Spine Trauma

and
Management
C P T S A M U E L R O C K E R , A PA - C

LC D R A R I D O U C E T T E , PA - C
Disclosures
CPT Rocker and LCDR Doucette have
no financial interests to disclose with
regard to this subject or the contents
of the presentation.
 Non-deployed:

• 3% of blunt trauma patients sustain a

spinal column injury
• 1% sustain a spinal cord injury
Importance
Deployed:

• 1/5 spinal column injuries has

involved the cord
• 1/2 of those are complete
Mechanisms of Injury
Mechanical causes too numerous to list here,
but may include
• Rapid deceleration (e.g. MVC)
• Externally forced rotation (e.g. MVC,
Machinery Acc)
• Blunt trauma (e.g. MV vs Ped, FFS)
• Penetrating trauma (e.g. GSW, SW)
 Non-deployed:
• 1/2 from Motor Vehicle Accidents
• Risk factors: Speeding, ETOH, Unrestrained
• Rollover  Cervical spine injury
• Falls, sports, violence
Mechanisms
Deployed:
• 2/3 Explosive
• 17% GSW
• 3% Falls
• 66% Blunt, 28% Penetrating, 5% Combined
Spinal Anatomy
A BRIEF REVIEW OF
N O R M A L A N ATO M Y:

33 BONY VERTEBRAE:
7 C E RV I C A L
12 THORACIC
5 LU M B A R
5 SACRAL (FUSED)
4 C O C C YG EA L ( ~ F U S E D )
Cervical Spine:
C1-C3
Craniocervical
Ligaments:
Internal
 Atlanto -occipital dislocation
Atlanto -axial dislocation
Cervical Spine
Injuries C1 Burst (Jefferson)
C1 Posterior Arch
C2 Pedicle (Hangman’s)
C2 Odontoid
Atlanto-
occipital
dislocation
 Atlanto-
occipital
dislocation
Basion-posterior axial line
interval (BAI)
& Basion-dental interval
(BDI)

If either exceeds 12mm,

suggests A-O dislocation
Atlanto-axial
dislocation
C1 Burst
“Jefferson”
fracture
C1 Posterior
Arch fracture
C2 Pedicle
“Hangman’s”
fracture
C2 Odontoid
(“dens”)
fracture
Craniocervical
Ligaments:
External
 Flexion and
Extension
fractures
Anterior wedge - due forceful forward flexion.
Typically stable

Flexion teardrop - also due to forceful

forward flexion with compression. Unstable

Extension teardrop - severe abrupt extension

avulses anterior corner of spine from rest of
vertebral body. Unstable
 Burst fractures
Vertical compression due to axial loading

Stable vs unstable
 Spinous
process
fractures
Clay shoveler’s fracture, stable
 Laminar
fractures
Typically associate with other fractures

The other fracture determines stability

 Facet
dislocations
Not necessarily a fracture, but…

Bilateral facet dislocation

Very unstable
 Facet
dislocations
Not necessarily a fracture, but…

Unilateral facet dislocation

Stable
 Anterior Wedge
General Flexion or Extension teardrop
Vertebral Spinous Process
Fracture Burst
Patterns
Laminar
Facet
Ligamentous
Spinal Cord Injury With-Out Radiographic
Abnormality (SCIWORA)
Thoracic
Vertebrae

Anterior Middle Posterior

Thoracic
Ligaments
Lumbar
Vertebrae
Chance fracture
Spinal Cord:
Nerve Roots
Spinal Cord:
Protection
Spinal Cord:
Blood Supply
Spinal Cord:
Blood Supply
Mechanisms of Spinal
Cord Injury
• Vertebral column injury may result in
spinal cord injury through:
• Transection
• Compression
• Contusion
• Vascular Compromise
Transection
Penetrating or blunt may
transect all or part of the
spinal cord

