SPINE AND SPINAL

CORD TRAUMA
ANATOMY AND PHYSIOLOGY
SPINAL COLUMN
The spinal column
consists of 7
cervical, 12
thoracic, and 5
lumbar vertebrae,
as well as the
sacrum and the
coccyx
SPINAL CORD ANATOMY
The spinal cord originates at the caudal end of the medulla
oblongata at the foramen magnum. In adults, it usually ends near
the L1 bony level as the conus medullaris.

Below this level is the cauda equina, which is somewhat more

resilient to injury. Of the many tracts in the spinal cord, only three
can be readily assessed clinically: the lateral corticospinal tract,
spinothalamic ract, and dorsal columns (n FIGURE 7-2).

Each is a paired tract that can be injured on one or both sides of the
cord. The location in the spinal cord, function, and method of testing
for each tract are outlined in
Table 7.1.
SENSORY EXAMINATION
How do I assess the patient’s neurologic status?

A dermatome is the area of skin innervated by the sensory

axons within a particular segmental nerve root. Knowledge of the major
dermatome levels is invaluable in determining the level of injury and
assessing neurologic improvement or deterioration. The sensory level is
the lowest dermatome with normal sensory function and can often differ
on the two sides of the body. For practical purposes, the upper cervical
dermatomes (C1 to C4) are somewhat variable in their
cutaneous distribution and are not commonly used for localization.
However, it should be remembered that the supraclavicular nerves (C2
through C4) provide sensory innervation to the region overlying the
pectoralis muscle (cervical cape)
MYOTOMES

Each segmental nerve (root) innervates

more than one muscle, and most
muscles are innervated by more than
one root (usually two).

Nevertheless, for the sake of simplicity,

certain muscles or muscle groups are
identified as representing a single spinal
nerve segment. The key myotomes are
shown in n FIGURE 7-4.
The key muscles should be tested for strength on both sides.
Each muscle is graded on a six-point scale from normal
strength to paralysis (Table 7.3). Documentation of the strength
in key muscle groups helps to assess neurologic improvement
or deterioration on subsequent examinations. In addition, the
external anal sphincter should be tested for voluntary
contraction by digital examination
NEUROGENIC SHOCK VERSUS SPINAL SHOCK

How do I identify and treat neurogenic and spinal

shock?

• Neurogenic shock results from impairment of the descending

sympathetic pathways in the cervical or upper thoracic spinal cord. This
condition results in the loss of vasomotor tone and in sympathetic
innervation to the heart. Neurogenic shock is rare in spinal cord injury
below the level of T6;

• Loss of vasomotor tone causes vasodilation of visceral and lower-

extremity blood vessels, pooling of blood, and, consequently,
hypotension.
EFFECTS ON OTHER ORGAN SYSTEMS

 Hypoventilation due to paralysis of the intercostal muscles may result from

an injury involving the lower cervical or upper thoracic spinal cord. If the
upper or middle cervical cord is injured, the diaphragm also is paralyzed
because of involvement of the C3 to C5 segments. which innervate the
diaphragm via the phrenic nerve.
CLASSIFICATIONS OF SPINAL CORD INJURIES

When do I suspect spine injury?

Spinal cord injuries can be classified according to
(1) level
(2) severity of neurologic deficit
(3) spinal cord syndromes, and
(4) morphology.
LEVEL
The neurologic level is the most caudal segment of the spinal cord that
has normal sensory and motor function on both sides of the body.
When the term sensory level is used, it refers to the most caudal
segment of the spinal cord with normal sensory function. The motor
level is defined similarly with respect to motor func-tion as the lowest
key muscle that has a grade of at least 3/5 (see Table 7.3).
SEVERITY OF NEUROLOGIC DEFICIT
Spinal cord injury may be categorized as:
• Incomplete paraplegia (incomplete thoracic injury)
• Complete paraplegia (complete thoracic injury)
• Incomplete quadriplegia (incomplete cervical injury)
• Complete quadriplegia (complete cervical injury)
SPINAL CORD SYNDROMES

frequently encountered in patients with spinal cord

injuries,
• such as central cord syndrome
• anterior cord syndrome
• and Brown-Séquard syndrome.
SPINAL CORD SYNDROMES

