75 - spine trauma and spinal cord injury - semantic … · 645 spine trauma and 75 spinal cord...

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75 Spine Trauma and Spinal Cord Injury

Michelle Lin and Swaminatha V. Mahadevan

PATHOPHYSIOLOGY

In the setting of spinal trauma, the bone, ligaments, spinal cord, and vascular structures may be injured. Anatomically, the vertebral bony spine can be divided into structural columns. The cervical spine is traditionally divided into two columns—anterior and posterior. The anterior column consists of the load-bearing vertebral bodies, intervertebral disks, anterior longitudinal ligament, and posterior longitudinal ligament (Fig. 75.1). The posterior column consists of the more poste-rior structures, including the pedicles, laminae, and transverse and spinous processes (Fig. 75.2).

In contrast, the thoracic and lumbar vertebral spines are divided into three columns based on the modified Denis model—anterior, middle, and posterior (Fig. 75.3). The anterior column consists of the anterior longitudinal ligament, the anterior two thirds of the vertebral body, and the interver-tebral disk. The middle column consists of the posterior longitudinal ligament, the posterior third of the vertebral body, and the intervertebral disk. Any disruption of the middle column predisposes a patient to significant spinal cord injury because the middle column abuts the spinal canal. The posterior column consists of the remaining posterior structures.

The C1 and C2 vertebrae are anatomically unique (Fig. 75.4). C1 (atlas) is a ring-link structure without a vertebral body. It articulates superiorly with the occipital condyles. This articulation allows 50% of normal neck flexion and extension. C2 (axis) projects the dens superiorly to articulate with C1. The transverse ligament tethers the dens to the anterior arch of C1. This atlantoaxial articulation allows 50% of normal neck rotation left and right.

The spinal cord spans from the foramen magnum to the L1 level, whereupon the spinal cord tapers into the conus medul-laris and cauda equina, a collection of peripheral lower lumbar and sacral nerve roots. Because the spinal cord is thickest in the cervical spine, there is relatively less spinal canal space in the cervical levels than in the thoracic or lumbar spine. Thus spinal cord injuries occur more frequently with cervical spine trauma than with thoracic or lumbar spine trauma. The neurologic dermatomes can help localize the injury (Table 75.1).

The vertebral arteries branch off the subclavian arteries and course superiorly within the transverse foramina of C2 to C6. These arteries then merge to form the basilar artery.

• Patientswithspinalpainandspinefracturesshouldreceiveathoroughneurologicexaminationtolookforspinalcordinjury.

• Spinefracturesareassociatedwithahighincidenceofconcurrentnoncontiguousspinefracturesandspinalcordinjuries.

• TheNationalEmergencyX-radiographyUtilizationStudycriteriaortheCanadianCervical-SpineRulecriteriacanbeusedtoidentifylow-riskpatientswhodonotneedcervicalspineimaging.

• Imagingwithplainfilmsversuscomputedtomographyofthecervicalspineshouldbebasedonthepretestprobabilityofasignificantinjuryandtheirradiationriskwithcomputedtomography.

• Spinalshock,ortransientphysiologictransectionofthespinalcordasaresultoftrauma,isdifferentfromneurogenicshock,whichisphysiologicsympathectomyoftheupperspinalcordleadingtoperipheralvasodilation.

• Patientswithaspinalcordinjurycausedbyblunttraumaareoftengivenhigh-dosecorticosteroidswithin8hoursofinjury,althoughsuchtherapyiscontroversial.

KEY POINTS

EPIDEMIOLOGY

The estimated annual cost of spine injuries, including inability to work and health care costs, exceeds $5 billion in the United States.1

In the emergency department (ED), all trauma victims are screened for vertebral fractures, ligamentous disruptions, and spinal cord injuries because of the potentially devastating neurologic consequences of overlooking these injuries. Patients with a delayed diagnosis of spinal fracture are 7.5 times more likely to sustain secondary neurologic deficits.2 Neurologic deficits from spinal cord injury may be subtle and can easily be missed if not specifically evaluated. Adding to these difficulties, plain film radiographs of the spine, though an adequate screening tool for other fractures, can miss 23% to 42% of cervical spinal fractures3,4 and 13% to 50% of lumbar fractures.5,6

SECTION VIII TRAUMATIC DISORDERS

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Patients with spinal cord injuries may have a spectrum of findings ranging from subtle neurologic deficits to grossly obvious paralysis. Spinal cord injuries should be suspected in any trauma victim who complains of neck or back pain, espe-cially pain exacerbated by movement. Neurologic symptoms suggesting spinal cord injury include numbness, tingling, par-esthesias, focal weakness, and paralysis. Other worrisome symptoms include urinary or fecal incontinence and urinary retention. Unconscious patients and those with impaired con-sciousness secondary to intoxication may harbor occult spinal cord injuries. Physical examination should focus on the spine and areas where associated injuries may occur (Tables 75.2 to 75.4).

PRESENTING SIGNS AND SYMPTOMS

Patients with vertebral fractures usually have significant midline spinal tenderness on palpation. High-risk findings include spinal soft tissue swelling, ecchymosis, and step-off misalignment of the spine. Pain radiating along a dermatomal distribution suggests an associated radiculopathy. Thoracic spine fractures are uncommon because the articulating ribs provide stability to the spinal column; however, the thoraco-lumbar junction (encompassing the T10 to L2 vertebral levels) is commonly injured because the spine curvature changes from the kyphotic thoracic spine to the lordotic lumbar spine.