Either directly, or by
displacing bony fragments
into the spinal canal or
through disk herniation

https://prod-images-static.radiopaedia.org/images/47636226/659df49efc3fea3fc2d05a9b526b6f_big_gallery.jpeg
https://www.researchgate.net/figure/MRI-sagittal-image-of-included-patient-with-complete-spinal-cord-transection-All_fig1_333294520
 Compression
Osteoarthritis
Spondylolysis  spondylolisthesis
Disc Herniation

Trauma:
• Edema
• Hematoma
• Fracture fragments

https://www.merckmanuals.com/-/media/manual/professional/images/spinal_cord_compression_slide_high.jpg
Contusion
Bony dislocations
Subluxations
Fracture fragments

https://radiopaedia.org/images/51203318
Vascular
compromise
Causes ischemia

Suspected when
discrepancy b/w
clinically apparent
neurologic deficit and
the known level of
spinal column injury

Important -
Don’t miss
http://www.ajnr.org/content/36/5/825
3 general clinical categories:
1. Patients with complete spinal cord
syndromes
2. Patients with an incomplete spinal cord
injury
3. Patients with a spine fracture but normal
neurological function
Thoracolumbar
Spinal Trauma

BE.CONVDOCS.ORG/PARS_DOCS/REFS/113/112418/112418_HTML_4C6EB2ED.JPG
Thoracolumbar
Spinal Trauma

https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf
Thoracolumbar
Spinal Trauma

Spinal Shock Neurogenic Shock

◦ Transient ◦ Circulatory collapse
◦ Decreased function ◦ Fluid resuscitation/pressers
◦ Is complete when Bulbocavernosus reflex
returns

https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf
Thoracolumbar
Spinal Trauma -
The Role 1
ATLS/TCCC - Address life threats first

High index of suspicion given MOI

Stabilize and Evacuate

Hemodynamic Goals for Evacuation

 Thoracolumbar Spinal
Trauma - The Role 2
ATLS/TCCC - Address life threats first

High index of suspicion given MOI

Plain Films Available

Stabilize and Monitor vs Evacuate

Hemodynamic Goals for Evacuation

HTTPS://MEDIA.DEFENSE.GOV/2017/MAY/19/2001749400/1088/820/0/170510-F-CH060-002.JPG
 Thoracolumbar
Spinal Trauma -
The Role 2
Stable Patterns

◦ Wedge Fractures
◦ Transverse Process Fractures

https://www.uptodate.com/contents/images/RADIOL/83217/MildcompressionL2.jpg
Thoracolumbar
Spinal Trauma -
The Role 2

https://www.uptodate.com/contents/images/RADIOL/83469/Xrayfraclumbartransproc.jpg
 Thoracolumbar Spinal
Trauma - The Role 2

Radiographic Findings

Stable Patterns

◦ Wedge Fractures
◦ Transverse Process Fractures

HTTPS://WWW.UPTODATE.COM/CONTENTS/IMAGE?IMAGEKEY=RADIOL%2F83140&TOPICKEY=EM%2F357&SOURCE=SEE_LINK&SP=0&SEARCH=
Thoracolumbar
Spinal Trauma -
The Role 2
Radiographic Findings
Unstable Fracture Patterns
◦ Burst Fracture
◦ Shear Fractures
◦ Translational distraction

https://www.uptodate.com/contents/images/RADIOL/83106/Verteburstfraclumbspine.jpg
 Thoracolumbar
Spinal Trauma -
The Role 2
Flexion Distraction Fracture
◦ Be concerned for intrabdominal
process
◦ High Likelihood for permanent
neurological injury

https://www.uptodate.com/contents/images/RADIOL/60907/Chancefraclumbarspine.jpg
Thoracolumbar
Spinal Trauma -
The Role 2
Translational Spinal Fracture
◦ Fracture dislocation
◦ Shear Fracture

https://www.uptodate.com/contents/images/EM/61587/Thoraclmbrfraxdislctradg.jpg
 Thoracolumbar
Spinal Trauma - The
Role 2
When to EVAC to higher level of care

