Spinal Trauma

Overview
Spinal anatomy and physiology

Spinal motion restriction (SMR)

• Mechanisms of injury indicating need
• Process of application
• Emergency Rescue and Rapid Extrication
• History and assessment indicating no need
• Special situations indicating need for alteration

Neurogenic and hemorrhagic shock

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Spinal Trauma
Devastating and life-threatening
• Skillfully assess mechanism of injury and patient

Spinal motion restriction (SMR)

• BTLS recommendations are guidelines
• Based on careful evaluation of mechanism,
reliable patient condition, special situations
• Know your local protocol

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Spinal Column

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Spinal Cord

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Spinal Injury
Mechanism
• Hyperextension
• Hyperflexion
• Compression
• Rotation
• Lateral stress or distraction
• Less common

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Blunt Spinal-Column Injury
Requires significant force
• Unless preexisting weakness or defect in bone
• Higher risk: elderly, severe arthritis
• Sudden movement of head or trunk
• Frequently injured in more than one place

Spinal cord involvement

• Column injuries with cord injury: 14%
• Cervical region : 40%

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Blunt Spinal-Column Injury
Signs and symptoms
• Pain most common symptom
• Frequently masked by other injures
• Back pain with or without movement of back
• Tenderness along spinal column
• Obvious deformity or wounds
• Paralysis
• Weakness
• Paresthesia

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Blunt Spinal-Cord Injury
New cord injuries each year
• MVC (including pedestrian)
• Falls
• Penetrating
• Recreational activities

Young adults most common

• Under 8 years, usually high cervical
• Elderly

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Blunt Spinal-Cord Injury
Primary damage
• At time of force
• Cut, torn, crushed, cut off blood supply
• Usually irreversible

Secondary damage
• After time of force
• Hypotension, generalized hypoxia, blood vessel
injury, swelling, compression from hemorrhage
• Good prehospital care may help prevent
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Spinal Injury
2

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Neurogenic Shock
Cervical or thoracic cord injury
• High-space shock
• Malfunction of autonomic nervous system
Signs and symptoms
• Hypotension
• Normal skin color and temperature
• Inappropriately slow heart rate
Diagnosis of exclusion
• May have both neurogenic and hemorrhagic
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Assessment
BTLS Primary and Secondary Surveys
Motor and sensory function
• Conscious
• Motor: move fingers and toes
• Sensation: abnormal is suspicious
• Unconscious
• Motor: pinch fingers and toes
• Sensation: pinch fingers and toes
– Flaccid paralysis, no reflexes or withdrawal means injury

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Clues to Spinal Injury
Mechanism
• Blunt trauma above clavicle
• Diving accident
• Motor vehicle or bicycle accident
• Fall
• Stabbing or impalement near spinal column
• Shooting or blast injury to torso
• Any violent injury with forces acting on spine

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Clues to Spinal Injury
Patient complaints
• Neck or back pain
• Numbness
• Tingling
• Loss of movement
• Weakness

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Clues to Spinal Injury
Signs revealed during assessment
• Pain on movement of back or spinal column
• Obvious deformity of back or spinal column
• Guarding against movement of back
• Loss of sensation
• Weak or flaccid muscles
• Loss of control of bladder or bowels
• Erection of penis (priapism)
• Neurogenic shock
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Complications of SMR
Airway compromise and aspiration
• Head and airway are in fixed position
Head and low back pain
• Directly related to being on hard backboard
Life-threatening hypoxia
• Obese
• Congestive heart failure
Pressure sores
• Uneven skin pressure
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SMR

Apply when most likely benefit.

Avoid if not necessary.

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SMR Indicated
Positive mechanisms
• High-speed MVC
• Falls >3 times patient’s height
• Axial load
• Diving accidents
• Penetrating wound in or near spinal column
• Sports injuries to head or neck
• Unconscious trauma patient

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SMR Indicated
Potential mechanism with at least one:
• Altered mental status
• Evidence of intoxication
• A distracting painful injury
• e.g., long bone extremity fracture
• Neurologic deficit
• Spinal pain or tenderness

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SMR Decision
Reliable patient Unreliable patient
• Calm • Acute stress reaction
• Cooperative • Head/brain injury
• Sober • Altered mental status
• Alert • Intoxication with drugs
and/or alcohol
• No distracting injuries
• Distracting injuries

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SMR Not Indicated
No high-risk mechanism of injury
No alteration of mental status
No distracting injuries
Not intoxicated
No pain or tenderness along spine
No neurological deficits

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Management
Spinal motion restriction (SMR)
• Minimize movement to avoid aggravating injury
• No specific device proven more effective
• SMR success depends on application process

Modification required
• Immediate danger of death
• Critical degree of ongoing danger that requires
an intervention within 1–2 minutes

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Management
Emergency rescue
• Reserved for immediate (within seconds)
environmental threat to life of victim or rescuer
• Move to safe area in manner that minimizes risk

Rapid extrication
• Considered for medical conditions or situations
that require fast intervention to prevent death
• One or two minutes, but not seconds

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Neutral Alignment
Always monitor airway and breathing

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Log Roll
Single unit: spinal-column, head, pelvis
• Patients lying prone or supine

Modification required
• Painful arm, leg, chest
• Roll onto uninjured side
• Unstable fractured pelvis
• Scoop stretcher
• Lift carefully by four or more rescuers

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Special SMR Situations
Combative patient
• Children
• Altered mental status
• Under influence

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Special SMR Situations
Require side transport
• Airway
• Unconscious patients
who are not intubated

• Pregnant
• 20 weeks or more
• Vacuum board best

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Special SMR Situations
Closed-space rescue
• Safety is first priority
• In line with long axis

Water emergencies
• Backboard floated under
• Secure then remove Courtesy of Roy Alson, MD

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Special SMR Situations
Pediatric Elderly

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Special SMR Situations
Prone, seated or standing
• Minimize movement into supine position

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Special SMR Situations
Protective gear
• Motorcycle helmet: removal
• Poorly fitted to patient
• Significant neck flexion
• Full face and open face

• Note:
• Remove to evaluate and manage airway

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Special SMR Situations
Protective gear
• Remove athletic helmet when:
• Face mask not removed timely
• Airway cannot be controlled
• Does not hold head securely
• Helmet prevents stabilization

• Note:
• Cut chin strap; do not unhook

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Special SMR Situations
Protective gear
• Shoulder pad: removal
• With helmet removal
• Neutral alignment inability
• Unable to secure to board
• Access to chest needed

• Note:
• Cut axillary straps and laces on front,
open from core outward, slide out from under

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Special SMR Situations
Neck wounds
• Caution: cervical collar
• May prevent Ongoing Exam
• Compromised airway
with subcutaneous air,
expanding hematomas,
or mandible fracture
• Note:
• May be needed to avoid cervical collar; use manual
stabilization, head cushion devices, blanket rolls

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Summary
Unstable or incomplete spinal damage
is not completely predictable.
• Unconscious trauma or dangerous mechanism
affecting head, neck, trunk should have SMR.
• Uncertain mechanisms may not require SMR.
• Special cases may require special techniques.
• Maintain neutral alignment specific for patient.
• Be prepared to manage airway compromise.

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 Discussion

© Bob Krist/CORBIS
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