe risk of hyperglycaemia with an increase in
lactate and decrease in pH is associated with a
worse outcome.
Dysfunction of the CNS
During the primary survey it may become apparent
that there is a symmetrical weakness. This should be
noted, but the full definitive neurological assessment
must wait until the secondary survey.
Exposure and environmental control
The patient needs to be completely divested of all
remaining clothes to allow a full examination, while
not forgetting their dignity. All patients cool rapidly
once exposed, but particularly those with spinal
cord injury due their inability to control and maintain
body temperature and the associated vasodilatation.
Every effort must be made to minimise heat loss
using blankets, warm air blowers or overhead heaters
whilst avoiding hyperthermia as it is associated with
increased neurological injury. The overall aim should
be for normothermia.
In the conscious patient it is essential that there
is minimal handling and that all manouveres and
procedures are fully explained on beforehand. At all
times it is also essential to ensure there is no twisting
of the spine. This means using a co-ordinated log roll
when examining the patient’s back and removing
them from a spinal board.
Secondary survey
As already described, this consists of a head-to-toe
examination of the patient to detect any injuries that
were not immediately apparent during the primary
survey. It may only be at this phase of the patient’s care
that a VCI or SCI becomes apparent. Therefore should
the secondary survey be delayed for any reason (e.g.
the need for emergency surgery) spinal immobilization
should be maintained. The requirement for a spinal
examination must also be clearly documented in the
patient’s notes and relayed to the clinician responsible
for the in-patient care at handover.
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The remainder of this section will concentrate on
those aspects of the secondary survey that relate to
the management of patients with spinal injuries. In the
conscious patient, a number of signs and symptoms
are associated with the presence of spinal injury:
Qpain in the spine at the level of the injury worsened
with movement;
Qareas of abnormal or absent sensation;
Qignorance of other injuries, particularly fractures, in
the absence of intoxicants;
Qpresence of weakness or inability to move a limb
or limbs.
Log rolling the patient
If Whole Body CT scanning is part of the primary
survey, log rolling is not a priority in blunt trauma.
It may cause fracture dislocation, pain, distress or
clot disruption in patients with pelvic fractures or
other injuries. The classical log roll is performed if no
immediate imaging is available and meant to detect
superficial lacerations, wounds, bruising, swelling
and deformity as external signs of vertebral column
injury. Palpation of the entire spine from occiput
to coccyx is performed to identify any tenderness,
steps, deformations and gaps between the spinous
processes. Finally, if indicated, a rectal examination is
carried out to rule out sacral sparing. Any indication
of the potential presence of vertebral column injury
mandates appropriate radiological investigation,
according to local protocols.
Removal of the spinal board
Prolonged immobilization on a spinal board can be
of danger to the patient. If not done so already, a
long spinal board must now be removed in the ED
to minimize the risk of the development of pressure
sores and at the same time a note must be made of the
state of the pressure areas. The spinal board serves the
primary purpose as an extrication and transportation
device. The patient should be transferred to a trauma
stretcher as soon as possible.
Log Roll (see page 124)
KEY POINTS
Indication: in every stable blunt trauma patient once
imaging is completed.
Procedure: safe, coordinated turning of the patient
to allow examination of their back,
removal of the spinal board and if
indicated, rectal examination
Complications: unsafe movement of the spine, with the
risk of secondary injury, displacement of
lines and tubes, clot dislodgement
Common uncoordinated team effort
pitfalls:
Neurological function
Assessment of the neurological function is complex
and should therefore be done systematically to ensure
that subtle signs are not overlooked. The ASIA Chart
(figure 9.2.) is a neurological assessment tool for patients
with suspected SCI. It looks at all aspects of motor and
sensory function and guides the clinician through the
examination in a structured way. Additionally tendon
reflexes and a rectal examination should be performed.
Dermatomes
Sensory function is evaluated according to segmental
organization in dermatomes of the human body. A
dermatome is an area of the skin supplied predominantly
by the sensory axons within a particular segmental
nerve root (figure 9.2). In order to determine the level
of spinal cord injury the lowest dermatome level with
normal sensory function is taken as the sensory level.
Do not forget to test for perianal sensation, its
presence may be the first indication of an incomplete
spinal cord injury (see spinal cord injury below).
Myotomes
Although strictly speaking most muscles are innervated
by more than one nerve root, the functions that can
be regarded as being performed predominantly by
muscles with one spinal root value are shown in figure
9.2. The power of the muscle supplied by the spinal
nerves is evaluated using either the MRC (UK) scale or
the ASIA scale.
Reflexes
The following reflexes with their approximate nerve
root values should be evaluated (the order presented
is simply to act as an aide memoire):
Qankle (S1, S2);
Qknee (L3, L4);
Qbiceps (C5, C6);
Qtriceps (C7, C8).
Rectal tone
The external anal sphincter muscle needs to be
tested by digital examination and asking the patient
to voluntary contract. Perianal sensation may be
assessed at the same time.
CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 121
 (OERZÀH[RUV (OERZÀH[RUV
:ULVWH[WHQVRUV :ULVWH[WHQVRUV Date/Time of Exam _____________________________
Patient Name_____________________________________
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
(OERZH[WHQVRUV (OERZH[WHQVRUV
CLASSIFICATION OF SPINAL CORD INJURY
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Examiner Name ___________________________________
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MOTOR SENSORY SENSORY