When to sit on a patient

http://www.stripes.com/polopoly_fs/1.153264.1317334783!/image/2526600154.jpg_gen/derivatives/landscape_804/2526600154.jpg
 Thoracolumbar Spinal
Trauma - Role 3
148 Beds (24 ICU Beds)

Up to 4 OR tables

Multiple specialties

CT Available

https://a57.foxnews.com/a57.foxnews.com/static.foxnews.com/foxnews.com/content/uploads/2018/11/640/320/1862/1048/louvre-istock.jpg?ve=1&tl=1?ve=1&tl=1
Thoracolumbar
Spinal Trauma -
Role 3
Transverse Process Fracture

https://www.uptodate.com/contents/images/RADIOL/83470/CTtransverseprocessfrac.jpg
 Thoracolumbar
Spinal Trauma -
Role 3
Burst Fracture

No MRI in Role 3

https://www.uptodate.com/contents/images/EM/104227/ThoraccvrtbrlfraxCTMRI.jpg
 Thoracolumbar
Spinal Trauma -
Role 3
CHANCE FRACTURE

http://boneandspine.com/wp-
content/uploads/2011/01/chance-fracture-reconstructed.jpg
Thoracolumbar
Spinal Trauma -
Role 3
WEDGE FRACTURE

https://radiologyassistant.nl/assets/spine-injury-tlics-
classification/a548ac011b1f9a_1.jpg
Thoracolumbar Spinal
Trauma - Role 3
Management

Medical

Handling

NonOP vs OP
◦ Blunt
◦ Penetrating

HTTPS://WWW.ARMY.MIL/E2/C/IMAGES/2012/08/30/262219/ORIGINAL.JPG
 Review questions
He arrives to your aid station:
You are the new role 1 PA. Shortly after you arrive 1st PLT Cco was hit
with an IED. They are evacuating a 25YOM suffering a blast injury and A - Patent
was thrown 10 feet. The senior medic on the ground relays that the Pt is
GCS 14 (1 off for confusion), BP of 90P, HR 110, resp 18. The pt has B- RR 20, 99 RA, Equal rise and fall of the chest, LCTAB
shrapnel wounds along the anterior BL LE that has achieved hemostasis
C - BP 100/60, HR 106. LE wounds hemostatic with pressure dressing
with pressure dressings. Pt complains of excruciating LBP. The medic was
concerned of ecchymoses and exquisite tenderness located at L3/4. But D - GCS 14 (1 off for confusion). Neuro Intact. Rectal tone was intact. Bogginess noted midline l spine
is otherwise neuro intact.| around L3-4. TTP midline spine at that location.

E-Placed in “blizzard blanket”

Treatment: BL 18G IV, 20mg Ketamine IV, Spine Board, C-Collar,
Do you evac patient or sit on patient if this is your only patient?

Your EMEDS is located approx. 26 km away (40 min drive) air or ground evac?

Its been two hours since the pt was evaced from POI on a spine board. What should you do?

What should you ensure about his blood pressure?

 Review questions
He arrives to your role 2:
The Role 1 PA relays that the Pt is GCS 14 (1 off for confusion), BP of
100/60, HR 110, resp 18. The pt has shrapnel wounds along the anterior
A - Patent
BL LE that has achieved hemostasis with pressure dressings. Pt
complains of excruciating LBP. The PA was concerned of ecchymoses and
B- RR 26, 90 RA, Equal rise and fall of the chest, decreased lung sounds left
exquisite tenderness located at L3/4 and paresthesia's noted in the L3
side. JVD noted.
distribution of the left side. But is otherwise neuro intact.
C - BP 100/60, HR 115. LE wounds hemostatic with pressure dressing
Treatment: BL 18G IV, 25mg Ketamine IV, Spine Board, C-Collar, Blizzard
blanket D - GCS 14 (1 off for confusion). CN II-XII grossly intact, EOMI sans diplopia
Neuro intact.. Rectal tone was intact. Bogginess noted midline l spine around
L3-4. TTP midline spine at that location.

