Objectives

Evaluate for suspected spinal injury.

Appropriately manage spinal injury.
Determine appropriate patient
disposition.
 Key Questions

When do I suspect spine injury?

How do I confirm the presence or
absence of a significant spine injury?
How do I protect the spine during
evaluation and transport?
How do I assess the patients neurologic
status?
 More Key Questions

How do I identify and treat neurogenic

and spinal shock?
How do I treat the patient with spinal
cord injury and limit secondary injury?
Unconscious patient
Neurologic deficit
Spine pain / tenderness
 Spinal Injury Screening

If patient is If no neck or spine pain

or tenderness
Conscious
If still no pain or
Cooperative
tenderness with
Able to voluntary movement
concentrate on No further evaluation
c-spine or x-ray necessary
Remove c-collar
 Spinal Injury Screening

Radiographic: Normal x-rays

Clinical
Normal neurologic exam and
Absence of spinal pain and tenderness

Drugs, alcohol, and other

injuries may mask spinal injury
 Spine Injury Screening

Altered Sensorium
Radiographic visualization of entire
spine
Plain films
CT scan of suspicious or poorly
visualized areas
 C-spine X-rays

Crosstable lateral film excludes 85% of

fractures
Addition of AP and odontoid views
exclude most fractures
Also may require
Swimmers view MRI
CT scan for bony detail
 C-spine X-rays

10% of patients with a c-spine fracture

have a 2nd, associated noncontiguous
vertebral column fracture
Identify 1 abnormality? Look for
another!
Radiographic screening of entire spine
required in this situation
 How do I protect the spine?

Immobilize entire patient on long spine

board with proper padding
Apply semirigid cervical collar
Protection is priority; detection is
secondary
 How do I protect the spine?

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
 At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.
 Assess neurologic status?

Neurologic level
Most caudal level of motor / sensory
function
Motor and sensory may not be same
Sensory may vary on each side
Bony level: Site of vertebral column
damage
 Assess neurologic status

Complete: No motor or sensory function

below injury level
Incomplete:
Any motor or sensory preservation below
injury level
Sacral sparing may be only residual
function
 Injury effect on assessment /
management?

Inadequate ventilation
Abdominal evaluation compromised
Occult compartment syndrome
 Identify / treat neurogenic
shock?

Associated with cervical / high thoracic

spine injury
Hypotension and slow heart rate
Treatment: Fluid Resuscitation and
occasional atropine and vasopressors
 Identify spinal shock?

Neurologic, not hemodynamic

phenomenon
Occurs shortly after cord injury
Variable duration
Flaccidity and loss of reflexes
 Treat / prevent secondary
injury?
Ensure adequate ventilation and
oxygenation
Maintain blood pressure
Atropine as needed for bradycardia
Methylprednisolone
Assess for associated bleeding

Consider neurogenic shock

Monitor urinary output
Blunt injury only
Start within 8 hours of injury
30 mg / kg over 15 minutes
5.4 mg / kg over next
23 hours if started within 3 hours of injury
48 hours if started within 3 to 8 hours after
injury
 Management

Provide respiratory support as needed

Properly immobilize entire patient
Avoid transfer delay!
 Who do I transfer?

Unstable fractures
Neurologic deficit
Avoid transfer delay!
Treat life-threatening injuries first
Immobilize
Appropriate spine films
Document examination
Neurosurgical / orthopedic consult
Transfer unstable fracture / cord injury