EMCrit.org

Spinal Injuries

Cervical Spine

Clinical Decision Rules

Canadian C-Spine Rules (NEJM 2003;349:2510-8 and Annals EM 42:3, Sept 2003)

For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in stable condition and in whom cervical-spine injury is a concern, the determination of risk factors guides the use of cervical-spine radiography. A dangerous mechanism is considered to be a fall from an elevation 3 ft or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km/hr) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.
 99.4% Sensitive and 45.1% Specific

How important is the age 65 criterion in the Canadian C-Spine Rule? (Stiell IG)
For the older patients it the sensitivity of CCR was 92.1% (78-97%) and would have missed 3 injuries. CONCLUSIONS: In older patients, several CCR criteria, particularly "Dangerous Mechanism", perform less well and the overall sensitivity of the CCR is insufficient. The "Age 65" criterion remains an important component of the CCR and all potential neck injury patients aged 65 and older should undergo imaging.

N Engl J Med. 2003 Dec 25;349(26):2510-8.  The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.

Nexus C-Spine Rules

1. No midline tenderness
2. No pain with neck movement
3. No distracting injury
4. No Neurodeficit
5. No Alcohol or Drugs
6. No Altered Mental Status 

• Validated in elderly (have a higher prevalence of odontoid fx) (Ann Emerg Med 40(3):287, 2002)
• Validated in Peds >9 y/o (greater prevalence of lower vertebral c-spine fx) (Pediatrics 108:2, 2001)

Hoffman explains the difference in specificity between the two rules b/c NEXUS incorporated the fact that a good portion of the patients would not even be entered b/c nexus ideas has already been integrated. Only patients who you would have gotten an x-ray would have entered the spec. calculation. Ex If we created a rule with 100% sens and 90% spec, then if a thousand patients with 10 c-spine fractures, 10 would have positive films, 90 would have negative films and 900 would not be filmed (900 true neg, 10 true pos, 90 false pos, 0 false neg). Once the rule becomes common practice, Only 100 patients would be entered into study, so (10 true pos, 90 false pos, 0 false neg, 0 true neg) so equates to unconscious use of rules and therefore not considering the same denominator as CCR which enrolled all patients. Only included patients who got an x-ray

What is a Distracting Injury (Acad Emerg Medicine Jan 2001 8:1) 45 patients in NEXUS had a distracting, painful injury (DPI) as their only criteria for the need for radiography.

1. Long Bone Fracture (Most common DPI)
2. Visceral Injury Necessitating surgical consultation
3. Large laceration, degloving injury, or crush injury
4. Large Burns
5. Any injury producing acute functional impairment

One study would indicate that any fracture can be a distracting injury for vertebral injury detection (JEM 2005;28(2):147)

Another study states that only upper torso injuries are distracting (J Trauma 2005;59:1396)

Note on the Normal Mental Status Section:

An altered level of alertness can include any of the following:

a) Glasgow Coma Scale of 14 or less;

b) disorientation to person, place, time, or events;

c) inability to remember three objects at 5 minutes;

d) delayed or inappropriate response to external stimuli; or

e) other.
 

Trauma study which challenges the nexus results with ct scan as the gold standard

missed 7 fractures in on-intox, gcs 15 patients.(J Trauma 2007;62:1405)

Radiography

Computed tomography should replace radiographs in suspected cervical spine trauma
Quick on the heels of recently issued guidance in the UK (by NICE) on the role of computed tomography (CT) in head injury, this US study advocates an increasing role for CT in suspected cervical spine injury. Altogether 1199 blunt trauma patients underwent both conventional radiographic imaging and CT evaluation of the cervical spine. Cervical injuries were identified in 116 patients (9.5%). Both methods successfully identified the injury in 75 of these patients. The remaining 41 (3.2%) patients had injuries not seen on plain radiographs, but seen only on CT scan. The authors conclude that CT scan in a trauma patient population identified more bony injuries in the cervical spine than standard conventional radiographs. More importantly, all injuries missed by cervical spine radiographs required treatment. The authors therefore suggest that there does not seem to be any role for cervical spine radiography in the clearance of blunt cervical spine injury. The data from this study have led to an adjustment in practice protocol at the authors’ institution, with CT scan alone used for the initial screening of adult patients at risk for blunt cervical spine injury. However, such a protocol needs to be prospectively validated before it becomes universal practice.

 Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan. (J Trauma 2003;55:222–7.)

CT is cheaper (12. Blackmore CC, Ramsey ST, Mann FA, Deyo RA (1999) Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 212:117–125)
 

Many, many missed injuries on plain films in this study (J Trauma 2005;59(4):897)
--------------------------------------------------------------------------------
Another Study:
Results: Four hundred thirty-seven unconscious, intubated, blunt trauma patients underwent CT scanning of the cervical spine. Sixty-one patients had a cervical spine injury and 31 (7.0%) were unstable. CT scanning had a sensitivity of 98.1%, a specificity of 98.8%, and a negative predictive value of 99.7%. There were no missed unstable injuries. In contrast, an adequate lateral cervical spine film detected only 24 injuries (14 unstable), with a sensitivity of 53.3%. (J Trauma Volume 58(5) May 2005 pp 897-901)
 

and pseudoMA

Conclusion: Despite the absence of a randomized controlled trial, ample evidence exists that CT significantly outperforms plain radiography as a screening test for patients at very high risk of cervical spine injury and thus CT should be the initial screening test in those patients with a significantly depressed mental status. There is insufficient evidence to suggest that cervical spine CT should replace plain radiography as the initial screening test for less injured patients who are at low risk for cervical spine injury but still require a screening radiographic examination. ((J Trauma Volume 58(5) May 2005 pp 897-901)
 

Study showing radiographs miss fxs all over the entire spinal column (J Trauma 2005;58:890)

Grogan EL, Morris JA, Dittus RS, et al. Cervical spine evaluation in urban

trauma centers: lowering institutional costs and complications through

helical CT scan. J Am Coll Surg 2005;200:160-165.