Fig. 75.1 Bony anatomy of a typical lower cervical vertebra (C3-C7): superior axial view with the anterior aspect oriented upward and the posterior aspect oriented downward.

Spinous process

Lamina

Spinal canal

Superior articular facet

Pedicle

Transverse process

Transverse foramen

Lower cervical spine

Vertebral body

Nucleus pulposus(disk)

Annulus fibrosus(disk)

Fig. 75.2 Bony anatomy of a typical thoracic and lumbar vertebra (T1-L5): superior axial view with the anterior aspect oriented upward and the posterior aspect oriented downward.

Spinous process

Lamina

Spinal canal


Pedicle

Transverse process

Vertebral body

Thoracic/lumbar spine

Nucleus pulposus(disk)

Annulus fibrosus(disk)

Fig. 75.3 Schematic diagram illustrating the lateral view of the anatomic columns of the cervical and thoracic/lumbar spine.Notethatthecervicalspine’santeriorcolumniscomposedofthesamestructuresasthethoracic/lumbarspine’santeriorandmiddlecolumns.

Vertebral bodyIntervertebral disk

Spinous processTransverse processSpinal canal

Cervical spine columns:

Thoracic-lumbar spinecolumns

Anterior Posterior

PosteriorMiddleAnterior

Fig. 75.4 Bony anatomy of the upper cervical spine (C1 and C2): posterolateral view.TheC1lateralmassesarticulatewiththeoccipitalcondyles.TheC2densprojectscephalad,articulateswiththeC1anteriorarch,andisstabilizedbytheC1transverseligament.

Spinous process

Transverseligament


Transverse processTransverse foramen

Pedicle

Dens

Lateral mass

Transverse processTransverse foramen

Anterior archC1 atlas

C2 axis

Posterior arch

Table 75.1 Individual Spinal Sensory Dermatomes, Motor Function, and Reflex Arcs

SPINAL LEVEL SENSORY DISTRIBUTION MOTOR FUNCTION REFLEX

C2 Occiput

C3 Thyroidcartilage

C4 Suprasternalnotch Spontaneousrespiration

C5 Infraclaviculararea Shouldershrugging Biceps

C6 Thumb Elbowflexion Triceps

C7 Indexfinger Elbowextension

C8 Littlefinger Fingerflexion(withT1)

T4 Nippleline

T10 Umbilicus

L1 Inguinalligament Hipflexion(withL2)

L2 Medialthigh Hipflexion

L3 Medialthigh Hipadduction

L4 Medialfoot Hipabduction Patellar

L5 Webspacebetweenbigtoeandsecondtoe Footdorsiflexion

S1 Lateralfoot Footplantarflexion(withS2) Achilles

S2 Perianalarea(withS3,S4) Footplantarflexion

S3-4 Perianalarea Rectalsphinctertone

Table 75.2 Physical Examination Findings Associated with Vertebral Fractures and Spinal Cord Injuries

INJURYPHYSICAL EXAMINATION AREA ASSOCIATED FINDINGS

Vertebralfracture

Spine Tendernessoftheneckand/orback.Examinetheentirespinebecausevertebralfracturesmayoccurinmultiples.

Neurologic Seespinalcordinjurybelow.Chest Thoracic spine fractures:Checkforchesttenderness,unequalbreathsounds,andarrhythmia,

whicharesuggestiveofanassociatedintrathoracicinjuryormyocardialcontusion.Abdomen/pelvis Thoracolumbar and lumbar spine fractures:Checkforabdominalorpelvictenderness.For

instance,upto50%ofpatientswithatransverseprocessfracture7and33%ofpatientswithaChancefracture8haveconcurrentintraabdominalpathology.Atransverseareaofecchymosisonthelowerabdominalwall(seatbeltsign)increasesthechanceofanabdominopelvicinjury.

Extremity Thoracolumbar and lumbar spine fractures:Checkforcalcanealtendernessbecause10%ofcalcanealfracturesareassociatedwithalowthoracicorlumbarfracture.Mechanistically,theseareasarefracturedasaresultofaxialloading.

Spinalcordinjury

Neurologic,motor(anteriorcolumn)

Assessmotorfunctiononascaleof0to5(seeTable75.3).Motor levelisdefinedasthemostcaudalsegmentwithatleast3/5strength.Injuriestothefirsteightcervicalsegmentsresultintetraplegia(previouslyknownasquadriplegia);lesionsbelowtheT1levelresultinparaplegia.

Neurologic,sensory(spinothalamictract)

Assesssensoryfunctionviapinprickandlighttouchonthefollowingscale:0=absent;1=impaired;2=normal.Thesensory levelisdefinedasthemostcaudalsegmentofthespinalcordwithnormalsensoryfunction.Thehighestintactsensorylevelshouldbemarkedonthepatient’sspinetomonitorforprogression.

