Spinal Trauma

Nerve injury is common in multiple trauma, both of the spinal cord and other nerves. Cervical spine injury is common in patients with moderate to severe head injury.

The first priority is the Primary Survey:

• Airway and Cervical Spine
• Breathing
• Circulation
• Disability
• Exposure

Anatomy

The Vertebral Column^[2]

Consists of 33 Vertebrae:^[3]

• 24 Articulating
  • Cervical = 7
  • Thoracic = 12
  • Lumbar = 5
• 9 Fused
  • Sacral = 5
  • Coccygeal = 4

Musculature of the Back

• Superficial Muscles^[4]
• Intermediate Muscles^[5]
• Intrinsic/Deep Muscles^[6]

The Spinal Cord^[7]

There are a Total of 31 Paired Spinal Nerves:^[3]

• Cervical = 8
• Thoracic = 12
• Lumbar = 5
• Sacral = 5
• Coccygeal = 1

Spinal Cord Injury^[8] (SCI)

Classification

Complete SCI

Consists of:

ABSOLUTE LOSS of Sensory AND Motor Function

BELOW the Level of Injury

Incomplete SCI^[9]

• Central Cord Syndrome^[10]
• Anterior Cord Syndrome^[11]
• Brown-Sequard Syndrome^[12]
• Posterior Cord Syndrome^[13]
• Cauda Equina Syndrome^[14]
• Conus Medullaris Syndrome^[15]

Assessment

Examination of spine-injured patients must be carried out with the patient in the neutral position (i.e. without flexion, extension or rotation) and without any movement of the spine.

The patient should be:

• Log-Rolled
• Appropriately Immobilised
  • Manual In-Line Immobilisation
    • OR
  • Stiff Neck Cervical Collar, Sandbags and Tape

With vertebral (bony) injury, which may be associated with spinal cord injury, look for:

• Local tenderness along the back
• Deformities and stepping
• Swelling and bruising

Clinical findings indicating injury of the cervical spine include:

• Difficulties in respiration (diaphragmatic breathing - check for paradoxical breathing)
• Floppy limbs and no reflexes
• Loose anal sphincter and loss of sensation in perineum
• Urinary and bowel incontinence or retention
• Neurogenic Shock: Hypotension with bradycardia (without hypovolaemia or blood loss)

Assessment of the Level of Spinal Injury

If the patient is conscious, ask the patient questions about sensation in the limbs and on the torso - note where the sensation changes

Ask the patient to do minor movements of the upper and lower limbs, starting with the fingers and toes - note where there is no movement and what movements the patient can do.

If Possible and Appropriate - Undertake Complete Neurological Examinations:

• Upper Limb^[16]
• Lower Limb^[17]

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

This tool represents the gold standard for assessment and documentation of spinal cord injury.^[18] It is produced by the American Spinal Injury Association (ASIA), and the International Spinal Cord Society (ISCoS), the most recent version was produced in 2019.^[18]

It serves as an extremely useful tool, to ensure that assessment and documentation of affected dermatomes and myotomes remains consistent.

For a downloadable PDF version of the 2019 ISNCSCI Worksheet,^[19] please visit: https://asia-spinalinjury.org/

• 
  Page 1 of the ISNCSCI Worksheet: Indicates Dermatomes and Corresponding Assessment Locations, as well as Key Myotomes and Corresponding Assessment Movements.
• 
  Page 2 of the ISNCSCI Worksheet: Describes Muscle Function and Sensory Grading Scores, the ASIA Impairment Scale (AIS), and an Overview of the Steps of Classifying Spinal Cord Injuries.

X-Rays^[21]

All patients with a suspicion of cervical spine injury should have an AP and a lateral neck X-ray with a view of the atlantoaxial joint.

All seven cervical vertebrae and the junction with T1 must be seen on the AP and lateral views.

Management

Stepwise management of spinal injury:

• Stabilise the airway, breathing and circulation
• Immobilise the cervical spine with a hard collar, sand bags or whatever you have available
• Keep the patient lying flat on the back and in a neutral position
• Pain relief and anti-nausea medication if available
• Keep the temperature stable
• Insert a urinary catheter
  • Male^[22]
  • Female^[23]
• Transport the patient for surgical care in a neutral position; do not sit them up

Associated Conditions

Spinal Shock

Clinical Features^[24]

• Initial
  • Areflexia
  • Flaccidity
• Later
  • Spasticity

Clinical Course^[25]

1. Areflexia
2. Initial Reflex Return
3. Initial Hyperreflexia
4. Spasticity

NOT a Form of Circulatory Collapse

Neurogenic Shock^[26]

Clinical Features^[27][28]

• Hypotension
  • Refractory Despite Adequate Fluid Resuscitation
• Bradycardia

Pathophysiology

• Typical Level of Injury is T6 Vertebrae and Above^[29]
• Autonomic Dysfunction → DISTRIBUTIVE Shock:^[27]
  • Parasympathetic Function = PRESERVED → Inappropriate Bradycardia
  • Sympathetic Function = ABSENT→ Inappropriate Vasodilation → Loss of Preload → Hypotension

Management^[29]

1. RULE OUT Another Cause of Shock
2. ENSURE Adequate Resuscitation
3. CONSIDER^[30] - If Available:
   • Vasopressors
   • Inotropes
   • Chronotropes