This article basically echoes the findings of the several above. It

compared helical CT scan with plain radiography in the initial

radiographic evaluation of the cervical spine in moderate to high-risk

patients with trauma. The conclusion of the study was that helical CT scan

is the preferred initial screening test for the detection for cervical spine

fractures among moderate- to high-risk patients seen in urban trauma

centers. The authors found that the use of CT to evaluate the cervical

spine was more sensitive, more accurate, and more cost-effective. The

initial evaluation of the cervical spine in patients of high to moderate risk

of cervical spine fracture should be performed by helical CT rather than

by plain films.







Grogan EL, Morris JA, Dittus RS, et al. Cervical spine evaluation in urban

trauma centers: lowering institutional costs and complications through

helical CT scan. J Am Coll Surg 2005;200:160-165.



This article basically echoes the findings of the several above. It
compared helical CT scan with plain radiography in the initial
radiographic evaluation of the cervical spine in moderate to high-risk
patients with trauma. The conclusion of the study was that helical CT scan
is the preferred initial screening test for the detection for cervical spine
fractures among moderate- to high-risk patients seen in urban trauma
centers. The authors found that the use of CT to evaluate the cervical
spine was more sensitive, more accurate, and more cost-effective. The
initial evaluation of the cervical spine in patients of high to moderate risk
of cervical spine fracture should be performed by helical CT rather than
by plain films.

Latest study

(J Trauma 2007;62:1427)

55.5% of clinically sig. fractures missed by 3-series radiography

 

Plain Film Evaluation

Lateral

AP

Open Mouth

One way to evaluate for this and other upper cervical injuries involves the use of the posterior spinous line.  The posterior spinous line is a straight line which bisects the base of the spinous processes of C1 and C3 (line joining the blue dots in Figure 9 below). The C2 spinous process base (Green dot in Figure 9 below) should not be displaced more than 2 mm from this line.  If it is, true injury should be suspected, and if displaced posteriorly, may indicate a hangman’s fracture.

Fractures

Width of canal is 17 mm, the cord is 11 mm in the neck Ligameta Flava is the posterior margin of the canal

Unstable Fractures

• Jefferson:  C2 Burst Fx
• Bifacet Dislocation or Fracture
• Odontoid:  II-body or III-Lateral masses
• Any Fx with dislocation/subluxation
• Hangman’s:  posterior C2 secondary to hyperextension
• Teardrop:  anterior chip of any vertebrae

Not all cervical spine injuries result in clinical instability.
Generally, fractures are considered to be clinically
insignificant if failing to identify them would be unlikely
to result in harm to the patient or, alternatively, recognizing
the injury would prompt no specific treatment.
Two groups have categorized, by expert consensus, a
number of injuries as not clinically important.11,12 The
National Emergency X-Radiography Utilization Study
(NEXUS) group identified the following injuries as not
clinically significant: spinous process fractures, wedge
compression fractures with loss of 25% or less of body
height, isolated avulsion fractures without ligament injury,
type 1 odontoid fractures, end-plate fractures, isolated
osteophyte fractures, trabecular fractures, and isolated
transverse process fractures.11 Similarly, the
Canadian CT Head and Cervical Spine Study group identified
the following injuries as not significant: simple
osteophyte fractures, transverse process fractures, spinous
process fractures, and compression fractures with
loss of less than 25% of body height.12

 

Clay Shoveler’s:  C6-7 spinous process, can send home Anterior Column=Bodies and DiscPosterior Column-everything else

Flexion Injuries

Clay Shovelers Fx-oblique fracture of base of spinous process of lower cervical vertebrae, caused by avulsion fx from neck flexion against supraspinous ligament

Subluxation-ligamentous rupture s bony injury

Bilat Facet Dislocation-vertebrae’s inferior facets pass over lower’s superior

Atlanto-Occ or Axial Dislocations-

Extension Injuries

Extension Teardrop-unstable

Compression

Jefferson-C1 anterior/posterior arch.  Predental space >3 mm in adults or >5 mm in kids

Occipital Condyle Fractures         

These fractures require a high velocity impact and usually present with impaired level of consciousness or severe occipital-cervical pain.  Occasionally, patients present with lower cranial nerve palsies.  Plain films have a very low sensitivity - on the order of 3% - for detecting this injury.  CT of the skull base is required to make the diagnosis.  These fractures respond well to external immobilization.

Atlanto-Occipital Dislocation

This injury is often difficult to diagnose on plain films or CT and often presents with subtle clinical signs (2).  Many diagnostic criteria have evolved to diagnose this injury on plain films.  However, the most sensitive (n = .76) are by Harris et al. (3-4) and are shown below.  The distance between the basion and the dens should be 12 mm or less, and the posterior axial line should be no more than 12 mm posterior or 4 mm anterior to the basion.  Note on the diagram below that the basion can overhang the dens in an anterior or posterior fashion. Prevertebral swelling over 7mm at C3 is non-specific, and seen in about 50% of patients with AOD.  While CT is usually highly sensitive for cervical spine injuries, the sensitivity for AOD is only 84%.  Treatment for this condition is surgical.

