Spinal Trauma

Assessment Principles

• Patient position — supine versus lateral.
• Mechanism and witnesses — significant mechanism of injury in which injury cannot be ruled out.
• Complaints — what the patient reports.
• Physical exam — Pulse, Motor, Sensory checks (initial and rapid).
• Neurological exam — rapid assessment with more detail.

Major Neck Injury Loading Mechanisms

• Head extension with tension
• Head axial impact
• Head hyperextension
• Compression

Mechanism and Witness

The mechanism of injury and any witness account drive the index of suspicion. If the mechanism transferred enough energy to cause spinal injury, treat the patient as if it did until you can prove otherwise.

Spinal Cord Injury Mechanisms

Spinal cord injury can be sustained through many different mechanisms, but the following are the most common:

• Destruction from direct trauma
• Compression by bone fragments, hematoma, or disk material
• Ischemia by bone fragments, hematoma, or disk material
• Subsequent edema

Complete vs Incomplete Spinal Cord Injury

Type	Findings	Recovery
Complete	Absence of sensory and motor function below the neurologic level of injury	Minimal change of functional motor recovery
Incomplete	Sensory, motor, or both functions partially present below the level of injury	Expected to have some degree of recovery

Spinal Cord Tracts — Three That Matter

The spinal cord has many ascending and descending tracts. Three are important for neuroanatomic localization of cord lesions: corticospinal, spinothalamic, and dorsal (posterior) columns.

Tract	Direction / Function	Crosses Where	Damage Result
Corticospinal (lateral, 90% of fibers)	Descending motor	Crosses at the lower medulla	Contralateral motor findings
Corticospinal (ventral, 10% of fibers)	Descending motor	Does not cross; descends to cervical and upper thoracic cord	Ipsilateral findings, increased deep tendon reflexes, Babinski sign
Spinothalamic	Ascending sensory: pain and temperature	Crosses the midline near the level of entry	Contralateral loss of pain and temperature sensation
Dorsal columns	Ascending sensory: vibration and position sense	Axons enter ipsilateral dorsal column; do not cross until they reach the medulla	Ipsilateral loss of vibration and position sense

Incomplete Spinal Cord Lesions — The Four Syndromes

• Anterior cord syndrome
• Central cord syndrome
• Brown-Sequard syndrome
• Cauda equina syndrome

Anterior Cord Syndrome

Etiology: damage to the corticospinal and spinothalamic pathways with preservation of posterior column function. Caused by direct anterior cord compression, flexion of the cervical spine, or thrombosis of the anterior spinal artery.

Symptoms: loss of motor function and loss of pain and temperature sensation distal to the lesion. Vibration, position, and crude touch are preserved.

Prognosis: poor.

Central Cord Syndrome

Etiology: usually seen in older patients with preexisting cervical spondylosis who sustain a hyperextension injury. Damage to the central fibers of the corticospinal and spinothalamic tracts.

Symptoms: quadriparesis that is greater in the upper extremities than in the lower extremities. Some loss of pain and temperature sensation, also greater in the upper extremities.

Prognosis: good.

Brown-Sequard Syndrome

Etiology: transverse hemisection of the spinal cord. Most often from penetrating injury (stab or gunshot wound).

Symptoms: ipsilateral loss of motor function, proprioception, and vibratory sensation. Contralateral loss of pain and temperature sensation.

Prognosis: good.

Cauda Equina Syndrome

Etiology: peripheral nerve injury (the cauda equina is the bundle of nerve roots below the conus medullaris, not the cord itself).

Symptoms: variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and saddle anesthesia.

Prognosis: good with surgical intervention.

Neurogenic Shock

Acute injury to the spinal cord causes disruption of sympathetic outflow.

• Loss of sympathetic arterial tone results in decreased systemic vascular resistance and decreased blood pressure.
• Loss of sympathetic innervation to the heart (T1 to T4 level) leaves the parasympathetic cardiac innervation unopposed, resulting in bradycardia.
• Inability to redirect blood from the periphery to the core may result in hypothermia.

Triad: hypotension, bradycardia, and hypothermia.

Diagnosis should be one of exclusion. Never presume hypotension is due to neurogenic shock until other causes are excluded. The higher the injury, the more likely and severe the symptoms. Symptoms typically last 1 to 3 weeks.

Spinal Shock

Temporary loss of all sensorimotor functions and spinal reflexes below the level of injury.

• The lower the injury, the more likely that all distal reflexes will be absent.
• Flaccid paralysis, loss of bowel and bladder function, and sometimes sustained priapism are present.
• Duration varies from hours to weeks.
• Loss of neurologic function during spinal shock can cause an incomplete spinal cord injury to mimic a complete spinal cord injury. Cord lesions cannot be deemed complete until spinal shock resolves.

General Approach to Spinal Cord Injury

• Recognition
• Immobilization
• Stabilization
• Physical examination
• Neurologic examination
• Diagnostic imaging
• Consultation and evacuation

Recognition and Immobilization

Recognize patients at risk for spinal cord injury. During initial assessment, limit movement. This does not apply if imminent danger exists.

Risk factors that should trigger immobilization:

• Mechanism of injury
• Neck or back pain or tenderness
• Significant injury above the clavicles
• Any neurologic complaint

Apply appropriate spinal immobilization as allowed by the tactical situation. Immobilize any penetrating object in place.

Stabilization

Evaluation of a patient with potential spinal cord injury should not differ substantially from any multi-system trauma patient.

• Treat life threats first.
• Maintain inline cervical immobilization while assessing and managing the airway.
• Any patient with an injury at C5 or above should have a definitive airway placed.
• A cervical collar by itself does not provide adequate stabilization if injuries exist.