 Central cord syndrome is characterized by a disproportionately

greater loss of motor strength in the upper extremities than in the
lower extremities, with varying degrees of sensory loss.
 Usually this syndrome occurs after a hyperextension injury in a
patient with preexisting cervical canal stenosis (often due to
degenerative osteoarthritic changes), and the history is commonly
that of a forward fall that resulted in a facial impact.
 Central cord syndrome is thought to be due to vascular compromise
of the cord in the distribution of the anterior spinal artery. This artery
supplies the central portions of the cord. Because the motor fibers to
the cervical segments are topographically arranged toward the center
of the cord, the arms and hands are the most severely affected.
ANTERIOR CORD SYNDROME
Anterior cord syndrome is characterized by
 Paraplegia

 temperature sensation

 and a dissociated sensory loss with a loss of pain

Dorsal column function (position, vibration, and deep pressure

sense) is preserved. Usually, anterior cord syndrome is due to
infarction of the cord in the territory supplied by the anterior
spinal artery. This syndrome has the poorest prognosis of the
incomplete injuries.
BROWN-SÉQUARD SYNDROME

 results from hemisection of the cord, usually as a result of a

penetrating trauma.
 In its pure form, the syndrome consists of ipsilateral motor loss
(corticospinal tract) and loss of position sense (dorsal column),
associated with contralateral loss of pain and temperature
sensation beginning one to two levels below the level of injury
(spinothalamic tract).
MORPHOLOGY

Spinal injuries can be described

 as fractures

 fracturedislocations

 spinal cord injury without radiographic

 abnormalities (SCIWORA)

 and penetrating injuries.

Each of these categories may be further described as stable or

unstable.
 Specific Types of Spinal Injuries

Cervical spine injuries can result from one or a

combination of the following mechanisms of injury:
• Axial loading
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
 ATLANTO-OCCIPITAL DISLOCATION

 Craniocervical disruption injuries are uncommon and result

from severe traumatic flexion and distraction.
 Most patients with this injury die of brainstem destruction and
apnea or have profound neurologic impairments
 Patients may survive if prompt resuscitation is available at the
injury scene.
 Spinal immobilization is recommended initially
ATLAS (C1) FRACTURE

 The atlas is a thin, bony ring with broad articular surfaces.

 Fractures of the atlas represent approximately 5% of acute
cervical spine fractures.
 Approximately 40% of atlas fractures are associated with
fractures of the axis (C2)
 The most common C1 fracture is a burst fracture (Jefferson
fracture)
C1 ROTARY SUBLUXATION

 most often seen in children

 It may occur spontaneously, after major or minor trauma, with
an upper respiratory infection, or with rheumatoid arthritis.
 AXIS (C2) FRACTURES
 The axis is the largest cervical vertebra and is the
most unusual in shape.
 Therefore, it is susceptible to various fractures
depending on the force and direction of the impact.
 Acute fractures of C2 represent approximately 18% of
all cervical spine injuries.
ODONTOID FRACTURES

 Approximately 60% of C2 fractures involve the odontoid process, a peg-

shaped bony protuberance that projects upward and is normally
positioned in contact with the anterior arch of C1.
 Type I odontoid fractures typically involve the tip of the odontoid and are
relatively uncommon.
 Type II odontoid fractures occur through the base of the dens and are
the most common odontoid fracture (n FIGURE 7-7).
 Type III odontoid fractures occur at the base of the dens and extend
obliquely into the body of the axis.
 POSTERIOR ELEMENT FRACTURES
 A hangman’s fracture involves the posterior elements of C2—
that is, the pars interarticularis (n FIGURE 7-8).
 This type of fracture represents approximately 20% of all axis
fractures and usually is caused by an extension type injury.
 Patients with this fracture should be maintained in external
immobilization until specialized care is available.
 Variations of a hangman’s fracture include bilateral fractures
through the lateral masses or pedicles.
OTHER C2 FRACTURES

 Approximately 20% of all axis fractures are

nonodontoid and nonhangman’s.
 These include fractures through the body,
pedicle, lateral mass, laminae, and spinous
process.
FRACTURES AND DISLOCATIONS
(C3 THROUGH C7)
A fracture of C3 is very uncommon, possibly because it is
positioned between the more vulnerable axis and the more
mobile “relative fulcrum” of the cervical spine— that is, C5 and
C6, where the greatest flexion and extensio of the cervical spine
occur. In adults, the most common level of cervical vertebral
fracture is C5, and the most common level of subluxation is C5
on C6
THORACIC SPINE FRACTURES
(T1 THROUGH T10)

Thoracic spine fractures may be classified into four broad

categories:
 Anterior wedge compression injuries

 Burst injuries

 Chance fractures

 Fracture-dislocations
THORACOLUMBAR JUNCTION FRACTURES
(T11 THROUGH L1)

 Fractures at the level of the thoracolumbar junction are due to

the relative immobility of the thoracic spine as compared with
the lumbar spine. They most often result from a combination
of acute hyperflexion and rotation, and, consequently, they are
usually unstable. People who fall from a height and restrained
drivers who sustain severe flexion energy transfer are at
particula risk for this type of injury.
 Patients with thoracolumbar fractures are particularly
vulnerable to rotational movement. Therefore, logrolling
should be performed with extreme care.
LUMBAR FRACTURES