 

A) Normal anatomy within the craniocervical junction. Note the basion-dens interval (a) and the posterior axial line, which is drawn along the posterior cortex of the axis (b).Harris criteria for the diagnosis of AOD: (1) Basion to dens interval > 12mm (2) Basion to posterior dens tip > 12 mm if it lies posterior to the basion, > 4mm if it lies anterior to the basion.
B) Atlanto-occipital dislocation. Cross-table lateral radiograph shows atlanto-occipital dislocation with a basion-dens interval of 25 mm.

C1 Atlas Fractures

Isolated fractures of the atlas are rare and divided into three types (5).  Type I involves either the anterior or posterior neural arch.  Type II involves the anterior plus posterior arch.  Jefferson first described this fracture pattern as a “burst” pattern in 1920.  Type III is a fracture of the lateral masses.  Regardless of fracture type, stability is defined as an intact transverse longitudinal ligament.  Stable C1 fractures are usually treated conservatively (collar, halo, Minerva jacket) while unstable injuries require surgery.  The “Rule of Spence” states that on an open-mouth odontoid view, displacement of the lateral masses of C-1 on C-2 of over 6.9 mm implies a ruptured ligament (see below).  Recent studies have shown the Rule of Spence to have 60% sensitivity compared to MRI with 100% sensitivity.  Thus all stable patients with a C-1 fracture should undergo MRI to assess the integrity of the ligament.  If the ligament is ruptured, this is considered the most unstable of all C-spine fractures (6). 

C1 fracture demonstrating rule of Spence. If the distance of  A + B is greater than 6.9 mm then transverse ligament rupture is suspected.

C2 Axis Fractures

Fractures of the axis are also divided into three types (7).  Type A involves a fracture of the dens.  Type B is traumatic spondylolithesis of C2 on C3 also known as a Hangman’s fracture (bilateral fracture of pedicles of the axis).  Type C is any other C2 fracture not fitting the above classification.

The dens fracture is the most common form and has four subtypes: I (dens tip), II (dens base), IIa (dens base with comminution), III (dens plus body of C-2).  Type I and III are stable and treated with rigid external immobilization.  Type II and IIa are often managed surgically in cases of dens displacement over 6mm and in patients over 50 years old.

The hangman’s fracture is caused by extreme hyperextension.  The fracture is through both pars interarticularis (the space between the superior and inferior articular facet). The hangman’s fracture (figure) is considered unstable when the angle between C-2 and C-3 is over 11 degrees or there is complete C-2 – C-3 disruption.  While the unstable injuries require surgery, most other cases can be managed conservatively.

Type C fractures are rare and respond well to external immobilization.

Type I dens fracture	Type II dens fracture  (IIa if comminuted)	Type III dens fracture

Hangman’s fracture with angulation and spondylolithesis noted

Axis with Atlas Fractures

Combination fractures of C1 and C2 are relatively common and should be evaluated by CT with reconstruction whenever an isolated C1 or C2 fracture is seen (8).  In the largest case series examining combined fractures, 43% of axis fractures and 16% of atlas fractures occur in unison (9).  There are four main fracture combinations.  The most common is the C1-type II odontoid fracture. The least common fracture pattern is the C1-Hangman’s.  The indications for surgery are the same as in isolated C1 or C2 fractures.

Subaxial Fractures           

The stability of C3 – C7 fractures is based on a three-column theory described by Denis (10, 11).  The three spinal columns are anterior, middle and posterior.  The anterior column is comprised of the anterior longitudinal ligament (ALL) and the anterior two-thirds of the vertebral body.  The middle column is formed by the posterior longitudinal ligament (PLL) and the posterior third of the vertebral body.  The posterior column is made up of the remaining ligamentous and vertebral structures.  Fractures are considered unstable if more than one column is disrupted. 

Figure displaying 3-column theory of Denis (A) Anterior column (B)  Middle column (C) Posterior column

Clayshoveler’s fracture

Bilateral Facet Dislocation  (note relationship of C4 to C5)	Flexion teardrop fracture

Flexion-Rotation
The unilateral facet dislocation is caused by a single inferior articular facet slipping over a superior articular facet.  Radiographically this is seen as subluxation of 25-50%.  This is considered a relatively stable injury.  When associated with a fracture, ligamentous injury, or locked facet, surgery is generally indicated.

 

A)  Illustration of the lateral masses of the cervical vertebrae
B) Unilateral Facet Dislocation: The anterior aspect of a vertebra's lateral masses are usually seen on a lateral view as a single dense line since they are superimposed. A unilateral facet dislocation may be diagnosed if one lateral mass is more anterior than the other. In this case, the lines will be less dense since the lateral masses are not superimposed anymore (see arrows).

Extension

The Hangman’s fracture, neural arch fracture, and posterior atlanto-occipital dislocation have been discussed previously.

The extension teardrop fracture is radiographically similar to the flexion teardrop fracture, involving the anterior-inferior portion of a vertebral body.  This is an avulsion injury caused by the pull of the anterior longitudinal ligament as opposed to a compression injury seen in flexion.  Thus, it is a more stable injury, only disrupting one column, and is only unstable in hyperextension.  It responds well to immobilization.
 

Compression

The Jefferson burst fracture of C1 has been discussed previously.