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KEY SENSORY POINTS
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KEY SENSORY POINTS
Light Touch (LTL) Pin Prick (PPL)
MOTOR(OERZÀH[RUV
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Elbow flexors C5 C3
C3
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(Upper Extremity Right) Elbow extensors C7
‡ C4
C2 T3
T2
C7 Elbow extensors (Upper Extremity Left)
Points T4 C5
Finger flexors C8 T5
C8 Finger flexors
Finger abductors (little finger) T1 T6 T1 Finger abductors (little finger)
T7
T2 C3 C8 6 C8 T2
Comments (Non-key Muscle? Reason for NT? Pain?): C6 C
T8
MOTOR
T3 C7 C7 T9 T1 T3 (SCORING ON REVERSE SIDE)
+LSÀH[RUV T4
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T5 1 = palpable or visible contraction
T12 2 = active movement, gravity eliminated
$QNOHGRUVLÀH[RUV T6 $QNOHGRUVLÀH[RUV
T6 3 = active movement, against gravity
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L1
Palm
/RQJWRHH[WHQVRUV T7 /RQJWRHH[WHQVRUV
T7 4 = active movement, against some resistance
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T8 5* = normal corrected for pain/disuse
S3
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C8 6 C8
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Hip flexors L2 Dorsum Dorsum L2 Hip flexors
Knee extensors L3 L3 Knee extensors LEL
LER L4
(Lower Extremity Right) Ankle dorsiflexors L4 L4 Ankle dorsiflexors (Lower Extremity Left)
L5
Long toe extensors L5 L5 Long toe extensors
S1
Ankle plantar flexors S1 L5 S1 Ankle plantar flexors
S2 S2
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(VAC) Voluntary Anal Contraction S4-5 (DAP) Deep Anal Pressure
(Yes/No)
S4-5
(Yes/No)

122 | EUROPEAN TRAUMA COURSE

RIGHT TOTALS LEFT TOTALS
(MAXIMUM) (MAXIMUM)
MOTOR SUBSCORES
6WHSVIRUFODVVL¿FDWLRQ SENSORY SUBSCORES
UER + UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)

NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L

LEVELS ZONE OF PARTIAL

Figure 9.2
1. SENSORY LEVEL OF INJURY Incomplete = Any sensory or motor function in S4-5 SENSORY
Steps 1-5 for classification
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal level with any innervation