Physical Examination

• Perform a complete detailed physical examination when the tactical situation permits.
• Maintain inline stabilization during all patient movements (log roll).
• Pad hard spine boards to prevent skin breakdown and pressure sores.

Neurologic Examination — Components

• Mentation exam (Glasgow Coma Scale)
• Motor exam
• Sensation exam
• Brain stem reflexes
• Spinal reflexes

Sensation Exam

Modality	Tract Tested	Method
Pain and temperature	Spinothalamic tracts	Suitable sharp tool (safety pin, broken cotton swab). Temperature testing if there is any question of normal pain sensation.
Proprioception and vibration	Dorsal columns	“Up and Down” test for position; tuning fork for vibration. Start distal, move proximal as needed.
Light touch	Both spinothalamic tracts and dorsal columns	Fine wisp of cotton. Compare areas. Avoid calloused skin.

Deep Tendon (Spinal) Reflexes

Only relevant when compared side to side or between upper and lower extremities. Graded 0 to 4 (zero indicates no reflex elicited).

Reflex	Spinal Level
Ankle jerk	S1-S2
Knee jerk	L3-L4
Biceps	C5-C6
Brachioradialis	C5-C6
Triceps	C7-C8

Anogenital Reflexes

• Bulbocavernosus reflex (S3-S4) — squeeze the penis to determine if the anal sphincter simultaneously contracts. Rectal tone can be tested at the same time.
• Cremasteric reflex (L1-L2) — run a pin or blunt instrument up the medial aspect of the thigh. If the scrotum rises, there is some spinal cord integrity.
• Anal wink (S3, S4, S5) — contraction of the anal musculature when tested with a pin indicates at least some sacral sparing.
• Priapism — indicates complete spinal cord injury.

Reflex Categories

• Superficial reflexes: corneal, nasal, cremasteric, plantar, anal.
• Deep reflexes: jaw, biceps, triceps, patellar, Achilles.
• Visceral reflexes: light, accommodation, carotid sinus, bulbocavernosus, bladder, rectal.

Diagnostic Imaging

• Image patients with suspected spine or spinal cord injury.
• Clinical guidelines exist to assist judgment on whom to image.
• Different modalities detect injuries to bone, ligamentous structures, and cord.
• If you find any spinal column injury, image the rest of the spine. About 10% of patients will have a second fracture.

Plain Films — Standard 3-View C-Spine Series

• Lateral
• Anteroposterior
• Odontoid

89% sensitive. Does not rule out all injuries. Continue immobilization of high-risk patients even if the films are normal. Anterior and lateral films can be used for initial assessment of thoracic and lumbar spine injury.

Imaging Hierarchy — X-ray, CT, MRI

Modality	Best For
Plain film X-ray	Initial assessment; misses subtle injuries
CT scan	More sensitive and specific than plain films for evaluating the spine (bone)
MRI	Diagnostic test of choice for neural, muscular, and soft tissue injury. Not as sensitive as CT for bone. Indicated for patients with neurologic findings with no clear explanation after plain films and CT.

C-Spine Radiograph Systematic Approach — ABCS

• A: adequacy and alignment
• B: bones — continuity (fracture), density (shadowing, contrast), extra growths
• C: cartilage and disk — continuity, space changes
• S: soft tissue

Follow with a detailed examination of each individual vertebra.

Named Fracture Patterns to Recognize

• Jefferson fracture — burst fracture of C1 ring.
• Tear drop fracture — flexion injury, fragment off the anteroinferior vertebral body.
• Burst fracture — axial loading injury, vertebral body shatters outward.
• Hangman’s fracture — bilateral pars interarticularis fracture of C2, classically from hyperextension.

Consultation and Evacuation

• Consult with orthopedics or neurosurgery for any spine or spinal cord injury.
• Evacuation is required for any patient with an unstable spine or spinal cord injury.

Treatment Goals

• Prevent secondary injury
• Alleviate cord compression
• Establish spinal stability
• Maintain immobilization
• Keep movement to a minimum

Stabilization Techniques

• Inline stabilization
• Stabilization while ventilating
• Stabilization during intubation

Long Spine Board and Improvised Stabilization

• Standard option for transport stabilization.
• Special considerations apply when the patient is found in an unusual position — maintain inline alignment during the move.
• Improvised spinal stabilization can be assembled from available materials when standard equipment is not available.

Neurogenic / Spinal Shock Protocol — Findings

• Neurogenic shock triad (hypotension, bradycardia, hypothermia)
• Priapism
• Altered mental status
• Oliguria
• Bowel and/or bladder incontinence
• Warm extremities below the point of injury (loss of sympathetic tone leaves vessels dilated)
• Hypothermia

Initial Management

• Perform Tactical Polytrauma Algorithm / Critical Trauma Management (TPA/CTM) trauma interventions.
• Manage hypotension using the SOCM fluid protocol.
• Infuse intravenous fluids to maintain blood pressure above 90 mmHg.
• Monitor for fluid overload.
• If neurogenic or spinal shock is suspected and the patient is not responsive to fluid challenges, consider epinephrine 5 to 20 mcg of 1:100,000 solution.

Push-Dose Epinephrine Preparation

Additional Management Steps

• Pad bony prominences that contact the spine board. Skin breakdown begins within 30 minutes.
• Manage bradycardia:
  • Atropine 0.5 mg every 3 to 5 minutes (maximum dose 3 mg)
  • Transcutaneous pacing
  • Dopamine 2 to 10 mcg/kg/min
  • Epinephrine 2 to 10 mcg/min
• Manage hypothermia.