Neurologic,sensory(dorsalcolumn)

Assessvibratorysensoryfunctiononascaleof0to2byusingatuningforkoverbonyprominences.Assesspositionsense(proprioception)byflexingandextendingthegreattoe.

Neurology,deeptendonreflex

Onascaleof0to4,assessthedeeptendonreflexesintheupper(biceps,triceps)andlower(patellar,Achilles)extremities(seeTable75.4).

Anogenital Assessrectaltone,sacralsensation,signsofurinaryorfecalretentionorincontinence,andpriapism.Alsochecktheanogenitalreflexes:ananal wink(S2-S4)ispresentiftheanalsphinctercontractsinresponsetostrokingtheperianalskinarea.Thebulbocavernosus reflex(S3-S4)iselicitedbysqueezingtheglanspenisorclitoris(orpullingonaninsertedFoleycatheter),whichresultsinreflexivecontractionoftheanalsphincter.

Head-to-toeexamination

Aspinalcordinjurymaymaskapatient’sabilitytoperceiveandlocalizepain.Imagingofhigh-riskareas,suchastheabdomen,andareasofbruisingorswellingmayberequiredtoexcludeoccultinjuries.


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Spinal shock is a neurologic phenomenon resulting from physiologic transection of the spinal cord. It results in flaccid paralysis and loss of reflexes below the level of the spinal cord lesion. Spinal shock is temporary, commonly lasting for 24 to 48 hours, although it can persist for weeks. Patients suffering from spinal shock may appear (clinically) to have a complete spinal cord injury only to “miraculously” recover once the spinal shock has passed. Termination of spinal shock is identi-fied by return of segmental reflexes; anogenital reflexes are the earliest to recover.

Neurogenic shock may occur in patients with cervical or high thoracic spinal cord injuries. It is a neurocardiovascular phenomenon resulting from impairment of the descending sympathetic pathways in the spinal cord. As a result, vasomo-tor tone is lost and visceral and peripheral vasodilation and hypotension ensue. Diminished sympathetic innervation to the heart also occurs and results in relative bradycardia despite the presence of hypotension.

DIFFERENTIAL DIAGNOSIS AND MEDICAL DECISION MAKING

INDICATIONS FOR CERVICAL SPINE IMAGING

In the year 2000, in the hope of reducing the number of low-risk patients undergoing cervical spine plain film radiography, a multicenter study by the National Emergency X-radiography Utilization Study (NEXUS) group validated a set of five low-risk criteria for determining which patients do not require radiographic imaging if all the criteria are met (Box 75.1). This clinical decision tool demonstrated a sensitivity of 99.6% and a specificity of 12.9% for detecting clinically significant cervical spine fractures. It was thus extrapolated that 4309 (12.6%) of the 34,069 patients enrolled could have avoided plain film radiography.9

Following development of the NEXUS criteria, the Cana-dian Cervical-Spine Rule (CCR) was developed (Fig. 75.5). The validated sensitivity and specificity for this decision rule were 99.4% and 45.1%, respectively.10

The CCR study excluded the following subjects: patients younger than 16 years; patients with an abnormal Glasgow Coma Scale score, abnormal vital signs, injuries more than 48 hours old, penetrating trauma, paralysis, and history of vertebral disease; patients seen previously for the same injury;

Table 75.3 Graded Assessment of Motor Function

GRADE ASSESSMENT ON PHYSICAL EXAMINATION

0 Noactivecontraction

1 Tracevisibleorpalpablecontraction

2 Movementwithgravityeliminated

3 Movementagainstgravity

4 Movementagainstgravityandresistance

5 Normalpower

Table 75.4 Graded Assessment of Deep Tendon Reflexes

GRADE ASSESSMENT ON PHYSICAL EXAMINATION

0 Reflexesabsent

1 Reflexesdiminishedbutpresent

2 Normalreflexes

3 Reflexesincreased

4 Clonuspresent

BOX 75.1 NEXUS Low-Risk Criteria for a Cervical Spine Injury

Apatientdoesnotrequirecervicalspineradiographicimagingifallfiveofthefollowinglow-riskconditionsaremet:1. Noposteriormidlineneckpainortenderness2. Nofocalneurologicdeficit3. Normallevelofalertness4. Noevidenceofintoxication5. Noclinicallyapparent,painfuldistractinginjury*

*Definedasaconditionthoughtbythecliniciantobeproducingpainsuf-ficienttodistractpatientsfromasecond(neck)injury.

FromHoffmanJR,MowerWR,WolfsonAB,etal.Validityofasetofclini-cal criteria to rule out injury to the cervical spine in patients with blunttrauma.NEnglJMed2000;343:94-9.NEXUS,NationalEmergencyX-radiographyUtilizationStudy.

and pregnant patients. Because these cases were not studied, the CCR guidelines should not be applied to such patients.

CHOOSING THE IMAGING MODALITY TO EVALUATE THE CERVICAL SPINE (Fig. 75.6)When patients have at least one high-risk criterion for a spinal fracture, imaging begins with either plain films or computed tomography (CT) scans. The pros and cons of both imaging approaches are listed in Table 75.5.

