Chapter 27. Vertebral Column & Spinal Cord Trauma

Suspect Spinal Cord Injury

Patients with blunt trauma, particularly those with head injury, severe mechanism, or neurologic complaints should be assumed to have spine injuries until proven otherwise. Such injuries are major causes of morbidity and mortality in the trauma patient, so thorough assessment beginning in the prehospital setting is essential. The potential instability of such injuries necessitates that the utmost care be taken not to render additional harm to these patients.

Immobilization

Immobilization of the spine is essential to prevent further injury to the spinal cord. From the field, or when transferred, the patient should be on a long spine board, in a rigid cervical collar (Philadelphia) with lateral rolls and tape across the forehead. Upon arrival, logroll the patient off this board and onto the examination bed, maintaining in-line stabilization (see below). Careful immobilization should be maintained throughout resuscitation procedures, physical examination, and diagnostic evaluation.

Supine Position

The optimal position for examination and in-line immobilization is supine. Once in the emergency department, the patient's rigid collar should be changed to a semirigid collar (Miami-J). Remember to limit the amount of time the patient is kept on any hard surface to minimize discomfort and avoid pressure injury.

Lateral Position

If the patient cannot lie supine for any reason (eg, vomiting), the lateral position with careful in-line cervical stabilization is acceptable.

Technique for Moving the Patient

If the patient must be moved, in-line spinal stabilization should be maintained and the head and trunk rolled as one unit (logroll). Proper technique requires three individuals. The first individual stands at the head of the bed and is responsible for maintaining cervical spine immobilization and controlling the turn. The two remaining individuals stand to one side of the patient and are in charge of maintaining thoracic and lumbar spine immobilization.

Establish Airway and Maintain Ventilation

As with all patients in the emergency department, initial assessment should focus on airway and breathing. However, when vertebral or spinal injury is suspected, neck alignment and immobility must be maintained during all attempts to establish adequate ventilation.

In the patient with apnea or overt respiratory failure, a definitive airway should be established immediately. Whenever possible, rapid sequence intubation is the preferred as the least traumatic and most efficient method of achieving intubation (see Chapter 10). Designate an assistant to maintain cervical spine immobilization during intubation, and minimize neck extension induced by direct laryngoscopy. Airway adjuncts such as a fiberoptic bronchoscope or videolaryngoscope, in the hands of an experienced user may further minimize neck movement. Nasotracheal intubation is an option only in the spontaneously breathing patient.

Spontaneously breathing patients with cervical spinal cord injuries can have loss of diaphragmatic and/or intercostal muscle innervation, which may cause them to tire easily, causing ineffective ventilation and progressively worsening hypoxemia and hypercapnia. In such cases, continuous pulse oximetry, close clinical observation, and serial capnography are useful adjuncts to monitor changes in ventilatory status.

Establish Satisfactory Circulation

Shock or Hypotension

Although hypotension may be caused directly by spinal injury, hypovolemia remains more common in the setting of blunt or penetrating trauma. Therefore, shock must be presumed hypovolemic (ie, hemorrhagic) until proven otherwise (see Chapter 11). If open wounds are present, significant external hemorrhage may have occurred at the scene of the injury. Hypovolemia may also occur as a result of hemorrhage into internal compartments such as the chest or pelvis. Initial treatment of hypotension should be aimed at volume replacement using crystalloid and/or blood products.

Neurogenic shock causes hypotension as a result of loss of sympathetic tone below the level of a spinal cord injury. This can occur when there is injury at or above T6. Although this diagnosis can only be made once hypovolemia has been ruled out through appropriate examination, imaging, and laboratory studies, appropriate treatment should not be withheld during the workup. The therapeutic goal for neurogenic shock is maintenance of adequate perfusion, which is commonly refractory to volume replacement. Following fluid resuscitation of at least 2 L warmed crystalloid, start a vasopressor such as dopamine to keep the mean arterial pressure above 85–90 mm Hg. Place a Foley catheter and carefully monitor urine output, which should be equal to or greater than 30 mL/h.

