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
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
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