Patients with symptoms suggestive of a spinal cord injury should undergo CT and magnetic resonance imaging (MRI) of suspicious areas of the spine. Although plain films and CT do not directly reveal spinal cord injuries, they may supply indirect evidence of such injuries. Spinal cord injury without radiographic abnormality (SCIWORA) is a traumatic myelop-athy in which no abnormalities can be identified on plain films or CT.

Computed TomographyWith increasing evidence in the literature showing that CT is much more sensitive (98%) than plain film radiography (53%) in detecting cervical spine fractures, future recommendations will probably recommend cervical spine CT as the first-line diagnostic approach for most patients because of the neuro-logic significance of a missed cervical spine injury.11 Conven-tional radiography is especially difficult to interpret in the high cervical spine (occiput, C1, C2) and cervicothoracic

CHAPTER 75 SpInE TRAUMA AnD SpInAl CORD InjURy

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Fig. 75.5 Canadian Cervical-Spine Rule (CCR) algorithm for clinical clearance of the cervical spine.Thegreen boxsignifiesalow-risk,negativework-upandclinicalcervicalspineclearance.Orange boxessignifyamoderate-riskcondition,andthered boxsignifiesahigh-riskcondition,bothofwhichrequireplainfilmradiography.ED,Emergencydepartment;GCS,GlasgowComaScale;RR,respiratoryrate;SBP,systolicbloodpressure.(DatafromStiellIG,ClementCM,McKnightRD,etal.TheCanadianC-SpineRuleversustheNEXUSlow-riskcriteriainpatientswithtrauma.NEnglJMed2003;349:2510-8.)

• Age ≥ 16 years• GCS score of 15• Normal vital signs (RR, 10-24 breaths/min; SBP > 90 mm Hg)• Injury within 48 hours• Blunt (not penetrating) neck trauma mechanism• No acute paralysis• No known vertebral disease• Not evaluated previously for the same injury• Not pregnant

• Age ≥ 65 years• Dangerous mechanism � Fall from ≥3 feet or 5 stairs � Axial loading to the head � Motor vehicle crash at >62 mph (100 km/hr) � Motor vehicle crash with rollover or ejection � Motorized recreational vehicle crash � Bicycle crash• Extremity paresthesias

Yes

Yes

• Simple rear-end motor vehicle crash• In a sitting position in the ED• Ambulatory at any time after the trauma• Delayed onset of neck pain• Absence of midline cervical spine tenderness

No

Fulfills ALL eligibility requirements?

Presence of ≥1 high-risk finding?

Presence of ≥1 low-risk finding?

Yes

Able to rotate neck 45° left and right actively?

Yes

Low risk:Cervical spine clinically cleared

High risk:Obtain imaging

No Moderate risk:Obtain imaging

No Moderate risk:Obtain imaging

junction (C6, C7, T1), where coincidentally most cervical spine fractures occur.12 It is important to obtain sagittal CT reconstructions, in addition to the traditional axial views, to adequately assess spinal alignment.

Cost analyses have shown that cervical spine CT scans are actually less expensive than conventional radiography in high-risk patients. These studies factored personnel time, delays in patient management while obtaining films, and the neurologic sequelae of initially missing a cervical spine injury. Cost savings are especially evident if the patient is already under-going CT imaging of other body parts, such as head scanning for a closed head injury. With multidetector scanners being more readily available, an additional cervical spine scan would add less than 5 minutes of scan time at a relatively small cost.13

The risk for cancer from irradiation serves as the major deterrent against universally performing CT in all patients with neck trauma. It is estimated that up to 2% of cancers in the United States are attributable to CT studies.14 The thyroid gland, breast tissue, and lens are exposed to especially high levels of radiation in cervical spine CT, thus placing the patient at high risk for the development of thyroid cancer, breast cancer, and cataracts. Patients receive an effective dose of 0.2 millisievert (mSv) and 6 mSv for cervical spine plain films and CT, respectively. In contrast, the effective dose of a posteroanterior and lateral chest radiograph is just 0.1 mSv.15 The overall lifetime carcinogenic risk from CT imaging, however, varies depending on the patient’s age at the time of irradiation. Younger patients have greater risk, partly because they have more years of life left for the development of cancer.


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Magnetic Resonance ImagingMRI is the best available modality for detection and charac-terization of spinal cord injury, but it is less sensitive than CT for cervical spine fractures. In an acute trauma patient with potential spinal injury, indications for emergency MRI include (1) complete or incomplete neurologic deficits suspicious for a spinal cord injury, (2) deterioration of spinal cord neurologic function, and (3) signs of unstable ligamentous injury. Abnor-mal MRI findings may include the presence of spinal canal compromise, disk herniation, and spinal cord edema or hemorrhage.

OLDER AND OSTEOPENIC PATIENTSPatients older than 65 years old and those taking corticoste-roids on a long-term basis are probably osteopenic. They can sustain spinal fractures with mild trauma, such as a fall from a standing position, and often exhibit minimal associated pain. Specifically, patients older than 65 years have an increased risk for cervical spine fracture (relative risk of 2.09).16 In addition, acute back pain in chronic corticosteroid users is correlated with 99% specificity for a spinal compression frac-ture.17 Thus, imaging should be performed in these potentially osteopenic patients in the setting of neck or back pain.