Head Injuries

Head injuries are associated with approximately 25% of all patients with spinal cord injury. Patients with altered mental status, seizures, or cranial nerve or other focal neurologic deficits require emergency imaging of the brain after the initial assessment and stabilization of the ABCs. A noncontrast CT scan of the head is the study of choice to identify intracranial injuries. If the patient has only a history of loss of consciousness and is alert and oriented in the emergency department, head CT scan can be delayed and accomplished in conjunction with other CT scans that may be required to evaluate the patient with possible spinal injury.

Minimize Neurologic Injury

Consider Steroids in Acute Nonpenetrating Spinal Injury

There has been heavy debate over the clinical significance of the use of corticosteroids in the treatment of spinal injury based on the NASCIS II AND NASCIS III studies. The 8th edition of the Advanced Trauma Life Support Guidelines no longer recommends methylprednisolone administration, stating “at present, there is insufficient evidence to support the routine use of steroids in spinal cord injury.” In addition, the Canadian Association of Emergency Physicians no longer supports the use of steroids in the acute care of spinal cord injuries. It is important to note that, despite these conclusions, high-dose methylprednisolone remains a treatment option in acute blunt spinal cord injuries and remains widely utilized. If chosen as a treatment, give methylprednisolone, 30 mg/kg as an intravenous bolus over 15 minutes; after a 45-minute delay, begin a maintenance infusion of 5.4 mg/kg/h for 24 hours in patients receiving treatment within the first 3 hours after injury. Patients receiving treatment 3–8 hours after injury should be maintained on steroid therapy for 48 hours. Initiation of steroid treatment more than 8 hours after injury is not indicated. It is important to remember that there is risk associated with steroid therapy in both increased incidence of infection and avascular necrosis. Because of the often-limited information regarding time of injury in the initial emergency department evaluation, therapy may be instituted until injury time has been confirmed. Obtain specialty consultation as soon as possible.

Note: Steroids play no role in the treatment of penetrating spinal cord injuries.

Give Antibiotics for Penetrating Injuries

Patients with penetrating spinal cord injury (eg, gunshot wound) should receive prophylactic antimicrobials. Nafcillin, 200 mg/kg/d intravenously in 4–6 divided doses, is widely recommended.

Treat Complications

Urinary Incontinence or Retention

Patients may not note bladder dysfunction after spinal trauma because of loss of sensation below the lesion. Insert an indwelling catheter whenever spinal trauma is suspected to prevent urinary retention and to aid in monitoring urine output.

Ileus

Paralytic ileus and gastric atony are common after spinal trauma. Give the patient nothing by mouth until spinal injury is excluded. If spinal cord injury is confirmed, a nasogastric tube connected to intermittent low-pressure suction should be placed to prevent vomiting in the acute post-injury period.

Aspiration

Diligent suctioning of secretions and antiemetics are essential in management of spinal trauma. Aspiration pneumonitis is a serious complication in patients with decreased respiratory function and inability to adequately protect their airway.

Exposure

Denervated skin is prone to the development of pressure necrosis. Remove the spine board promptly during the evaluation while continuing to maintain logroll precautions. Completely undressing the patient will not only allow for a complete examination but it will also ensure that no foreign objects such as car keys, a belt, or wallet are pushing into the skin thereby increasing the likelihood of pressure ulcer formation.

Patients with spinal cord injury are particularly susceptible to exposure and, while exposure is essential, the patient should be covered with warm blankets in the emergency department to prevent hypothermia.

Take Additional Measures as Needed

A patient with spinal cord injury requires the same resuscitative measures customarily employed in major trauma. Evaluate and treat all life-threatening conditions (eg, tension pneumothorax, cardiac tamponade, hemorrhagic shock) that take precedence over definitive treatment of vertebral and spinal cord trauma (Chapter 11). In other words, follow the ABCs of trauma evaluation. Always maintain in-line spinal immobilization during resuscitation and treatment.

History

Mechanism is an essential part of the history to be obtained by the patient, EMS, or any person who witnessed the event. For instance, a restrained individual in a motor vehicle collision would be more prone to a flexion/extension injury, whereas an individual who fell and landed on his or her feet would be susceptible to compression force and subsequent vertebral damage.