 The radiographic signs associated with a

lumbar fracture are similar to those of thoracic
and thoracolumbar fractures.
 However, because only the cauda equina is
involved, the probability of a complete
neurologic deficit is much less with these
injuries.
PENETRATING INJURIES

 The most common types of penetrating injuries are those

caused by gunshot wounds or stabbings.
 It is important to determine the path of the bullet or knife. This
can be done by analyzing information from the history, clinical
examination (entry and exit sites), plain x-ray films, and CT
scans. If the path of injury passes directly through the vertebral
canal, a complete neurologic deficit usually results
BLUNT CAROTID AND VERTEBRAL
VASCULAR INJURIES
Blunt trauma to the head and neck is a risk factor for carotid
and vertebral arterial injuries. Early recognition and treatment of
these injuries may reduce the risk of stroke. Indications for
screening are evolving,but suggested criteria for screening
include:
 C1–C3 fracture

 Cervical spine fracture with subluxation

 Fractures involving the foramen transversarium

X-RAY EVALUATION

How do I confirm the presence or absence of a

significant spine injury?

Both careful clinical examination and thorough radiographic

assessment are critical in identifying significant spine injury.
CERVICAL SPINE

Cervical spine radiography is indicated for:

 All trauma patients who have midline neck pain

 tenderness on palpation

 neurologic deficits referable to the cervical spine

 an altered level of consciousness

 or a significant mechanism with a distracting injury

or
 in whom intoxication is suspected.
TWO OPTIONS FOR X-RAY EVALUATION

1. Multi-detector axial CT from the occiput

to T1 with sagittal and coronal
reconstructions.
2. Plain films consisting of lateral,
anteroposterior (AP), and openmouth
odontoid views should be obtained.
 Patients with neck pain and normal films may be
evaluated by magnetic resonance imaging (MRI) or
flexion-extension x-ray films, or treated with a
semirigid cervical collar for 2–3 weeks.
 Flexion-extension x-ray films of the cervical spine may
detect occult instability or determine the stability of a
known fracture, such as a laminar or compression
fracture.
 MRI is recommended to detect any soft tissue
compressive lesion, such as a spinal epidural
hematoma or traumatized herniated disk, that cannot
be detected with plain films.
THORACIC AND LUMBAR SPINE

 Indications:
screening radiography of the thoracic and
lumbar spine are the same as those for the
cervical spine
 The lateral films detect subluxations,
compression fractures, and Chance
fractures.
 CT scanning is particularly useful for
detecting fractures of the posterior elements
(pedicles, lamina, and spinous processes)
and determining the degree of canal
compromise caused by burst fractures.
 Sagittal reconstructions of axial CT images
or plain tomography may be needed to
adequately characterize Chance fractures.
GENERAL MANAGEMENT

How do I treat patients with spinal cord injury and limit

secondary injury?

General management of spine and spinal cord trauma

includes immobilization, intravenous fluids, medications,
and transfer, if appropriate.
IMMOBILIZATION

How do I protect the spine during evaluation, management,

and transport?

Prehospital care personnel usually immobilize patients before their

transport to the ED. Any patient with a suspected spine injury should be
immobilized above and below the suspected injury site until a fracture is
excluded by x-ray examination. Remember, spinal protection should be
maintained until a cervical spine injury is excluded.
INTRAVENOUS FLUIDS

In patients in whom spine injury is suspected, intravenous

fluids are administered as they would usually be for resuscitation of trauma
patients. If active hemorrhage is not detected or suspected, persistent
hypotension should raise the suspicion of neurogenic shock. Patients with
hypovolemic shock usually have tachycardia, whereas those with neurogenic
shock classically have bradycardia. If the blood pressure doesnot improve after
a fluid challenge, the judicious use of vasopressors may be indicated.
Phenylephrine hydrochloride, dopamine, or norepinephrine is recommended.
MEDICATIONS

At present, there is insufficient evidence to

support the routine use of steroids in spinal cord
injury
 TRANSFER
Patients with spine fractures or neurologic deficit should be
transferred to a definitive-care facility. The safest procedure is to
transfer the patient after telephone consultation with a spine
specialist. Avoid unnecessary delay. Stabilize the patient and
apply the necessary splints, backboard, and/or semirigid cervical
collar. Remember, cervical spine injuries above C6 can result
in partial or total loss of respiratory function. If there is any
concern about the adequacy of ventilation, the patient should be
intubated prior to transfer.