CLINICAL CLEARANCE OF THE CERVICAL SPINENot all patients require cervical spine imaging. To clinically clear a cervical spine, the patient’s neck should be reevaluated for tenderness. First, unfasten the cervical collar. Next, palpate the posterior aspect of the patient’s neck while applying the other hand to the patient’s forehead to prevent spontaneous and reflexive head lifting. In the absence of significant midline tenderness, remove your hands and instruct the patient to actively lift the head off the gurney and place the neck through a range of motion by looking right, left, caudad, and cephalad. Do not assist the patient.

If the patient is able to move spontaneously and easily without pain or neurologic symptoms, the patient’s neck is considered to be “clinically cleared” and the collar may be removed.

Furthermore, children are more radiosensitive. If irradiated after 40 years of age, the risk reaches its nadir, with an esti-mated lifetime attributable risk for death from cancer of less than 0.2%.14

Because of such concerns for radiation exposure, low-risk patients should undergo conventional radiography. Only patients with radiographic evidence of an injury on plain films should subsequently undergo CT scanning. For moderate- to high-risk patients, cervical spine CT should be the first-line imaging modality, especially for patients scheduled for CT scanning of another body part.

Flexion-Extension Plain Film RadiographyA normal cervical CT image adequately excludes a cervical spine fracture but cannot sufficiently evaluate ligamentous instability. In patients who have sustained significant flexion, extension, or rotational injury to the neck and have persistent neck pain, ligamentous stability should be assessed within 10 days either in the ED or by a neurosurgeon or orthopedic spine specialist.

In the ED, patients who are awake and alert and can actively flex and extend their neck 30 degrees may undergo flexion-extension plain film radiography to evaluate for spinal stability. Vertebral body subluxation or focal widening of the spinous processes suggests an unstable ligamentous injury. Because no serious adverse outcomes have resulted from voluntary neck movement by an awake, alert patient without neurologic deficits, manual manipulation of the patient’s neck should be avoided during flexion-extension radiography.

Many acutely injured patients have such severe associated cervical muscle spasms that they have limited neck mobility. As a result, flexion-extension films are often inadequate, and these patients should be immobilized in a semirigid cervical collar (e.g., a Philadelphia or Miami J collar) and undergo delayed flexion-extension plain film radiography after 7 to 10 days, when the cervical muscle spasm diminishes.

Table 75.5 Advantages and Disadvantages of Plain Film Imaging and Computed Tomography of the Cervical Spine

PLAIN FILM RADIOGRAPHY COMPUTED TOMOGRAPHY

Advantages Lessirradiationofthethyroid,breast,andlensCanbeperformedatthebedside

98%sensitivityindetectingfracturesMorecost-effectivethanplainfilmsLessdelayinpatientmanagement,especiallyifthepatientis

alreadygoingtoCTscannerforimagingofanotherbodypart

Disadvantages Only53%sensitivityindetectingfracturesThree-viewfilmsareinadequate>50%ofthetime,

especiallyfilmsofthecervicocranialandcervicothoracicjunction

Inefficientuseofradiologypersonnel,whoareoftenrepeatingfilmsbecauseofimageinadequacy

AsuspiciousfractureoronedetectedonplainfilmsrequiresadditionalevaluationbyCTforconfirmationandfurtherdelineation

Moreirradiationofthethyroid,breast,andlensRequiresthepatienttobehemodynamicallystablebecause

ofbeingtransportedoutoftheemergencydepartmenttotheCTscanner


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FACTS AND FORMULAS

Tenpercentofspinalfractureshaveasecondnoncontigu-ousfracturealongthevertebralspine.

Ten percent of patients with a calcaneal fracture have anassociatedthoracicorlumbarfracture.

The most commonly fractured cervical spine level is C2,especiallyintheelderly.

Approximately 20% of computed tomography–confirmedburstfracturesinthethoracicandlumbarspineappearaswedgefracturesonplainfilmradiography.18

High-dosemethylprednisoloneisadministeredasa30-mg/kgbolusandthenasa5.4-mg/kg/hrinfusionfor24hours(if started within 3 hours of injury) or for 48 hours (ifstartedwithin8hoursofinjury).

Considerearlyendotrachealintubationinspinalcordinjurypatients with a negative inspiratory force of less than−25cmH2Ooravitalcapacityoflessthan15mL/kg.

Table 75.6 Classic Upper Cervical Spine Injury Patterns (C1-C2)*

INJURY MECHANISM STABILITY FIGURE COMMENTS

Atlantooccipitaldislocation

Flexion Unstable 75.7,A OfteninstantlyfatalMorecommoninchildrenbecauseofsmall,horizontallyoriented

occipitalcondylesDislocationcanbeanterior(mostcommon),superiorlydistracted,or

posterior

Anterioratlantoaxialdislocation

Flexion Unstable 75.7,B AssociatedwithruptureofthetransverseligamentMostcommonlyoccursinpatientswithrheumatoidarthritisand

ankylosingspondylitisfromligamentlaxityWideningofthepredentalspaceseenonlateralplainfilms

Jeffersonfracture(C1burstfracture)