Complaints of back or neck pain should arouse a suspicion of spine injury and is more sensitive than pain with palpation of the spine. However, the absence of spinal pain does not eliminate the possibility of spinal injury, especially if the patient is under the influence of alcohol or other mind-altering drugs. Consider spinal injury in any patient with blunt head injury, a neurologic deficit anatomically consistent with injury at a particular spinal level, or a penetrating injury to the neck, chest, or abdomen.

General Physical Examination

A brief general physical examination should precede specific assessment of neurologic function. Obtain complete vital signs, including core temperature.

Carefully examine the head, chest, heart, abdomen, and extremities for other abnormalities. Remember that patients with spinal cord injuries may show few, if any, signs or symptoms of coexisting major injury because of anesthesia below the level of the lesion. Pain, guarding, rebound tenderness, and other signs may be absent despite the presence of fractured ribs, hemothorax, hemoperitoneum, peritonitis, and other major injuries. Examination of the genitals, rectum, and perineum may reveal priapism, decreased or absent rectal sphincter tone, or diminished perineal sensation, which are all suggestive of spinal cord injury. Diligent, repeated examinations, laboratory tests, and appropriate radiologic imaging are necessary to detect unsuspected injury.

Gently but thoroughly examine the neck and spine for deformity, edema, ecchymosis, muscle spasm, or tenderness indicating possible vertebral fracture. A palpable defect in the posterior neck ligaments may be the only clue to major spinal injury.

Neurologic Examination

Neurologic examination assesses the following functions: mentation, motor function, sensation, and brainstem and spinal reflexes.

Mentation

The spectrum of mentation includes all levels of consciousness ranging from alert to comatose. The patient's ability for mentation is best assessed by their Glascow Coma Score (Chapter 12). This systematic evaluation is easily reproduced to monitor changes, is widely used, and easily conveyed to the neurosurgical or orthopedic consultant.

Motor Function

(See Table 27–1.) The American Spinal Injury Association recommends the following scale for gradation of motor strength:

• 0—No contraction or movement
• 1—Minimal movement
• 2—Active movement, but not against gravity
• 3—Active movement against gravity
• 4—Active movement against light resistance
• 5—Active movement against full resistance

  1. Normal movement means that the patient moves all extremities spontaneously, purposefully (ie, in response to specific commands), and with full strength and range of motion. This would be a 5/5 on the above scale.

  2. Paralysis denotes no movement of the extremity or muscle group, either spontaneously or in response to painful stimuli. Complete paralysis would be a grade of 0/5 on the above scale. (Stimuli should be applied both directly to the extremity and to the trunk, because failure to move may be secondary to hypoesthesia of the extremity.) Failure to move at all, either spontaneously or in response to an unpleasant stimulus, may indicate paralysis due to a structural lesion (eg, fracture) or metabolic causes (eg, drug overdose). Often, failure to respond is simply due to an inadequately painful stimulus.

  3. Gradation between these extremes (grade 0–5) should be described precisely, for example, “Patient extends right arm and leg, flexes left arm, and extends left leg in response to supraorbital pressure.” Avoid broad descriptive terms such as “paraparesis” or “decerebrate posturing.”

Sensation

(See Figures 27–1 and 27–2 and Table 27–2.) Test as many sensory functions as possible in a patient with suspected spinal cord injury (in contrast to the more simple examination required for head trauma). Loss of some or all sensory functions below the lesion permits its precise anatomic localization. Perianal sensation should be tested; its presence eliminates the possibility of complete spinal cord transection and implies an improved prognosis.

Position, Vibration, and Light Touch

The dorsal columns can be tested by determining response to vibration, light touch, and changes in position.

Pain and Temperature

The ventral columns are tested by evaluating sensitivity to pain (pinprick) and temperature.

Impaired Mentation

When mentation is impaired, a pinprick or deep painful stimulation may be the only reliable sensory test.

Brain-Stem Reflexes

Brain-stem reflexes are usually intact except in the case of high cervical spinal cord injury, when nystagmus (mid-brain, pons), facial hypalgesia (spinal nucleus of the trigeminal nerve), and hypoventilation (phrenic nerve, intercostals) may be present.