A compression fracture of a vertebral body usually responds well to external immobilization.  Indications for surgery are

(1) compression > 25 – 40%

(2) retropulsion of bony fragments seen on CT or MRI and

(3) neurological symptoms.

CT Evaluation

Facet Fractures

Normal        Locked        Perched                 Reversed

Hamburger and Reversed-hamburger (JEM 2002;23(4):387)

SCIWORA

(Spinal Cord Injury WithOut Radiographic Abnormality)

SCIWORA is defined as the presence of neurologic symptoms in the absence of radiographic (X-ray) findings.  This is classically seen in children with symptoms ranging from transient neuropathy to complete cord lesion.  Often a transient neuropathy will have a “lucid interval” only to return hours to days later.

Recent evidence suggests adults present with SCIWORA at an incidence higher than previously thought.  Examination of the NEXUS database revealed 27 cases of SCIWORA--- all in adults.  The most common level was C4.  The presentation in adults ranged from central cord syndrome to complete paralysis.  The incidence of transient neuropathy in adults has not been investigated.

Treatment is based on MRI findings.  When disk herniation is present, rapid decompression has a good outcome Otherwise, in cases of cord hemorrhage or edema, steroids are recommended but with little improvement demonstrated

Negative CT and plain films had a 0.5% rate of unstable ligamentous injury (J Trauma 2001;50:457)

brief review (EMJ 2007;24:803)

Cord Injuries

Brachial Plexus Injuries

Transient Quadriplegia

Incomplete

Brown-Sequard Syndrome hemidisection of cord, ipsi motor contra temp and painusually traumatic but can happen idiopathically from dural defect

Anterior Cord lose motor, retain posterior column

Posterior Cord

Cruciate Paralysis of Bell odontoid rams into cord will have hemiparesis of one arm and the opposite leg

Conus medullaris syndrome is a sacral cord injury with or without involvement of the lumbar nerve roots. This syndrome is characterized by areflexia in the bladder, bowel, and to a lesser degree, lower limbs. Motor and sensory loss in the lower limbs is variable.

Cauda equina syndrome involves injury to the lumbosacral nerve roots and is characterized by an areflexic bowel and/or bladder, with variable motor and sensory loss in the lower limbs. Because this syndrome is a nerve root injury rather than a true SCI, the affected limbs are areflexic. This injury is usually caused by a central lumbar disk herniation.

A spinal cord concussion is characterized by a transient neurologic deficit localized to the spinal cord that fully recovers without any apparent structural damage.

Autonomic Dysreflexia from alteration of sympathetic feedback loop.  First treatment is to put in a foley.

Evaluation

0-Nothing

1-twitch

2-moves on the bed

3-against gravity

4-resistance

5-normal

C4 Breathing

C5 Shrug Shoulders

C6 Flexion of Elbow

C7 Extension of Elbow

C8-T1 Flex Fingers

T1-T12 Intercostal and Abd Muscles

L1-L2 Flex Hip

L3 Adduct Hip

L4 Abduct Hip

L5 Dorsiflex foot

S1-S2 Plantar Flex Foot

S2-S4 Sphincter tone 

Spinal Shock-1st 24 hours, ends with return of bulbocavernous reflex (squeeze glans or insert foley and sphincter contracts)

Check for perineal sensation to a pinprick and by asking the patient if he or she can feel the
urinary catheter in situ. Check anal tone by digital examination. Check ‘anal wink’and
bulbocavernosus reflex. Testing of the anal and bulbocavernosus reflexes provides an
indication of the status of the sacral reflex arcs. The anal reflex presents as a visible
contraction (‘wink’) of the anal sphincter in response to a perianal pinprick. The
bulbocavernosus reflex provides a similar effect in response to squeezing of the glans penis
in the male or the clitoris in the female. Priapism can be used as an indicator of SCI in the
unconscious male.

C5 Quad means full function of C5, nothing at C6

C5 is completely dependant, C6 requires part time aide, C7 self sufficient

If SCIWORA  in adults without CT evidence, consider anterior vascular injury, there are no anastamoses to the anterior spinal artery, comes off vertebral. Clinical judgment on whether or not there is a spinal injury is only 50% sensitive (AEM 15:44, 1986) (AEM 16, p.738, 1987)

ASIA score is probably best for spinal injuries

SCI
Injury below c5 results in impaired expiratory function and impaired cough
lack of abdominal wall musculature drops the abd contents out and pulls diaphragm down decreasing vital capacity
as flaccidity is replaced by spasticity, increased tone will stabilize the abd and rib cage.

incomplete spinal cord injuries (sacral sparing) have the best chance of recovering some degree of function

Autonomic Effects of SCI
The significant feature of spinal shock is the way that it affects the activity and functions of
the autonomic nervous system.18,48 Sympathetic activity below the level of a spinal cord
lesion is suppressed. The effects of this are most manifest in injuries above the sixth thoracic
nerve (T6) – the base level of the body’s main sympathetic outflow. Parasympathetic activity
is not greatly affected by an SCI, so it dominates all autonomic activity. On average, the
duration of spinal shock is between 48 hours and 14 days after trauma. In some instances, it
can persist for up to 6 weeks or more.

Paralytic ileus is an immediate consequence of SCI.