Axialcompression

Unstable 75.7,C 33%withassociatedC2fractureLowincidenceofneurologicinjurybecauseofawideC1spinalcanalUsuallyinvolvesfracturesofboththeanteriorandposteriorC1

arches,oftenwith3or4fracturefragmentsComplication:transverseligamentrupture,especiallyiftheC1lateral

massesare≥7mmwiderthanexpected(MRIrecommended);vertebralarteryinjury(CTangiographyrecommended)

C1posteriorarchfracture

Extension Stable 75.7,C AnassociatedC2fracture(occurs50%oftime)makesaposteriorarchfractureunstable

Onplainfilms,nodisplacementoflateralmassesontheodontoidviewandnoprevertebralsofttissueswelling,unlikeaJeffersonburstfracture

C2densfracture Flexion Variable 75.7,D Type I (stable):AvulsionofthedenswithanintacttransverseligamentType II (unstable):Fractureatthebaseofthedens;10%havean

associatedruptureofthetransverseligament—MRIprovidesadefinitivediagnosisofligamentrupture

Type III (stable):Fractureofthedensextendingintothevertebralbody

Hangman’sfracture(C2spondylolisthesis)

Extension Unstable 75.7,E BilateralC2pediclefracturesAtriskfordisruptionofthePLL,C2anteriorsubluxation,andC2-C3

diskruptureLowriskforspinalcordinjurybecauseofC2anteriorsubluxation,

whichwidensthespinalcanal

Extensionteardropfracture

Extension Unstable 75.7,F SmalltriangularavulsionoftheanteroinferiorvertebralbodyattheinsertionpointoftheALL

OccursmostfrequentlyattheC2levelbutcanoccurinthelowercervicalspine

Complication:centralcordsyndromeasaresultoftheligamentumflavumbucklingduringhyperextension

RequiresCTdifferentiationfromaveryunstableflexionteardropfracture(see“flexionteardropfracture”inTable75.7)

*Listedinprogressiveorderfromtheocciput,toC1,toC2.ALL,Anteriorlongitudinalligament;CT,computedtomography;MRI,magneticresonanceimaging;PLL,posteriorlongitudinalligament.

CLASSIC FRACTURE PATTERNS (Tables 75.6 to 75.8; Figs. 75.7 to 75.9)

CERVICAL SPINE INJURIESBased on the NEXUS study of 818 patients with cervical spine injury, fractures occurred most commonly at the level of C2 (24% of all fractures), C6 (20%), and C7 (19%). Anatomically, the most commonly fractured part of the cervi-cal spine was the vertebral body, which accounted for 30% of fractures at the C3 to C7 levels. It was more common than fractures of the spinous process (21%), lamina (16%), and articular process (15%). Subluxations occurred most com-monly at the C5-C6 (25%) and C6-C7 (23%) levels.19

THORACIC AND LUMBAR SPINE INJURIESSimilar to patients undergoing cervical spine assessment, low-risk patients may selectively be cleared clinically without radiographic imaging. Although no large studies of thoracic and lumbar spine injuries equivalent to the NEXUS and CCR


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Fig. 75.7 A,Cross-sectionalsagittalviewofanterioratlantooccipitaldislocationwithassociatedspinalcordinjury.B,Posterolateralviewofanterioratlantoaxialdislocationfromruptureofthetransverseligament.C,PosterolateralviewofaC1JeffersonburstfracturethroughtheanteriorandposteriorarchandanisolatedC1posteriorarchfracture.D,PosterolateralviewofthethreetypesofC2densfractures.E,Sagittalviewofahangman’sfracturewithbilateralC2pediclefracture.PLL,Posteriorlongitudinalligament.F,SagittalviewofaC2extensionteardropfracture.ALL,Anteriorlongitudinalligament.

Stretchedspinal cord

Anterior atlantoocciptaldislocation

Brain

Skull

A

C1 atlas

C2 axis

Dens

Anterior dislocationof C1 over C2

Rupturedtransverse ligament

B

Posterior arch

Transverse ligament

Lateral mass

Anterior archC1 burst fracture

C

Type I

Type II

Type III

Dens

D

Risk for C2subluxation

from PLL rupture

Bilateral C2pedicle fracture

Risk forC2-C3

disk rupture

C1

C2

E

Neckextension

Avulsion ofC2 body

ALL

C1

C2

F

projects have been conducted, recommendations can be extrapolated from the relevant literature.

Based on the NEXUS criteria, patients with (1) significant back pain or tenderness, (2) clinical evidence of drug- or alcohol-related intoxication, (3) lower extremity neurologic deficits, (4) Glasgow Coma Scale score lower than 15, or (5) a distracting injury cannot be cleared clinically for a thoracic

or lumbar fracture. Patients with alcohol intoxication, for example, should not be cleared clinically until they are sober and found to fulfill no other high-risk criteria.

Furthermore, based on the CCR criteria and the American Healthcare Research and Quality “red flag” indications for imaging, injured patients who are (1) older than 65 years with any degree of back pain or tenderness, (2) are receiving


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below the level of injury. During the first few days following injury, this diagnosis cannot be made with certainty because of the possibility of concurrent spinal shock.

INCOMPLETE INJURYA spinal cord injury is incomplete if motor function, sensa-tion, or both are partially present below the level of the injury. Signs of an incomplete injury may include (1) the presence of any sensation or voluntary movement in the lower extremi-ties or (2) evidence of sacral sparing. Signs of sacral sparing include perianal sensation, voluntary anal sphincter contrac-tion, and voluntary great toe flexion.

chronic corticosteroid therapy, or (3) have a history of verte-bral disease should undergo radiography.