Note: The presence of brain-stem signs should not be attributed to spinal cord injury until an intracranial lesion has been excluded.

Spinal Reflexes

Tendon jerks and plantar responses are usually absent below the level of an acute complete spinal cord transection (Table 27–3); asymmetry is also common. Spasticity or increased tone in muscle groups may occur with partial spinal cord injuries. Anal sphincter tone (reflex and voluntary) becomes flaccid following complete spinal cord transection. Priapism occurring soon after injury suggests immediate complete spinal cord lesion. Onset at a later time may indicate that the lesion has progressed from an incomplete to a complete stage. Sweating and skin vasomotor tone are absent below the level of a spinal cord lesion.

The bulbocavernosus reflex is dependent on an intact S1 and S2 spinal reflex. If the bulbocavernosus reflex is preserved in the presence of complete perineal sensory loss and flaccid paralysis of the lower extremities, it indicates that the period of spinal shock has passed and that the neurologic deficit is due to a lesion above the S1 segment. Absence of the bulbocavernosus reflex may indicate either the presence of spinal shock or a spinal cord lesion including the S1 and S2 segments. Spinal shock usually resolves within 24 hours and is accompanied by return of the bulbocavernosus reflex if the S1 and S2 segments are not directly involved in the spinal cord lesion.

Spinal Cord Syndromes

Complete Spinal Cord Lesion

The absence of sacral sparing (perianal sensation, rectal sphincter tone) indicates a complete spinal cord lesion, with recovery unlikely if the condition persists longer than 24 hours. Sacral sparing suggests an improved prognosis.

Partial Spinal Cord Lesions

Brown-SéQuard Syndrome

This syndrome is usually caused by penetrating injuries resulting in hemisection of the spinal cord. The findings include loss of distal ipsilateral position and vibration sense, distal ipsilateral motor loss and vasomotor paralysis, and distal loss of pain and temperature sense below T12 on the contralateral side (including the genitals and perineum).

Central Cord Syndrome

This syndrome is usually due to cervical hyperextension, involving the central gray matter and the central parts of the lateral spinothalamic tracts. Quadriplegia may result, with minimal sacral sparing. The upper extremities are more involved than the lower extremities.

Anterior Cord Syndrome

This syndrome results from cervical hyperflexion injuries. Position and vibration (posterior column functions) are preserved, but motor function, temperature, and pain sensation are lost bilaterally below the lesion.

Reexamination

Neurologic examination is helpful only if it is repeated often enough to establish a diagnosis, suggest further diagnostic steps, or clearly establish a trend in neurologic function. If successive examinations indicate improvement, further specialized testing may not be necessary. Failure to improve—verified by repeated examinations—indicates that additional studies are necessary, as does progressive deterioration from a baseline established by examination done on arrival in the emergency department. It is particularly important to note progressive neurologic dysfunction if injury involves the cervical spinal cord, because respiratory failure may result.

Laboratory Examination

Perform a baseline laboratory evaluation, including complete blood count (CBC), coagulation profile, basic metabolic profile, blood type, crossmatch, and urinalysis. Arterial blood gas measurements are necessary if ventilation is impaired or potentially threatened.

Imaging

Suspicion of spinal injury in a patient necessitates radiographic imaging, the modality of which must be chosen based on the patient's history and physical examination. In today's emergency setting, CT has become increasingly popular due to rapid and widespread availability, as well as and increased sensitivity for many injuries. In addition, the development of decision rules to help direct this endeavor have been established and validated over large patient populations.

Careful and correct interpretation of radiographs is critically important in the treatment of spinal cord injury. Many spine abnormalities (eg, minor facet fractures and nondisplaced fractures) may be more easily recognized by a radiologist. In a large study of blunt trauma patients, C-spine injuries were identified in 2.4% of patients. Three-view C-spine radiographs identified a C-spine injury in 1.5% of the patients. Radiographs were interpreted as normal in 0.9% of patients later found to have a C-spine injury.