Confirmed Cord Injury

Steroids

Solumedrol 30 mg/kg then 5.4 mg/kg/hr x 23 hours (Spine 26(24S):539 2001)

Evidence against using steroids and

Trauma Wiki

From Neurosurgery EBM Book

15% of patients with Down’s have atlantoaxial subluxation Furthermore, the collar does not effectively restrict cervical motion.  Studies show that the cervical collar allows motion of 48% with flexion, 68% with extension, 65% with rotation and 82% with lateral bending (34-35).  Because this approach is ineffective and offers a false sense of security it should not be used.(34)   Rosen PB, McSwain NE, Arata M. Comparison of Two New Immobilization Collars.  Annals of Emergency Medicine. 1992; 21: 1189-1192(35)   Cline JR, Scheidel E, Bigsby EF. A Comparison of Methods of Cervical Immobilization used in Patient Extrication and Transport. J Trauma. 1987; 25: 649-656 Intubation with Miller reduced axial motion by 50% over Mac(19)   Gerling MC, Davis DP, Hamilton RS, Morris GF.  Effects of Cervical Spine Immobilization Technique and Laryngoscope Blade Selection on an Unstable Cervical Spine in a Cadaver Model of Intubation.  Annals of Emergency Medicine. 2000; 36: 293-300.

Acute spinal cord injuries (Neurosurg 2002;50(3) supplement)
blood pressure
MAP push improved neurologic outcome in poor quality studies
MAP>85 for seven days is based only on animal studies

dvt proph
continue for 3 months post-injury, consider filter
 

Albuterol for spinal bradycardia 4 mg PO Q6

There is an oral alpha-agonist as well, Midodrine
 

Acute Whiplash Injury

Various interventions have been advocated for the treatment of acute whiplash-type cervical sprain injuries. Systematic reviews and randomized controlled studies have shown the following:

Early mobilization as compared to immobilization or rest plus use of a cervical collar significantly reduces pain.

Advice to "act as usual" plus anti-inflammatory drugs versus immobilization plus 14 days sick leave improves mild subjective symptoms.

One randomized controlled study (1) found that multimodal treatment (postural training, psychological support, eye fixation exercises, and manual treatment) significantly reduced pain as compared to physical therapy using physical agents (e.g. ultrasound and transcutaneous electrical nerve stimulation).

Despite the continued widespread practice of discharging patients from the ED following a whiplash injury in a cervical collar with advice to rest, there is extensive evidence indicating that early mobilization is preferable and that rest and restriction of motion is detrimental and slows the healing process.

References:

(1) Provinciali L, Baroni M, Illuminati L, et al. Multimodal treatment to prevent the late whiplash syndrome. Scand J Rehabil Med 1996;28:105–111.
(2) Verhagen AP, Peeters GG, de Bie RA, et al. Conservative treatment for whiplash (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Search date 1998; primary sources Medline, Embase, Cinahl, Psychlit, and Cochrane Controlled Trials Register.
(3) Bonk AD, Ferrari R, Giebel GD, et al. Prospective, randomized, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. J Musculoskel Pain 2000;8:123–132.
(4) Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine 2000;25:1782–1787.
(5) Söderlund A, Olerud C, Lindberg P. Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clin Rehab 2000;14:457–467.Clearing C-Spines in Unconscious PatientsInordinately low incidence of missed injuries on good quality ct scan (BMJ  2004;329:495-499)

EAST Guidelines

Ghanta MK, Smith LM, Polin RS, et al., An analysis of Eastern Association for the Surgery of Trauma Practice Guidelines for cervical spine evaluation in a series of patients with multiple imaging techniques. Am Surgeon 2002;68:563–8. The Eastern Association for the Surgery of Trauma in 1998 published a set of 16 evidence-based guidelines for cervical spine evaluation in trauma patients, which is available online at www.east.org, and with which all caregivers involved with trauma patients must be familiar. The present study was undertaken to assess how the guidelines did at their institution. They reviewed the charts of 124 consecutive patients over a 14 month period, and found that the guidelines were adequate for all patients except those who are obtunded. The EAST guidelines for these patients state that standard 3-view plain x-rays and thin cut CT through C1 and C2 are sufficient to rule out significant injury. Many trauma general, orthopedic, and neurological surgeons, however, remained concerned with the possibility of ligamentous and disc injury that might be missed with these studies alone, and several papers have been published recommending either complete C-spine MRI or controlled flexion-extension fluoroscopy for obtunded patients even if the plain films and C1-C2 CT are negative. The present report confirms these concerns: 22% of obtunded patients with normal plain films and CT has an abnormal MRI, and 30% of non-obtunded patients with persistent neck pain had potentially unstable injuries not detected by plain films or CT. The injuries identified by MRI only included 4 disc herniations, two ligamentous injuries, two other soft-tissue traumas, one meningeal tear, and one cord transection. This issue is not decided: in the meantime, I will stay with getting a cervical spine MRI for all my multiple-trauma patients who are obtunded before I remove the cervical spine immobilization.

Lovenox

72 hours post injuy

1 week after corpectomy

Trach

1 week after surgery

Related injuries

Pressure Ulcers

From collar, should try to remove as soon as possible

Bradycardia

If the gut is working start
orciprenaline at 20mg QDS and again titrate to heart rate of 90.
The unopposed vagal activity also has bad effects on the lung, and a
useful side effect was a marked reduction in respiratory failure. I
have a lot of stuff on this buried some where - I will try and dig out
the references.


Medline was useless. Quick trip to the loft and found the original
papers and our unpublished series buried up there.


1: Lancet. 1975 Dec 13;2(7946):1183-5.
Mechanisms of reflex cardiac arrest in tetraplegic patients.
Frankel HL, Mathias CJ, Spalding JM.
 