Classic patterns of thoracic and lumbar spine injuries are shown in Table 75.8.

CLASSIFICATION OF SPINAL CORD INJURIES

COMPLETE INJURYA spinal cord injury is classified as physiologically complete if the patient has no demonstrable motor or sensory function

Table 75.7 Classic Lower Cervical Spine Injury Patterns (C3-C7)


Articularmassfracture

Flexion-rotation

Stable 75.8,A AssociatedwithtransverseprocessandvertebralbodyfracturesUncommon

Burstfracture Axialcompression

Stable 75.8,B CompressivefractureoftheanteriorandposteriorvertebralbodyIntactALLandPLLComplication:spinalcordinjurybecauseofaretropulsedvertebral

bodyfragment(especiallyanteriorcordsyndrome)

Clayshoveler’s(spinousprocess)fracture

Flexion Stable 75.8,B SpinousprocessfracturefromforcefulneckflexionMostcommonlyoccursinthelowercervicallevels,usuallyC7Notassociatedwithneurologicinjury

Extensionteardropfracture

Extension Unstable 75.7,F MostcommonlyoccursatC2SeeTable75.6

Facetdislocation,bilateral

Flexion Unstable 75.8,C Significantanteriordisplacement(>50%)ofthespinewhenbilateralinferiorfacetsdisplaceanteriortothesuperiorfacetsbelow

Atriskforinjuringthedisk,vertebralarteries,andspinalcord

Facetdislocation,unilateral

Flexion-rotation

Stable 75.8,D Usuallycauses25-50%anteriordisplacementofthespineComplication:vertebralarteryinjury(CTangiographyrecommended)

Flexionteardropfracture

Flexionandaxialloading

Unstable 75.8,E Oneofthemostunstablefracturesinthelowercervicalspinebecauseitinvolvesbothcolumns

Fractureandanteriordisplacementoftheanteroinferiorvertebralbody(appearssimilartoanextensionteardropfractureexceptthatitismuchmoreunstable)

Uniquefindingsforflexion(versusextension)teardropfracturesincludesame-levelfracturesanddisplacementofposteriorstructures

RuptureofbothALLandPLLcomplexesUsuallyoccursatC5orC6CanresultfromdivingintoshallowwaterorafootballtacklinginjuryOftenassociatedwithspinalcordinjuryandtetraplegia

Subluxation,anterior Flexion Unstable 75.8,F AnteriorslippingofavertebraoveranotherRupturedPLLsuchthattheanteriorandposteriorvertebrallinesare

disruptedComplication:vertebralarterydissection(CTangiography

recommended)Maybeevidentonlyduringflexionviewsbyconventionalradiography

whentheinterspinousdistancewidensandthevertebralbodysubluxatesanteriorly

Transverseprocessfracture

Lateralflexion Stable 75.8,A Complication:vertebralarteryinjurybecauseittravelswithinthetransverseforamina(CTangiographyrecommended);associatedcervicalradiculopathyandbrachialplexusinjuriesin10%ofcases

Wedgefracture Flexion Stable 75.8,G Compressionfractureofonlytheanterosuperiorvertebralbodyendplate

DisruptionoftheanteriorvertebrallineIntactposteriorvertebralbodyandposteriorvertebralline

ALL,Anteriorlongitudinalligament;CT,computedtomography;PLL,posteriorlongitudinalligament.


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Vertebral body

Transverse foramen

Fracture througharticular pillar

Superiorarticular

facet

Transverseprocess fracture

A

C5 spinousprocess fracture

Posterior vertebral line

Anterior vertebral line

C4 burstfracture

C3

C5

B

Both C4 inferior facets “jump”over C5 articular facets

>50% anteriordisplacement

C4 inferiorarticular facet

C5 superiorarticular facet


C4

C5

C

Single C4 inferior facet “jumps”over C5 articular facet


C5 superiorarticular facet


C4

C5

D

C4

C6

Axial loading Posteriordisplacement

Flexion

C5 flexionteardropfracture

Posteriorligamentous

instability

E

Fig. 75.8 A,Superioraxialviewofanarticularpillarfractureandtransverseprocessfracture.B,SagittalviewofaC4burstfractureandC5clayshoveler’s(spinousprocess)fracture.C,SagittalviewofbilateralC4facetdislocation.D,SagittalviewofunilateralC4facetdislocation.E,SagittalviewofaC5teardropfracture. Continued

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Table 75.8 Classic Thoracic and Lumbar Spine Injury Patterns


Wedgefracture

Flexion Stable,usually

75.8,G MostcommonfractureinthethoracicspineIsolatedanteriorcolumnfractureDisruptionoftheanteriorvertebrallinewithanintactposteriorvertebralline

(classic)MaintainalowthresholdtoobtainspineCTfordifferentiationofawedge

fromaburstfracture(upto22%ofburstfracturesappeartohaveanintactposteriorvertebralline)