Note: Normal radiographs do not exclude the presence of spinal cord injury. Spinal cord injury without radiographic abnormality is an uncommon but well-described condition, especially in children with flexible spinal columns and relatively larger head-to-body size ratios. In the NEXUS study—a large, observational, multicenter study—these injuries occurred in 0.07% of all blunt trauma patients and in 6% of all the patients with spinal injuries. Central cord syndrome (central hemorrhage) and spontaneously reduced dislocations can be associated with normal X-rays, as can ligamentous tears resulting from flexion–extension injuries. A thorough physical examination and a careful repeated neurologic evaluation are therefore essential in all cases.

Chest, Skull, and Pelvis

Portable chest and pelvis radiographs are standard in the initial evaluation of the patient with blunt spinal injury. Associated head injuries are common, and spinal injury patients often require CT scan of the head to evaluate intracranial injuries.

Cervical Spine

Both the National Emergency X-Radiography Utilization Study (NEXUS) criteria and Canadian C-spine Rules (CCR) have been shown reliable in terms of negative predictive value in the detection of cervical spine injury. The NEXUS criteria suggest that cervical spine imaging is unnecessary when all of the five following criteria are met:

1. No neurologic abnormalities are present

2. The patient has normal mental status

3. There is no evidence of intoxication

4. There is no posterior midline cervical spinal tenderness

5. There is no distracting painful injury

At a minimum, anteroposterior and lateral views of the C-spine extending from C1 to T1 and an odontoid (open mouth) view are required if cervical cord injury is suspected. The lateral C-spine view alone is only 79% sensitive in detecting C-spine injuries. If the segments from C6 to T1 are not visible, a “swimmer's” view should be obtained by having the patient supine, with one upper extremity abducted and extended (arm raised above head) and the opposite upper extremity adducted and extended (arm kept at side of body). The shoulder of the adducted and extended extremity is then depressed by having a person stand at the foot of the bed and pull gently on the patient's hand. The X-ray is shot upward through the axilla of the abducted, extended extremity. Oblique views increase the sensitivity of the C-spine series and are recommended by some in the evaluation of suspected cervical spinal injury. Standard oblique views require neck rotation; this can be avoided by performing a trauma oblique view, which is a modification of the oblique view. The trauma oblique view is obtained by aiming the X-ray beam at a 60° angle to the plane of the table with the patient supine (and immobilized).

Other diagnostic modalities must be used if all of the cervical vertebrae cannot be seen adequately with these techniques or if clinical suspicion for injury remains in the setting of normal radiographs. Flexion–extension views of the cervical spine are not routinely recommended in the acute evaluation of cervical instability. Any patient with a new neurologic symptom requires imaging with CT and/or MRI.

Magnetic resonance imaging (MRI), with superior ability to visualize soft tissues plays a significant role in the evaluation of the ligamentous structures of the cervical spine, as well as the spinal cord itself. Patients with neurologic symptoms not explained by radiograph or CT must undergo MRI to evaluate for cord compression or injury.

Patients with persistent cervical pain or tenderness despite normal imaging should be assumed to have a ligamentous injury. Even if the patient has a normal neurologic exam and no neurologic symptoms, continuous immobilization with a well-padded, rigid cervical collar is recommended for 14–28 days until follow-up studies such as flexion–extension radiographs or MRI can be performed.

Table 27–4 summarizes the mechanisms and common findings in many of the radiographically identifiable C-spine injury patterns.

Thoracic and Lumbar Spines

There are no established decision rules for imaging the thoracic and lumbar spines. However, criteria similar to that of the cervical spine are commonly applied. These criteria mandate that full radiographic evaluation be performed unless the patient is fully alert and has no evidence of midline bony tenderness; focal neurologic defect; intoxication; or painful, distracting injury. In addition, if a patient has a fracture in one portion of the spinal column, the entire spinal column should be imaged because the occurrence of an associated fracture at another level is relatively common.