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 11/15
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Unconscious patients
The key to recognizing the presence of a spinal cord
injury in unconscious patients is a continued high index
of suspicion and checking for features listed in table 9.1.
When there is spontaneous movement it is important to
note if it was voluntary or a response to pain and whether
there is any difference between limbs. Unconscious
patients will require a detailed reassessment.
TABLE 9.1
Features suggesting spinal cord injury in an
unconscious patient
Q Hypotension with a bradycardia
Q Flaccid areflexia
Q Diaphragmatic breathing
Q Loss of response to pain below an identified dermatomal level
Q Absence of reflexes below an identified level
Q Priapism
Types of vertebral column injuries
In spinal trauma the following injuries may be encountered:
Atlanto–occipital dislocation
QDefinition: internal decapitation in which the
skull becomes separated from the spinal column.
QMechanism: usually results of high energy trauma
with severe flexion and distraction.
QSymptoms: mostly fatal due to brain stem
destruction, apnoea or severe neurological
compromise. Survivors usually arrive at hospital
intubated and ventilated.
Atlas fracture (C1 fracture)
QDefinition: isolated fracture of the bony ring or
a burst fracture of C1 (Jefferson fracture) with
involvement of the anterior and posterior arches
of the vertebra.
QMechanism: axial loading of the spine due to a
fall onto the top or back of the head e.g. diving
in shallow water.
QSymptoms: variable from isolated neck pain to fatal.
QAssociated injuries: high incidence of
combination injuries with fracture of the axis and
lower cervical spine injuries.
Atlas subluxation
QDefinition: rotatory subluxation of C1.
QMechanism: variable (atraumatic, minor or major
trauma to head).
QSymptoms: torticollis (rotation of the head).
Axis fractures (C2 fractures)
Odontoid fractures
QDefinition: fractures of the odontoid process of
C2 are subdivided into:
t
O  ype I extends through the tip of the dens;
t
O  ype II through the base of the dens;
type III through the vertebral body of the axis.
O
Mechanism: combination of flexion/extension
Q
and rotation. In elderly patients often due to a
ground level fall.
QSymptoms: variable, from isolated neck pain to
high cervical paralysis.
Posterior element fracture of C2
QDefinition: bilateral fractures of the posterior
elements (pars interarticularis or pedicles) are
referred to as a hangman`s fracture.
QMechanism: forced extension with distraction.
Despite their eponym, common in deceleration
injuries in which the patient’s face hits an object
leading to forced cervical spine extension.
QSymptoms: dependent on the degree of
dislocation. Spectrum ranges from death due
to medullary compression, stroke symptoms in
cases of dissection of either or both vertebral
arteries and isolated neck pain.
Injuries to the lower cervical spine (C3-C7)
QDefinition: vertebral fractures, subluxation and
ligamentous injuries to C3-C7.
QMechanism: variable.
QSymptoms: neurological impairment is dependent
on the degree of fracture displacement and has a
high incidence in uni- or bilateral facet dislocation.
Fractures of the thoracic and lumbar spine
QDefinition: fractures are divided into the following
entities; compression fractures, burst fractures,
transverse fractures (Chance fractures) and
fracture-dislocations.
QMechanism: compression and burst fractures are
mainly caused by axial loading. Chance fractures
are a result of violent forward flexion. Fracture-
dislocations are due to severe flexion or multi-
directional forces.
QSymptoms: in thoracic fractures (apart from pure
compression fractures) there is a high incidence
of neurological impairment due to the narrow
vertebral canal. In adults fractures below L2 have
a low incidence of complete neurological deficit
since they can only involve the cauda equina.
QAssociated injuries: Chance fractures have a high
incidence of associated intra-abdominal injuries
(>50%).
Spinal cord injury
Spinal cord injuries can be classified as either complete
or incomplete according to ASIA. The former should
be suspected when there has not been any recovery of
sensory or motor function within 48 hours. However,
during the first few weeks, this diagnosis cannot be
made with certainty due to the presence of spinal
shock. This is a condition where there is a complete
but transient loss of sensation, muscle tone (including
rectal tone), muscle power and reflex activity (flaccid
CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 123
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areflexia) below the level of the cord injury. It can
