CHAPTER 8

SPINE TRAUMA
TRAUMA LIFE SUPPORT MALAYSIA

PROVIDER COURSE
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 Learning Outcomes

1. Able to anticipate, recognise, categorise and grade spinal

injury

2. Able to perform spinal immobilisation and stabilisation

3. Able to understand the appropriate imaging modalities for

investigation

4. Able to understand the need for referral and further

management

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 Introduction
• The outcome of a spinal injury depends upon the speed
and precision of initial care, resuscitation, diagnosis and
emergency intervention.

• When it comes to spinal cord trauma,

“Time is Outcome”

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 Introduction
5% of head injury patients has an associated spinal injury.

25% of spinal injury patients has at least mild traumatic brain injury.

Cervical
(C1-C7)

Approximately, Injuries according to

region: Thoracic
(T1-T12)

55% in the cervical region,

15% in the thoracic region,
Lumbar
15% in the thoraco-lumbar region and (L1-L5)

15% in the lumbo-sacral area Sacrum

Coccyx 4
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Approximately 10% of all cervical spine
fractures has a second, non-contiguous
vertebral column fracture

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Anatomy of Spine

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Anatomy of Spinal Cord

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 Pathophysiology
Spinal injury should be ruled out in following cases;

· Unconscious patient.

· Multiple injuries.

· Neurological deficit.

· Spinal column pain/tenderness.

· Dangerous and suggestive mechanism of injuries such as ;

- Whiplash injury (flexion and extension injury).

- Direct trauma.

- Vertical loading (e.g. fall from height).

- Seat-belt injury (e.g. Chance Fracture ).

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 Spine Injury
It is estimated that 10% of all polytrauma patients
have a spinal injury.

Patients require synchronous

🡪 Resuscitation

🡪 Evaluation

🡪 Treatment

🡪 Early spine intervention post stabilisation.

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 Spinal Shock and Neurogenic Shock
• Spinal shock
🡪 physiological response to spinal cord injury.
->Causes temporary loss of spinal reflex activity
below the level of the injury (spinal cord
concussion)

• Neurogenic shock
🡪 loss of sympathetic outflow
-> resulting in bradycardia, and a vasoplegic
hypotensive state
-> distributive shock
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 Types of Incomplete
Spinal Cord Injury
Central Cord Syndrome Posterior Cord Syndrome

Brown Sequard Syndrome

Anterior Cord Syndrome

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ASIA Chart

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 Resuscitation
Primary Survey [<c> ABCDE]

· LOC (usually GCS < 8 unable to protect airway and has concomitant
head injury that needs cerebral protection).
· Hypoventilation (Tetraplegia patient will have high incidence of
diaphragm involvement).

Airway Protection is PRIORITY

Spine Injury Detection is SECONDARY

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 HYPOVOLAEMIC SHOCK
Is the most common shock in trauma
NOT neurogenic shock

∙ Always rule out Hemorrhage as a cause of possible

hypotension

· Haemorrhage is still the most common source of hypotension

in trauma until proven otherwise

· Neurogenic shock can initially be treated with fluid boluses.

· Vasopressors and Inotropic support can be initiated after

adequate volume resuscitation is provided.
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 Secondary Survey
Spinal examination:

• Step deformity, haematoma, open fracture (when logged rolled).

• Perineal examination: External Anal Sphincter contraction (motor)

and perianal sensation (sensory).

• Do not routinely perform digital rectal examination (DRE)

unless indicated with coexisting neurology.

• Perform bulbocavernosus reflex when neurology is present to

look for evidence of coexisting spinal shock

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 NEXUS CRITERIA
NSAID
N – Neuro deficit
S – Spinal tenderness
A – Altered mental status
I - Intoxication
D – Distracting injuries

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What to do if significant cervical spine injury identified on radiographic
imaging?

1. Maintain C-Spine with a rigid cervical collar

2. Consider application of additional immobilization

• Eg; head block or towel roll
3. The patient should be kept non-ambulatory

4. Appropriate pain management

5. KNBM until a treatment plan is decided

6. Early involvement of the spine team

7. Emergent intervention should not be delayed 18

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 REMOVE Rigid Cervical Collar EARLY
Cervical collar causes:
- Increase intracranial pressure (ICP) due to jugular venous compression

- Mechanical respiratory restriction

- Harmful unfitted immobilization ie : ankylosing spondylitis

- Poor access to clinical assessment and intervention over the neck region

- Pain and discomfort for the patient causing further restlessness

- Risk of aspiration and airway obstruction in event of patient vomiting in

supine upright position

- Pressure sore formation

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 “Clearing the T and L’s Spine”
There are no validated decisions rules for clearing the thoracic or
lumbar spine.

Imaging is generally required, if there are the following:

🡪 Point tenderness at respective spinal column

🡪 Bony step deformity

🡪 Neurological findings consistent with a thoracic or lumbar injury

🡪 High risk and suspicious mechanism (example fall from height

and in the presence of distracting injuries)
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 SUMMARY
• Spine protection by immobilization is key
• Most common cause of hypotension is hypovolaemic shock
rather than neurogenic shock
• Always assure airway protection in high spinal injuries
• Suspect spine injury in high risk and suspicious mechanism
of injuries
• A normal cervical x-ray by itself cannot rule out clinically
significant cervical injury
• In assessing for step deformity, adjunct the examination
with a lubricated (Medical purpose gel / water based
lubricant) gloved hand

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Thank you
Any questions?

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