E-Placed in “blizzard blanket”

What do you want to do next to address low SPO2?

After Pt is stabilized?
Review
questions
YO U S H O OT A C H E S T X R AY , C
, T, L S P I N E P E LV I C F I L M S

HTTP://1.BP.BLOGSPOT.COM/-NULX7BWLHLE/TXD-
ODH9DZI/AAAAAAAAALE/7-WMBILQVU8/S1600/LEFT+RIBS+2.JPG
 Review
questions
C-Spine and T spine films are clear.
You notice this on L Spine films

What are you concerned of?

Do you Evac?

Should you consult a Neurosurgeon?

HTTP://WWW.IJOONLINE.COM/ARTICLES/2015/49/4/IMAGES/INDIANJORTHO
P_2015_49_4_471_159680_U6.JPG
 Review
questions
W H AT I F YO U P I C K E D U P O N
THIS?

W H AT A R E YO U WO R R I E D
ABOUT?

W H O E L S E S H O U L D I N VO LV E
I N T H E PAT I E N T ’ S C A R E ?
WO U L D YO U F I N D A N Y T H I N G
O N FA S T E X A M ?

https://www.uptodate.com/contents/images/RADIOL/83469/Xrayfraclumbartransproc.jpg
 Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient - Practice Management
Guideline. https://www.east.org/education/practice-management-guidelines/cervical-spine-collar-clearance-in-the-obtunded-
adult-blunt-trauma-patient. Accessed 27 Dec. 2019.

Cervical Spine Injuries Following Trauma - Practice Management Guideline. https://www.east.org/education/practice-

management-guidelines/cervical-spine-injuries-following-trauma. Accessed 27 Dec. 2019.

Eisen, Andrew. “Anatomy and Localization of Spinal Cord Disorders.” UpToDate, edited by TW Post, UpToDate
Inc, https://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders. Accessed 26 Dec. 2019.

Hansebout, Robert, and Edward Kachur. “Acute Traumatic Spinal Cord Injury.” UpToDate, edited by TW Post, UpToDate
Inc, https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury. Accessed 26 Dec. 2019.

Hoffman, J. R., et al. “Validity of a Set of Clinical Criteria to Rule out Injury to the Cervical Spine in Patients with Blun t Trauma.
National Emergency X-Radiography Utilization Study Group.” The New England Journal of Medicine, vol. 343, no. 2, July 2000, pp.
94-99, doi:10.1056/NEJM200007133430203.

Bibliography
Kaji, Amy. “Evaluation and Initial Management of Cervical Spinal Column Injuries in Adults.” UpToDate, edited by TW Post,
UpToDate Inc, https://www.uptodate.com/contents/evaluation-and-initial-management-of-cervical-spinal-column-injuries-in-
adults. Accessed 26 Dec. 2019.

Kaji, Amy, and Robert Hockberger. “Spinal Column Injuries in Adults: Definitions, Mechanisms, and Radiographs.” UpToDate, edited
by TW Post, UpToDate Inc, https://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-
radiographs. Accessed 26 Dec. 2019.

Netter, Frank H. Atlas of Human Anatomy. Philadelphia, PA: Saunders/Elsevier, 2006. Print.

Stiell, I. G., et al. “The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients.” JAMA, vol. 286, no. 15, Oct.
2001, pp. 1841-48, doi:10.1001/jama.286.15.1841.

Weingart, Scott. “Cervical Spine Injuries in the ED.” EMCrit Project, 25 Dec. 2011, https://emcrit.org/emcrit/cervical-spine-injuries-
i/.

CDR Chris Neal, Col Randall McCafferty, LTC Brett Freedman, MAJ Melvin Helgson. “Cervical and Thoracolumbar Spine Injury
Evaluation, Transport, and Surgery in the Deployed Setting” 05 Aug 2015,
https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Spinal_Injury_-
_Cervical_and_Thoracolumbar_Aug_2016_ID15.pdf
Questions?