last for a variable length of time (days or weeks), but
there is a potential for full recovery. Due to this delay,
an accurate prognosis for the patient cannot be given
in the first days and statements as such should not be
issued in the Emergency Department.
Incomplete spinal cord injury has a much better
prognosis for some functional motor recovery. The
presence of sacral nerve root function may be a more
stable and reliable indicator of the incompleteness
of an injury as it represents at least partial structural
integrity of the corticospinal and spinothalamic tracts.
Sacral sparing can be confirmed by finding intact
perianal sensation and anal sphincter tone.
Spinal cord syndromes in incomplete spinal cord injury
Central cord syndrome
QMost common pattern of incomplete spinal cord
injury.
QOften follows hyperextension to the neck, such
as from a fall on to the face. Typically seen in older
patients who have pre-existing degenerative
changes (e.g. cervical spondylosis) in their spine
with associated narrowing of the spinal canal.
QUsually results in a vascular event, compromising
blood flow to the centre of the cord.
QResults in damage to the corticospinal and
spinothalamic tracts, with preservation of
the sacral spino-thalamic and peripheral
corticospinal tracts.
QOn examination:
Ow eakness of the limbs, arms worse than legs;
Ofl accid paralysis of arms, worse distally;
Oi ntact perianal sensation and an early return of
bowel and bladder function;
Ot here may be disturbance of sensation with
hyperaesthesia, more pronounced in the arms
than the legs.
QReturn of motor function usually begins with the
sacral elements followed by the lumbar elements
of the ankle, knee and hip. Upper limb functional
return is usually minimal.
QThe chance of some functional motor recovery
has been reported to be about 75%.
Anterior cord syndrome
QDue to the loss of function of the anterior two-
thirds of the spinal cord.
QUsually the result of a flexion injury or an axial
loading leading to a burst fracture and damage
to the anterior spinal artery.
QMay also be seen after a period of profound
hypotension.
QOn examination:
Ol oss of motor function (flaccid paralysis), sharp
pain and temperature sensation below the lesion;
Op roprioception, vibration and deep pressure
sensation are all retained in the trunk and lower
124 | EUROPEAN TRAUMA COURSE
extremities because they are transmitted in the
intact posterior columns in the cord.
QCarries a poor prognosis, only a 10% chance of
functional motor recovery.
Brown-Séquard syndrome
QA rare injury resulting from a hemi-transection of the
spinal cord and associated unilateral spinal tracts.
QThe mechanism of injury is most commonly
the result of a penetrating wound from either a
gunshot or stabbing.
QOn examination:
Ol oss of power and proprioception, vibration and
deep pressure sensation on the side of the injury
from the level of the lesion;
Oo n the opposite side of the body there is a loss of
pain and temperature sensation below the level
of the lesion.
QAlmost all of these patients show a partial
recovery, and most regain bowel and bladder
function and the ability to ambulate.
Nerve root injury
QSpinal nerve root may be injured with the cord at
that level or in isolation.
QPrognosis is favourable for motor recovery, with
about 75% of those with complete spinal cord
injury showing no root deficit at the level of
injury or having a functional return.
QThose with higher cervical injuries have a 30%
chance of recovery of one nerve root level, those
with midcervical injuries have a 60% chance, and
almost all patients with low cervical fractures
have recovery of at least one nerve root level.
Further management of patients
Interventions
After the primary and secondary survey, the patient’s
condition dictates further management (e.g. surgery,
ICU). The following interventions complete the
management in suspected cases of spinal cord injury:
Qinsertion of a urinary catheter;
Qpass a naso/orogastric tube, ileus and aspiration
pneumonitis are common complications;
Qtake measures to prevent hypothermia and
hyperthermia;
Qinstitute measures to prevent respiratory
complications (e.g. atelectasis, muscle fatigue,
increased breathing effort and ventilation-
perfusion mismatch);
Qconsider antiemetics and analgesics;
Qrepeated neurological evaluation;
Qremoval of immobilization devices at the earliest
opportunity to prevent pressure sores;
Qglucose levels should be measured to aim for
a target blood glucose level within the normal
range (4.0–7.0mmol/l);
Qearly contact with a specialist/spinal
rehabilitation unit.
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1. Any high-risk factor which mandates Rule not applicable if:

radiography? - Non-trauma case
Q Age >65 years - GCS <15
or - Unstable vital signs
Q Dangerous mechanism* - Age <16 years
or - Acute paralysis
Q Paraesthesiae in extremities - Known vertebral disease
- Previous injury to the cervical spine

NO YES

2. Any low-risk factor which allows safe

assessment of range of motion?
Q Simple rear-end RTC**

or
Q Sitting position in the ED

or NO RADIOGRAPHY
Q Ambulatory at any time

or
Q Delayed onset of neck pain***

or
Q Absence of midline cervical spine

tenderness

UNABLE

YES

* Dangerous mechanism:
- Fall from elevation >1m (5 stairs)
- Axial load to the head
3. Able to actively rotate neck? - RTC high speed (>100km/hr, 60 mph),
450 left and right rollover, ejection
- Motorized recreational vehicle
- Bicycle collision
** Simple rear-end RTC excludes:
ABLE - Pushed into oncoming traffic
- Hit by bus/large truck
- Rollover
- Hit by high speed vehicle
*** Delayed onset of neck pain
NO RADIOGRAPHY - i.e. not immediate onset of neck pain

Figure 9.3 Canadian C-Spine Rule. For use with alert (GCS 15) and stable trauma patients where cervical spine injury is a concern.
ED=Emergency Department

Clinical clearance of the cervical spine

Patient meets all low-risk criteria?
Based solely upon the mechanism of injury many
patients have the potential for a vertebral column 1. No posterior midline cervical spine tenderness
injury, particularly to their cervical spine. In practice 2. No evidence of intoxication
however many will turn out to be uninjured. The 3. A normal level of consciousness
Canadian C-Spine Rule (figure 9.3) and the National 4. No focal neurological deficit
Emergency X-radiography Utilization Study (NEXUS) 5. No painful distracting injuries
Low-Risk Criteria (figure 9.4) are well established
systems to determine which patients need YES NO
radiological investigation of their cervical spine
and who can be cleared on the basis of history and
clinical examination. In these patients cervical spine NO RADIOGRAPHY RADIOGRAPHY
immobilization is no longer required and it is safe to
remove the collar. This is commonly referred to as Figure 9.4 National Emergency X-radiography Utilization Study
(NEXUS) criteria

CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 125

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‘clearing the cervical spine’. If any criteria are positive,
full immobilization is maintained and appropriate
radiological investigations (antero-posterior, lateral
and open mouth view) are obtained.
Pharmacological intervention with
corticosteroids
Some experimental studies have suggested that
treatment with methylprednisolone may be beneficial
in spinal cord injury. However, from a scientific point of
view, even after the National Acute Spinal Cord Injury
Studies (NASCIS), it is still questionable as to whether
treatment with methylprednisolone is beneficial.
Moreover, patients treated with it have an increase in
clinically important side effects e.g. severe pneumonia
and wound infections. Currently the evidence in use
of high-dose steroids for spinal cord injury remains
inconclusive and routine use of steroids is not supported.
Investigations
In patients suffering from major trauma and/or multiple
injuries, multi-slice CT of the whole spine is the preferred
initial imaging modality. It is more accurate in diagnosing
vertebral column injury than plain x-rays and the total
imaging time and patient manipulation are reduced.
Magnetic resonance imaging (MRI) is the investigation
of choice to identify soft tissue (non-osseous) injuries
of the vertebral column and spinal cord. However the
environmental restrictions and procedure time mean
MRI scans are at present limited in their application. It is
generally reserved for patients in whom life-threatening
injuries have been excluded and/or treated.
Plain x-rays
A lateral cervical spine x-ray is the most common type
of vertebral column x-ray. A number of errors can be
made when evaluating these films that can result in
injuries being missed. These include:
Qan inadequate x-ray;
Qassuming that a ‘normal x-ray’ rules out spinal
injury. A good quality lateral cervical spine x-ray
is only 85% sensitive;
QSCI due to a vascular event with no bony
injury. (spinal cord injury without radiological
abnormality - SCIWORA);
Qfailure to appreciate the severity of the abnormality;
Qfailure to systematically evaluate the x-ray.
CT
CT is indicated in the following situations:
QGCS ≤13 on initial assessment;
Qpatient anaesthetised;
Qinadequacy or abnormality (even suspicion) on
spinal x-rays;
Qother requirement for CT scan;
Qdementia;
Qnew neurological signs or symptoms;
Qneck pain: described as severe neck pain (> 7/10) or
in conjunction with pre-existing vertebral disease.
126 | EUROPEAN TRAUMA COURSE
Summary
The management of the patient with a spinal
injury starts at the scene and continues through
to rehabilitation in order to minimise the risk of
secondary injury and maximise the potential
for recovery. The management of vertebral
column and spinal cord injuries requires an
interdisciplinary team approach and is crucial for
the long-term quality of life for these patients.
Having worked through this chapter you are now
ready to apply the following knowledge in the
spine trauma workshop:
Qassessing and managing spinal injuries including
neurogenic shock;
Qneurological examination in patients with
suspected spinal injury;
Qspinal immobilization and clearing the cervical
spine;
Qinterpretation of spinal imaging.
These cognitive abilities will be integrated with
the practical skills during the course workshops.
Further information
Q American Spinal Injury Association:

http://www.asia-spinalinjury.org/
Q AO Spine: http://www.aospine.org
Q Connor D, Greaves I, Porter K et al on behalf of the
consensus group, Faculty of Pre-Hospital Care. Pre-
hospital spinal immobilisation: an initial consensus
statement. Emerg Med J 2013;30:1067-1069.
Q Moss R, Porter K, Greaves I on behalf of the
consensus group. Minimal patient handling: a
faculty of prehospital care consensus statement.
Emerg Med J 2013;30:1065-1066.
Q Kornhall DK, Jørgensen JJ, Brommeland T et al.
The Norwegian guidelines for the prehospital
management of adult trauma patients with
potential spinal injury. Scand J Trauma Resusc
Emerg Med 2017;25:2.
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Trauma to the vertebral column

and spinal cord - skills
Interpretation of the lateral cervical spine
x-ray
X-rays need to be interpreted in a systematic fashion
so that all the significant pathological processes
can be detected and mistakes avoided. The system
recommended on the course is described below.
Candidates with their own method review their system
to ensure it covers all elements described below.

Indication:
Qpatients identified by either the Canadian C-Spine

Rule or the National Emergency X-radiography

Utilization Study (NEXUS) as needing radiological
investigation of their cervical spine.

Procedure:
QAh!:

Ou
 se the first 10 seconds to simply look at the

image and note any immediately obvious

abnormalities. Then explore the image in more
detail using the AAABCS systematic review.
QAccuracy and Adequacy: Figure 9.5 Lateral cervical spine film showing the four longitudinal
curves
Oc
 orrect film for the patient and personal details

correct;
Oa
 re all 7 cervical vertebrae, the occipito-cervical Bones:
Q

junction and the C7-T1 junction visible? Oc heck the cortical surfaces of all vertebrae for

QAlignment: steps, breaks, or angulation;

Oc
 heck the contours of the four longitudinal Oc heck C1: the laminae and pedicles, think about

curves (figure 9.5): a Jefferson fracture;

P a
 nterior – along the anterior aspect of the Ocheck C2: the outline of the odontoid and

vertebral bodies from the skull base to T1; pars interarticularis, think about a hangman’s
P p
 osterior – along the posterior aspect of the fracture.
vertebral bodies from the skull base to T1; OC 3–T1 start at the anterior inferior corner of

P t
 he spinolaminar line – this should be
smooth except at C2 where there can be
slight posterior displacement (2mm);
P t
 he tips of the spinous processes – these
should trace out a tighter curve and
projection of the tips should converge to a
point behind the neck.
the vertebral body and proceed clockwise,
checking body, pedicles, transverse process,
laminae and spinous process. The height of the
anterior and posterior bodies should be the
same. More than 2mm difference suggests a
compression fracture.
QCartilages and joints:

OC heck the disc spaces, facet joints and

A break in any of these lines indicates a fractured interspinous gaps.