C-spine Clearance

J Trauma Volume 59(1), July 2005, pp 179-183

Cervical Spine Clearance in Blunt Trauma: Evaluation of a Computed Tomography–Based Protocol

Lumbar Spine

Chance Fracture-lap belt injury around L2-L4.  Both posterior and anterior elements fracture, but anterior longitudinal ligament stays intact so usually neurovascularly intact.  Associated with intraabdominal injuries a good portion of the time.

Screening for thoracolumbar injuries (J Trauma 2007;63:709)

EAST definition of High energy injuries

falls > 10 feet

MVC or MCC with or without ejection

ped struck

assault

sport or crush injury

bicycle accidents

concomitant c-spine fx

but by level iii evidence, this list is narrowed to MVC, falls, ped struck

Cost of CT Protocols

Every study says they are better and cheaper (J Trauma 2004;56:1022)

Lancet. 1975 Dec 13;2(7946):1183-5.
Mechanisms of reflex cardiac arrest in tetraplegic patients.
Frankel HL, Mathias CJ, Spalding JM.
Four patients with physiologically complete high cervical spinal-cord lesions, sustained within the previous 6 weeks, were observed. All needed intermittent positive-pressure ventilation. In the stage of spinal shock, stimuli to the trachea induced bradycardia, and in two patients cardiac arrest resulted. The bradycardia occurred when the patients were hypoxic, and seemed to be due to a vaso-vagal reflex. Normally this reflex is opposed by sympathetic activity, and during hypoxia by increased pulmonary (inflation) vagal reflex activity due to increased breathing. In these patients, however, compensatory sympathetic activity was prevented by the cervical cord lesion, and increased pulmonary vagal reflex activity by the fact that the breathing was artificial and therefore did not increase with hypoxia. Treatment in emergency includes the administration of atropine. Adequate oxygenation and, if this cannot be achieved, maintenance atropin should prevent the bradycardia and cardiac arrest associated with stimulation of the trachea in artificially ventilated tetraplegic patients.
 

Work-up of ligamentous injuries (J Trauma 2005;59(4):897)

they still need MRI

STC study on who needs mech vent in C-Spine injury (J Trauma 2005;59:912-916)

C5 and above always need to be vented

Incomplete Injuries

Patients with injuries on x-ray need CT scanning of the entire spine (Ann Emerg Med 2006;47:129)

Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis.

Spinal Shock Physiology

(Spinal Cord 2004;42:383-395)
4 Phases

1 Areflexia

2 Initial Reflex Return

3 Early Hyper-reflexia

4 Late Hyper-reflexia

Neurologic shock can persist through the first three phases

Respiratory Function
A direct relationship exists between the level of cord injury and the degree of respiratory dysfunction.
With high lesions (ie, C1 or C2), vital capacity is only 5-10% of normal, and cough is absent.
With lesions at C3 through C6, vital capacity is 20% of normal, and cough is weak and ineffective.
With high thoracic cord injuries (ie, T2 through T4), vital capacity is 30-50% of normal, and cough is weak.
With lower cord injuries, respiratory function improves.
With injuries at T11, respiratory dysfunction is minimal. Vital capacity is essentially normal, and cough is strong.
Other findings of respiratory disfunction include the following:
Agitation, anxiety, or restlessness

Poor chest wall expansion
Decreased air entry

Rales, rhonchi
Pallor, cyanosis
Increased heart rate
Paradoxic movement of the chest wall
Increased accessory muscle use
Moist cough

Spinal Level
With a complete transverse myelopathy, all motor and sensory function below the level of injury is absent. The neurological level of injury is the most caudal or lowest spinal cord segment with normal sensation and a muscle strength of 3/5 or better. An incomplete injury is present when there is preservation of any motor or sensory function below the zone of injury, including sacral sparing.

Upper cervical injuries can have brainstem effects
This cervicomedullary syndrome is characterized by respiratory dysfunction, hypotension, variable tetraparesis, hyperesthesia from C1 to C4, and sensory loss of the face with an onionskin pattern.

Partial or incomplete lesions of the spinal cord can result in four patterns of deficit. In the central cervical cord syndrome, the paresis involves the upper extremities, especially the hands, more than the lower extremities. The mechanism of injury is acute cord compression between bony bars or spurs anteriorly and thickened ligamentum flavum posteriorly, resulting in relatively more injury to the medial segments of the corticospinal tracts, which control arm function. The anterior cord syndrome, complete paralysis and hyperesthesia at the level of the lesion but intact light touch and vibration sense, is due to a large disc herniation compressing the anterior cord but without compression of the dorsal columns. The posterior cord syndrome is posterior column damage with impaired light touch and proprioception resulting from hyperextension injuries with fractures of the vertebral arch. The Brown-Séquard syndrome, caused by a lesion of half of the spinal cord, is defined by ipsilateral motor and proprioceptive loss and contralateral pain and temperature loss with the upper level one or two segments below the level of the lesion. This syndrome can occur after various injuries, including penetrating trauma, hyperextension and flexion injuries, locked facets, and compression fractures.

