TJOKORDA GB MAHADEWA, M.D., M.Med., Ph.

D
S.F.N.S. (jpn)
Presented in Block Neuroscience
 Trauma to bony or ligamentous structurs of
the spine, with or without spinal cord
damage
 Whiplash associated disorder (WAD): damage
to the soft tissues of the spine caused by
acceleration/deceleration
 Process of management prioritization of multiple
patient casualties
 What factors are considered in the Triage Process?
1. Degree of life threatening (ABCDE)
2. Injury severity
3. Salvageability
4. Resources: Man, Materials, Time, etc.
5. Information may be incomplete.
6. Decisions may differ.
7. Use all clues possible—Frequently requires survey from a
distance
8. Avoid indecision

≥ 5% of patients worsen neurologically at
hospital

Protection — priority;
detection— secondary

Spinal evaluation complicated by brain
injury

Remove spine board as soon as possible

High-Speed Crash

Unconscious patient

Multiple injuries

Neurologic deficit

Spinal pain / tenderness
 Conscious Patient
Presence of
paraplegia/quadriplegia /pentaplegia

Presume spinal instability

Identify bony Early

neurosurgical
fracture subluxation consult
Alert,sober, neurologically normal patient :

① If no neck or spine ④ If still no pain or

tenderness with
pain or tenderness to
voluntary movement
palpation or voluntary
⑤ No further spine
movement evaluation or c-spine x-
② If no painful ray necessary
distracting injury
③ Remove C-colar
Alert, sober, neurologically normal patient :

If “ yes” to any question

Neck or spine pain  Protect c-spine
or tenderness to  Obtain necessary
palpation or
x-ray exams
voluntary
movement ?

After removal of c-
collar ?
 Exclude other injuries.
 Palpate all spinous processes.
 Ask patient to move spine within the pain
limits.
 Inspect motor and sensory function.
 Look for Horner's syndrome.
 Torticollis.
 Cervical Thoracic Lumbosacral

C-5 Deltoid T-4 Nipple L-4 Medial Leg

C-6 Thumb T-8 Xiphoid L-5 1st/2nd toes
C-7 Middle T-10 Umbilicus S-1 Lateral foot
finger T-12 Symphysis S-4 Perianal
C-8 Little finger
Cervical / Thoracic Lumbosacral

C-5 Shoulder L-2 Hip flexion

abduction L-3 Knee
C-6 Wrist Extension extension
C-7 Elbow extension L-4 Ankle
C-8 Middle finger dorsiflexion
flexion L-5 Big toe
T-1 Little finger extension
abduction S-1 Big toe / ankle
plantar flexion
Neurogenic Shock

Hypotension associated with cervical /high
thoracic spine injury

Bradycardia

Treatment : Maintenance fluids, atropine and
occasionally vasopressors
Spinal “Shock”

Neurologic Not hemodynamic phenomenon

Occurs shortly after cord injury

Flaccidity

Loss of reflexes
Incomplete Complete

Any sensation 
No motor / sensory

Position sense function

Voluntary 
No sacral sparing
movement in 
May have reflexes
lower extremity

Sacral sparing
Spinal Cord Syndromes

Central cord

Posterior cord

Anterior cord

Brown – Sequard

Complete transection
Morphology

Fracture or fracture / dislocation

Spinal cord injury without radiographic
abnormality (SCIWORA)

Spinal Cord Injury without radiographic evidence
of Trauma (SCIWORET)

Penetrating
Morphology

Consider unstable if :
• X-ray evidence of injury
• Neurologic deficit
• Severe pain on spine movement or
palpation

Adequacy

Alignment

Bony abnormality

Base of skull

Cartilage , Contours

Disc space

Soft tissue

10% of patients with a C-spine fracture have
a 2nd, associated noncontiguous vertebral
column fracture

Indentify one abnormality ? Look for
another!

Radiographic screening of entire spine
required in this instance

Crosstable lateral film exludes 85% of fracture

Additional 2 views exludes most fractures

Also may require
• Swimmers view
• Ct scan for bony detail
• Flexion extension views
• MRI/CT myelogram
 Plain spine X-rays if indicated.
 Flexion extension views (by specialist).
 MRI (by specialist): this is considered the 'gold
standard' in detecting soft-tissue injury.
 Cervical spine fractures are often best demonstrated
on a high-resolution CT scan
Immobilization  MANAGEMENT

Entire Patient  Treat life threatening

Proper padding injuries first

Maintain until spine  Immobilize
injury excluded
 Appropriate spine

Avoid prolonged
imaging
use of backboard!
 Document
examination
 Definitive treatment

Ensure adequate ventilation especially for high level (c-4)
quadriplegic

Maintain blood pressure

Atropine as needed

Methylprednisolone (NASCIS III)
Steroids
 IV Methylprednisolone
 Proven spinal cord injury
 Starts within 1st 8 hours from injury only
 30 mg/kg over 15 minutes
 5.4 mg/kg over next 23 hours

Proven in blunt trauma only , Remain Debatable

Transfer

Unstable fractures

Neurologic deficit
Avoid delay

Properly Immobilized

Respiratory support as needed
 Never remove the helmet from an injured motorcyclist in the
field unless there are airway problems
 Never ask patient with suspected cervical spine injury to move
until spine stability is assured
 Never force passive movement of spine
 Never force a patient with ankylosing spondylitis to lie down flat
 Never refer for manipulation therapy unless serious cervical
spine injury has been excluded