vertebra or facet dislocation until proven
otherwise. Divergence of the spinous processes
is also abnormal. In some patients there is a
pronounced loss of the normal curve of the cervical
spine (lordosis). This may be due to muscle spasm,
age, previous injury, radiographic positioning or
the presence of a hard collar. Its presence therefore
only indicates that the patient may have sustained
a cervical spinal injury.
If the film is not adequate, it must be repeated
with the patient´s arms pulled down to remove the
shoulders from the field of view or take a ‘swimmer´s
view’. If these fail, then perform CT scan.
CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 127
Disc spaces should be of uniform height and
similar in size to those between adjacent
vertebrae. Facet joints have parallel articular
surfaces, with a gap less than 2mm. Widening
of the gap and visibility of both facets suggests
unifacetal dislocation. There will also be
anterior displacement of less than half the
width of the vertebral body and associated soft
tissue swelling. If there is displacement greater
than 50%, both facets are dislocated. There will
also be narrowing of the disc space, widening
(fanning) of the spinous processes and soft
tissue swelling.
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Check the gap between C1 and the front of the
O
odontoid peg.
The distance between the posterior surface of
the anterior arch of C1 and the anterior surface of
the odontoid should be less than 3mm in adults,
greater than this suggests rupture of the transverse
ligament. This may occur without there being
bony injury or cord damage (Steele’s rule of three:
‘One third of the spinal canal within C1 is occupied
by the odontoid, one third by an intervening space
and one third by the spinal cord’).
QSoft tissues:
C
O heck the soft tissue shadow anterior to the
cervical vertebrae.
Fractures of the cervical vertebrae or ligamentous
injury will result in a haematoma that is seen as
an increase in the width of the soft tissue shadow
adjacent to the injury. In some subtle injuries this
may be the only evidence. As a ‘rule of thumb’ the
soft tissue shadow between the anterior border
of C1–C3 and the air in the oro and nasopharynx
should be less than 7mm wide. From C5
downwards this increases to about 21mm, or
the width of the vertebral body. Occasionally,
this may be seen as anterior displacement of a
tracheal tube.
It must be remembered that the stability of the
cervical spine is dependent on the ligaments that are
not revealed on a plain x-ray. Therefore, the lateral
cervical film must be examined not only for signs of
bony trauma but also clues of ligamentous damage as
this may indicate the presence of an unstable injury.
Markers include facet joint widening, facet joint
overriding, widening of the spinous processes, >25%
compression of a vertebral body, >10° angulation
between vertebral bodies, >3.5mm vertebral body
overriding with fracture, Jefferson fracture, hangman’s
fracture and a tear-drop fracture.
Complications:
Qabnormalities missed on inspection, most
commonly:
Oa
 t the craniocervical junction;
Oa
 t the cervicothoracic junction due to an
inadequate film;
Ou
 nifacetal dislocations;
Os
 igns of ligamentous injury.
128 | EUROPEAN TRAUMA COURSE
Log roll
Indications:
Qto allow examination of the patient’s back;
Qremoval of the spine board;
Qif indicated, rectal examination.
Procedure:
QA minimum of five people is involved in the
procedure.
QOne person, standing at the head, should be
assigned as in charge and it is essential that all
the others follow his/her orders.
QIf conscious, the patient should be warned what
is about to happen.
QThe person at the head will maintain manual
control of the patient’s head, either with the
cervical collar in place or by MILS.
QThree assistants stand to the side of the patient
onto which the patient is to be turned:
O t he one nearest the patient’s head grasps the
patient’s far shoulder and pelvis;
O the second grasps the patient’s chest/arm with
one hand and places their second hand under
the patient’s knee;
O t he third places one hand under the patient’s
thigh and the other under the patient’s lower leg.
As a result, the assistants’ hands are placed such
that the three hands on the torso will be facing
palms down, whereas the three hands supporting
the leg will be palms up.
QThe person at the head will then identify the
command to be given that indicates the team
should turn the patient towards them e.g. “I will
count to three and we will turn the patient on three”.
QEnsure that the whole team understands and is
ready.
QThe count is made and the patient turned on
‘three’ (figure 9.6).
th
QThe 5 assistant then carries out the examination.
This will include an inspection of the back for
any signs of injury, palpation of the spine for
tenderness and in case of suspected or actual
neurological deficit, a rectal exam. It is also a
good opportunity to listen to the back of the
chest and to remove the spinal board if indicated.
QUpon completion of the examination the person
at the head will control the turn of the patient
supine. The same command structure is used as
for the initial turn; “I will count to three and we
will return the patient supine on three”.
QThe count is made and the patient returned
supine on ‘three’.
QIf the cervical collar has been removed for the
roll, it is now reapplied and spinal immobilization
completed. If at any time during the log roll
any of the assistants has a problem, they must
immediately alert the leader to allow a controlled
return of the patient supine.
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Figure 9.6 Log roll of a patient. Note the position of the team
members’ hands

Complications:
lack of coordination and risk of injury;
Q

tubes and lines being displaced;

Q

Qfatigue of team members.

CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 129