The conus medullaris syndrome is due to a compression injury at T12 that can occur from a disc herniation or a burst fracture of the body of T12. Because almost all the lumbar cord segments are opposite the T12 vertebral body, a severe compression can produce dysfunction in any or all of the lumbar as well as the sacral segments. Flaccid paralysis of the legs and anal sphincter with variable sensory deficits can be present. Because the spinal cord usually terminates at the L1–L2 disc space, trauma below this level injures the nerve roots. The cauda equina syndrome, which is compression of nerve roots below the L1 level, can be caused by fractures

A unique SCI syndrome—the burning hands syndrome—was first described in sports injury.[58] This syndrome appears to be a variation of central cord syndrome associated with severe burning paresthesias and dysesthesias in the hands and/or the feet. Other signs of neurological dysfunction are minimal or absent. Over 50 percent of the time there is an underlying spine fracture-dislocation. It is important to differentiate this syndrome from the much more common and usually innocuous "burner" or "stinger" of brachial plexus origin.

The syndrome of neurapraxia is also of special concern after athletic injury. Affected individuals experience dramatic, although transient, neurological deficits including quadriplegia. Frequently this syndrome is associated structurally with degenerative or congenital spinal canal stenosis. Many attempts have been made to quantitate the level of risk


In summary, spinal vertebral and spinal cord segmental levels are not necessarily the same. In the upper spinal cord, the first two cervical cord segments roughly match the first two cervical vertebral levels. However, the C3 through C8 segments of the spinal cords are situated between C3 through C7 bony vertebral levels. Likewise, in the thoracic spinal cord, the first two thoracic cord segments roughly match first two thoracic vertebral levels. However, T3 through T12 cord segments are situated between T3 to T8. The lumbar cord segments are situated at the T9 through T11 levels while the sacral segments are situated from T12 to L1. The tip of the spinal cord or conus is situated at L2 vertebral level. Below L2, there is only spinal roots, called the cauda equina.



Most clinicians would regard a person as complete if the person has any level below which no function is present. The ASIA Committee decided to take this criterion to its logical limit, i.e. if the person has any spinal level below which there is no neurological function, that person would be classified as a "complete" injury. This translates into a simple definition of "complete" spinal cord injury: a person is a "complete" if they do not have motor and sensory function in the anal and perineal region representing the lowest sacral cord (S4-S5).

bulbocavernosus reflex involves the S1, S2, S3 neurve roots and is spinal cord mediated reflex;

iscussion:
- bulbocaverosus reflex refers to anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley;
- reflex involves S-1, S-2, and S-3 nerve roots and is spinal cord- mediated reflex arc;
- following spinal cord trauma, presence or absence of this reflex carries prognostic significance;
- in cases of cervical or thoracic cord injury, absence of this reflex documents continuation of spinal shock
or spinal injury at the level of the reflex arc itself;
- period of spinal shock usually resolves w/ in 48 hours and return of bulbocavernosus reflex signals
termination of spinal shock;

Prognositic Significance:
- complete absence of distal motor or sensory function or perirectal sensation, together with recovery
of the bulbocavernosus reflex, indicates a complete cord injury, and in such cases it is highly
unlikely that significant neurologic function will ever return;
- therefore, if no motor or sensory recovery below the level of frx is present, pt has a complete
spinal cord injury and no further distal recovery of motor function can be expected;
- on other hand, any spared motor or sensory function below level of injury is considered
incomplete spinal cord injury;
- potential for recovery of incomplete lesion is determined by part of the cord most severely injured;

return of the bulbocavernosus reflex (anal sphincter contraction in response to squeezing the glans
penis or tugging on the Foley) signifies the end of spinal shock, and for complete injuries,
further neurologic improvement will be minimal;

along with sparing of perirectal sensation;

Practice Guidelines (Neurosurgery 2002 March Supplement)

Best Bets on Flex/Ex: no value in the 1st visit (Role of Flexion/Extension Radiography in neck injuries in adults)

- Anterior Subluxation:

- Ligamentous Instability:

- the flexed view is usually most helpful in detecting ligamentous injury that is not apparent on the neutral view

- ADI in children should be less than 3.5 mm;

- ADI in adults should be less than 3 mm;

- alignment of cervical canal should assume gentle kyphosis

- interspinous and interlaminar distances should remain symmetric, while facet joint & intervetebral spaces should not widen;

- vertebral body angulation / translation:

- as result of compression and rotation compenents, there is unilateral articular pillar frx, subluxation of contralateral facets,

- need to observe any abnormal movements of the C1-C2 level;

- distance > 3mm between anterior arch of Atlas & front of odontoid process is abnormal as is a distance

Calcitonin may help Spinal Fracture Pain (Blau LA et al: Analgesic efficacy of calcitonin for vertebral fracture pain. Ann Pharmacother 37:564, 2003;)

Neurologic deterioration secondary to unrecognized spinal instability following trauma--a multicenter study.
Spine, {Spine}, 15 Feb 2006, vol. 31, no. 4, p. 451-8, ISSN: 1528-1159.


STUDY DESIGN: A retrospective study was undertaken that evaluated the medical records and imaging studies of a subset of patients with spinal injury from large level I trauma centers. OBJECTIVE: To characterize patients with spinal injuries who had neurologic deterioration due to unrecognized instability. SUMMARY OF BACKGROUND DATA: Controversy exists regarding the most appropriate imaging studies required to clear the spine in patients suspected of having a spinal column injury. Although most bony and/or ligamentous spine injuries are detected early, an occasional patient has an occult injury, which is not detected, and a potentially straightforward problem becomes a neurologic catastrophe. METHODS: The study was designed as a retrospective review of patients who had neurologic deterioration as a direct result of an unrecognized fracture, subluxation, or soft tissue injury of the cervical, thoracic, or lumbar spine from 8 level I trauma centers. Demographics, injury information, and neurologic outcome were collected. The etiology and incidence of the missed injury were determined.


