Committee on Trauma Presents

Spine and
Spinal Cord
Trauma
Initial Assessment and Management
 Objectives

● Describe the evaluation of a patient with

suspected spinal injury.
● Explain the appropriate management of spinal
injury.
● Discuss appropriate patient disposition.
 Spinal Injury

When should you suspect a spine injury?

 Spinal Injury

When should you suspect a spine injury?

●Mechanism of injury
●Unconscious patient
●Neurologic deficit
●Spine pain / tenderness
 Spinal Injury

How do I protect the spine during evaluation and

transport?
 Spinal Injury

How do I protect the spine during evaluation and

transport?

●board
Immobilize entire patient on long spine
with proper padding.
●Apply semirigid collar.
Protection is priority; detection is
secondary.
 Spinal Injury Screening

●Clinical
● Normal neurologic exam and
● Absence of spinal pain and tenderness

Caution

Drugs, alcohol, and other injuries

can mask spinal injury.
 Spinal Injury Screening

●If patient is
● Conscious
● Cooperative
● Able to concentrate on c-spine
●If no neck or spine pain or tenderness
●If still no pain or tenderness with voluntary
movement
●No further evaluation or x-ray necessary
Clear spine and remove cervical collar.
 Spinal Injury Screening

Altered Consciousness or Symptoms

●Radiographic visualization of entire spine

●Plain films (7 c spine vertebrae and first
thoracic vertebrae)

●CT scan of suspicious or poorly visualized

areas
 Spinal Injury Screening

How do I confirm a spine injury?

 Spinal Injury Screening

How do I confirm a spine injury?

●Clinical signs of neurological deficit

●Radiological investigations
● Plain X-ray / CT / MRI
● Identify bony fracture / subluxation
●Presume spinal instability
●Early spine service consult
 Cervical Spine X-rays

●Crosstable lateral film excludes 85% of

fractures

●Addition of AP and odontoid views excludes

most fractures

●Also may require

● Swimmer’s view
● CT scan for bony detail
● MRI
 Cervical Spine X-rays

●10% of patients with a c-spine fracture have a

second, associated noncontiguous vertebral
column fracture

●Identify one abnormality? Look for another!

●Radiographic screening of entire spine required
in this situation
 Pitfalls

Pitfalls

● Spinal evaluation complicated by altered

sensorium
● Remove spine board as soon as possible and logroll
patient
● Pressure sores occur early in unconscious or
paralyzed patients
Caution

Caution

At least 5% of patients with spinal

cord injuries worsen neurologically
at the hospital.
 Neurologic Status

How do I assess the patient’s neurologic status?

 Neurologic Status

How do I assess the patient’s neurologic status?

Neurologic level
● Most caudal level of motor / sensory function
● Motor and sensory may not be the same
● Sensory can vary on each side
Bony level
● Site of vertebral column damage
 Neurologic Status

Complete Injury
● No motor or sensory function below injury
level

Incomplete Injury
● Any motor or sensory preservation below
injury level

● Sacral sparing may be only residual function

 Effects of Spinal Cord Injury

●Neurogenic shock
●Spinal shock
●Other consequences
Fasciculus gracilis
Dorsal column
Fasciculus cuneatus

Lateral corticospinal tract

Spinothalamic
 Effects of Spinal Cord Injury

Neurogenic Shock – Direct Effects

●sympathetic
Cardiovascular phenomenon due to loss of
tone

●spine
Associated with cervical / high thoracic
injury

●Hypotension and slow heart rate

●occasional
Treatment includes fluid resuscitation and
atropine and vasopressors
 Effects of Spinal Cord Injury

Spinal Shock – Direct Effects

●Neurologic, not hemodynamic phenomenon

●Occurs shortly after cord injury
●Variable duration
●Flaccidity and loss of reflexes
 Effects of Spinal Cord Injury

Other Consequences

●Inadequate ventilation
●Abdominal evaluation compromised
●Occult compartment syndrome
 Management

How do I manage patients with spinal cord injury and

limit secondary injury?
 Management

How do I manage patients with spinal cord injury and

limit secondary injury?

●oxygenation
Ensure adequate ventilation and

●Maintain blood pressure

●Maintain perfusion of spinal cord
 Management

Management of Hypotension

●Assess for associated bleeding

●Consider neurogenic shock
●Monitor urinary output
Stop
the
bleeding!
 Management

Whom do I transfer?

●Unstable fractures
●Neurologic deficit

Caution

Avoid transfer delay!

 Management

Management of Patients Requiring Transfer

●Provide respiratory
support as needed

●Exclude other life-

threatening injury

●Properly immobilize
entire patient

●Avoid hypothermia
 Summary

●Treat life-threatening injuries first

●Properly immobilize entire patient
●Obtain appropriate spine films
●Document examination
●Obtain neurosurgical / orthopaedic consult
●Transfer unstable fracture / cord injury