Special Studies

CT Scan

With advances in the speed, resolution, and the ability to reformat axial scans into two- and three-dimensional images, CT scanning of the spine has become very common and has replaced traditional plain films especially in evaluation of the C-spine. CT scan is the easiest and most sensitive imaging modality for evaluation of spinal column injury. MRI may be required for better visualization of the relationships between the spinal cord and the vertebral canal. For nonobese patients with a low pretest probability of thoracic or lumbar spinal fracture or dislocation, conventional radiographs are still an acceptable, clinically appropriate and cost effective diagnostic tool to evaluate the integrity of spinal column.

MRI

MRI is indicated in patients with suspected spinal cord injuries and in patients with documented cord injuries. MRI provides a detailed view of the spinal cord, associated edema or hemorrhage, and surrounding soft tissues. With information obtained from MRI scans, injuries can be followed or operative interventions for cord decompression and spinal stabilization can be planned.

Special Populations

Note that established decision rules do not apply to pediatric or pregnant patients. In addition, special consideration must be to limit radiation exposure in these subgroups, while still performing an adequate evaluation. When in doubt, it is best to obtain early subspecialty consultation in treating such patients. Signed informed consent is necessary when pregnant patients require radiographic imaging of the spinal column.

Disposition of the Patient with Vertebral Column or Spinal Cord Trauma

Clinical Findings

In vertebral fractures without spinal cord injury, there is generally focal pain and tenderness over the vertebral column. Radiographic imaging shows fractures that may be in the vertebral body, the transverse processes, or the spinous processes. Coexisting dislocation or instability may be present, however, the examination is normal.

The only patients who do not require hospitalization are those with mildly symptomatic or asymptomatic, linear, nondisplaced, stable fractures of the spinous or transverse processes, or similar fractures of the sacrum or coccyx. Such patients may be given analgesics and a cervical collar for immobilization (if fractures are in the cervical vertebrae). However, prior to discharge it is important to consult an orthopedist or neurosurgeon to make certain they are in agreement with this course of action and to ensure timely follow-up.

In contrast, spinal cord injury with or without vertebral fractures is associated with neurologic symptoms and neurologic deficit (eg, sensory deficit ending circumferentially at T8). Bony injury to the vertebrae demonstrable on radiography may or may not be apparent because severe flexion–extension injuries and bony instability from ligamentous tears may cause serious or even fatal spinal cord injury without bony abnormalities. Obtain emergent neurosurgical or orthopedic consultation.

Hospitalization is required for patients with neurologic deficit, an unstable or potentially unstable vertebral column (with or without fracture), fractures or subluxation of vertebral bodies, or severe pain requiring parenteral analgesics for relief.

Whiplash (Hyperextension) Injuries (C-Spine Sprain)

Clinical Findings

Patients with whiplash have a history of abrupt hyperextension of the neck (usually from a motor vehicle accident), usually without loss of consciousness. Injury from hyperflexion often occurs as well. Symptoms such as neck pain or muscle spasm, headache, hoarseness, and dysphagia often do not appear until 12–24 hours after injury. Neck pain may radiate to the arms or chest. Physical examination may show tenderness of posterior neck muscles and limited range of motion. Specifically, there is no evidence of neurologic deficit. By definition, whiplash does not cause fractures that are evident on cervical X-rays, although severe injuries may rupture the anterior disk fibers and result in widened disk spaces. X-rays are usually normal but may show reversal of the normal cervical lordosis. As previously mentioned, patients may have ligamentous instability despite normal C-spine radiographs. For this reason, patients with persistent midline C-spine tenderness should be immobilized in a well-padded, rigid collar 24 h/d for 7–14 days until reexamined by a primary-care physician or spine surgeon.

Treatment

Treatment consists of a rigid cervical collar, heat, and analgesics usually nonsteroidal anti-inflammatory medications are first line medications although narcotics are often required. Muscle relaxants may also be indicated. At the time of reexamination, if a ligamentous injury is present, flexion–extension views will detect subluxation. MRI can be useful to identify ligamentous injuries in patients with possible C-spine instability. If flexion–extension radiographs or MRI are abnormal, the patient should remain in the cervical collar and be referred to a spine surgeon to determine the significance of any subluxation.

Disposition

Hospitalization is rarely required. Refer the patient to a primary-care physician or neurosurgeon for further evaluation.