RESULTS: A total of 24 patients were identified who were treated or referred to 1 of the participating trauma centers and had an adverse neurologic outcome as a result of the missed injury. The average age of the patients was 50 years (range 18-92), and average delay in diagnosis was 19.8 days. Radiculopathy developed in 5 patients, 16 had spinal cord injuries, and 3 patients died as a result of their neurologic injury. The most common reason for the missed injury was insufficient imaging studies (58.3%), while only 33.3% were a result of misread radiographs or 8.3% poor quality radiographs. The incidence of missed injuries resulting in neurologic injury in patients with spine fractures or strains was 0.21%, and the incidence as a percentage of all trauma patients evaluated was 0.025%.

CONCLUSIONS: This multicenter study establishes that missed spinal injuries resulting in a neurologic deficit continue to occur in major trauma centers despite the presence of experienced personnel and sophisticated imaging techniques. Older age, high impact accidents, and patients with insufficient imaging are at highest risk.
 

Calcitonin may have good analgesic efficacy for vertebral fracture pain (Annals of Pharmacotherapy 2003;37:564)

Intranasal, rectal, and parenteral routes all provided good effect

Ephedrine PO may help

Midodrine

Fludrocortisone 0.1 mg BID

Airway Management

Review Article of intubation and its effects on c-spine injuries (Anesthesiology 2006;104(6):1293)

 DISCUSSION
TOP
ABSTRACT
METHODS
RESULTS
DISCUSSION
CONCLUSIONS
APPENDIX A
APPENDIX B
REFERENCES


The evidence for the use of methylprednisolone after acute, blunt spinal cord injury comes from subgroup analysis of one trial, NASCIS II. However, closer analysis of the trial’s results casts doubt on their robustness. NASCIS II was designed to assess the effects of methylprednisolone (or naloxone) on acute spinal cord injury when given within 12 h of injury; overall no treatment benefit was demonstrated when comparing the treated groups to those given placebo. The authors of the trial concentrated instead on evidence of benefit coming from a subgroup analysis of those patients treated within 8 h of injury. In this group it was claimed that patients treated within 8 h with methylprednisolone had significant improvement in motor function (p = 0.03), sensation to pinprick (p = 0.02), and touch (p = 0.03). The authors claimed that the 8 h subgroup had in fact been defined a priori, although the design of the trial fails to make this clear and the reliance on subgroup analysis undoubtedly detracts from the quality of the paper. It has also be argued that the placebo group treated before 8 h did poorly, not only compared to the methylprednisolone group treated before 8 h, but also in comparison to the placebo group treated after 8 h, suggesting that the positive result was caused by a weakness in the control group.8

Other criticisms levelled at the study include the charge that as no functional measurement of patient recovery was undertaken, it was therefore impossible to assess whether the improvement of motor and sensory scores demonstrated had any clinical significance,9 and that there was no consistency of approach in other treatment aspects between centres.6,12. A 1 year follow up found no significant difference between the patient groups in all neurological modalities studied.13

As with NASCIS II, the subsequent NASCIS III (which did not include a control group) has also been criticised for its reliance on post hoc subgroup analysis. The authors claimed the trial demonstrated a benefit in giving methylprednisolone even earlier, within 3 h of injury. As with NASCIS II, all primary outcomes defined before patient enrolments were negative, and the only interesting findings were encountered when post hoc analyses were performed.8 As a consequence of subgroup analysis, almost 70% of the patient population was excluded from further analysis and it has also been suggested that the small changes in neurologic function described were not clinically significant.14,15 Although the improvement was greatest in those with incomplete injuries at 6 weeks, as with NASCIS II, the benefits seen were not sustained at 1 year.

Despite the incorporation of recommendations for the use of methylprednisolone into ATLS guidelines, and the widespread publicity surrounding the publication of NASCIS II, including dissemination of results to clinicians before the release of the scientific paper,16 implementation of those guidelines has not been universal. Even in the USA, where it has been suggested that any physician who does not administer methylprednisolone will place themselves in "severe legal jeopardy",17 Gerhart et al reported clear documentation of implementation of the protocol in only 46% of eligible patients in 1990–91, rising to a maximum of 61% in 1993.18
 

Power's Calculation

Powers ratio measurement. Ratio = BC/OA; normal is <1. A, anterior arch of C1; B, basion; C, posterior arch of C1; O, opisthion.
From:   Spiteri: J Trauma, Volume 61(5).November 2006.1171-1177
 

Of importance in our extended study was that both helical CT and DS missed an atlanto-occipital dislocation. Powers’ et al.34 described a method of detection of this injury on plain radiographs. The distance between the basion and the posterior arch of C1 is measured in relationship to the distance between the opisthion and the anterior arch of C1 with a normal value being <1 (Fig. 4). However, poor visualization with plain radiography results in frequent false negative and false positive ratios. Recognition of an abnormal Powers’ ratio, calculated from the CT scan, might have allowed a more prompt diagnosis and it is our opinion that this is a more reliable means of detecting this particular injury, rather than by greater scrutiny of the DS images alone.

Powers B, Miller MD, Kramer RS, Martinez S, Gehweller JA. Traumatic anterior atlanto-occipital dislocation. Neurosurgery. 1979;4:12–17. External Resolver [Context Link]

positive flexex