Spine and spinal cord injuries (SCIs) can be devastating, life-changing events that include injury to the bony elements (vertebral fracture), the neural elements (spinal cord and nerve root injury), or both.
The spinal cord is most commonly injured by a direct mechanical cause, with resultant hemorrhage, edema, and ischemia. Patients may demonstrate neurogenic shock or spinal shock after a spinal cord injury. Neurogenic shock refers to the loss of sympathetic innervation leading to bradycardia and hypotension. The hypotension must be differentiated from hypovolemia due to hemorrhage. Spinal shock refers to the temporary loss or depression of spinal reflex activity below a spinal cord injury that can persist for days to weeks and prohibit the differentiation of an incomplete and complete lesion.
Patients may complain of neck and back pain, and close examination may note pain or bony abnormalities with palpation. Many unstable spinal fractures may present without spinal cord or nerve root trauma. Symptomatic patients may complain of paresthesias, dysesthesias, weakness, bowel or bladder incontinence, urinary retention, or other sensory disturbances with or without specific physical examination findings. More severely injured patients may have obvious neurologic deficits.
Consider an injury to the spine or spinal cord in any patient with an appropriate traumatic mechanism. Suspect SCI with any neurologic complaints, even if transitory. A complete neurologic examination should include motor strength and tone (corticospinal tract), pain and temperature sensations (spinothalamic tract), proprioception and vibration sensations (dorsal columns), reflexes, perianal sensation and wink, and bulbocavernosus reflex. “Sacral sparing” denotes preservation of reflexes and an incomplete SCI. Fig. 161-1 demonstrates the dermatomes for the sensory examination.
Dermatomes for sensory examination.
Validated clinical guidelines exist to identify patients who benefit from cervical spine imaging. The NEXUS (Table 161-1) and the Canadian Cervical Spine Rule for Radiography (Table 161-2) are intended for alert, stable adult patients.
Table 161-1 National Emergency X-Radiography Utilization Study Criteria: Cervical Spine Imaging Unnecessary in Patients Meeting These Five Criteria |Favorite Table|Download (.pdf)
Table 161-1 National Emergency X-Radiography Utilization Study Criteria: Cervical Spine Imaging Unnecessary in Patients Meeting These Five Criteria
Absence of midline cervical tenderness
Normal level of alertness and consciousness
No evidence of intoxication
Absence of focal neurologic deficit
Absence of painful distracting injury
Table 161-2 Canadian Cervical Spine Rule for Radiography: Cervical Spine Imaging Unnecessary in Patients Meeting These Three Criteria |Favorite Table|Download (.pdf)
Table 161-2 Canadian Cervical Spine Rule for Radiography: Cervical Spine Imaging Unnecessary in Patients Meeting These Three Criteria
Question or Assessment
There are no high-risk factors that mandate radiography.
High-risk factors include:
- Age 65 years or older
- A dangerous mechanism of injury (fall from a height of >3 ft; an axial loading injury; high-speed ...