Burstfracture

Axialloading Variable 75.8,B FractureoftheanteriorandmiddlecolumnsDisruptionoftheanteriorandposteriorvertebrallines(classic)65%haveassociatedspinalcordinjurybecauseofmiddlecolumn

compromise

Chancefracture

Flexion-distraction

Unstable 75.9,A Fracturethroughtheanterior,middle,andposteriorcolumns,progressingfromposteriortoanterior

UsuallylocatedattheT12-L2junctionClassicallycausedbyalapbelthyperflexionmechanisminamotorvehicle

collision33-89%associatedwithintraabdominalinjurySpinalcordinjuryisuncommonbecauseofthedistractionmechanism

Transverseprocessfracture

Stable 75.9,B MostcommonfractureinthelumbarspineClassicallyhasaverticalfractureorientationAhorizontaltransverseprocessfractureorientationsuggestsadistraction

injury(Chancefracture)Morethan50%oftransverseprocessfracturesaremissedbyconventional

radiographyanddetectedonspineCTClinicallyinsignificant,butariskfactorforotherinjurypatterns50%associatedwithanintraabdominalinjury30%associatedwithapelvicfracture(especiallyanL5transverseprocess

fracture)L2transverseprocessfractureisassociatedwithrenalarterythrombosis

Fracture-dislocation

Compressionordistraction

Unstable 75.9,C SignificantspinalmisalignmentandvertebralcolumndiscontinuityFracturethroughtheanterior,middle,andposteriorcolumnsExtremelyhighincidenceofspinalcordinjury

CT,Computedtomography.

C4 anterior subluxationwith disrupted anterior and posterior

vertebral lines

Posteriorligamentious

instability


C4

C5


F



G

C5 wedge fracturewith disruption of anterior vertebral line

C5

C4

Flexion

F,SagittalviewofC4anteriorsubluxation.G,SagittalviewofaC5wedgefracture.Fig. 75.8, cont’d


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Fig. 75.9 A,SagittalviewofanL2Chance(flexion-distraction)fracture.B,Superioraxialviewofatransverseprocessfractureinatypicallumbarspine.C,SagittalviewofanL1-L2fracture-dislocationinjury,whichisathighriskforaspinalcordinjurybecauseofdiscontinuityofthespinalcanal.

Intervertebral disk

Transverseprocess

Spinousprocess

Fracture from posteriorthrough anterior column

L1

L2

L3

A

Vertebral body

Transverseprocess

Spinous process

B

Spinal canalHigh risk for

spinal cord injury

Spinal canal

L1

L2

L3

C

along with loss of pain and temperature sensation a few levels below the lesion. Typically, posterior column function is preserved.

BROWN-SÉQUARD SYNDROMEBrown-Séquard syndrome is a rare hemicord injury that is usually associated with penetrating trauma. Patients have crossed sensory and motor deficits: ipsilateral loss of motor function and position sense below the level of the lesion and contralateral loss of pain and temperature sensation one to two levels below the injury.

CONUS MEDULLARIS SYNDROMEConus medullaris syndrome results from injury to the spinal cord with occasional involvement of the lumbar nerve roots. It results in areflexia of the bladder, bowel, and lower extremi-ties. Patients may exhibit perianal numbness. Motor and sensory deficits in the lower limbs vary.

CAUDA EQUINA SYNDROMEAlthough cauda equina syndrome is not a direct spinal cord injury because the cauda equina is composed entirely of peripheral nerves (lumbar, sacral, and coccygeal nerve roots),

Specific incomplete spinal cord injuries include central and anterior cord syndromes, Brown-Séquard syndrome, and conus medullaris syndrome. Patients with these syndromes have certain characteristic patterns of neurologic injury with distinct findings on physical examination.

CENTRAL CORD SYNDROMECentral cord syndrome is the most common spinal cord syndrome and is usually due to neck hyperextension. Trauma to the central portion of the cord results in injury to the medially located corticospinal motor tracts of the upper extremities. As a result, the upper extremities are predictably and disproportionately weaker than the lower extremities. Many patients exhibit bladder dysfunction (e.g., urinary retention) and varying degrees of sensory loss. Elderly patients are more at risk for central cord syndrome because of underlying cervical spondylosis, a thickened ligamentum flavum, or both.

ANTERIOR CORD SYNDROMEAnterior cord syndrome results from blunt or ischemic injury to the anterior spinal cord. Affected patients have a complete and usually bilateral motor deficit below the level of the injury


658

Fig. 75.10 In-line cervical spine immobilization during endotracheal intubation.Standingtothepatient’sside,theassistantusesbothhandstostabilizethenecktopreventhyperextension.

it still requires emergency neurosurgical intervention. Clinical findings include asymmetric sensory loss, weakness of the lower extremities, urinary retention or incontinence, decreased rectal tone, and saddle anesthesia.

TREATMENT

Prehospital and ED management should include protection of the spine and spinal cord until injuries can be identified or excluded. A rigid backboard should typically be removed promptly from beneath cooperative patients because a calm person can maintain spinal column neutrality. Extended use of a rigid backboard is associated with complications such as back pain, respiratory impairment, aspiration, and decubitus ulcers.

IN-LINE IMMOBILIZATION OF THE CERVICAL SPINEDuring the initial resuscitation phase of trauma victims, patients with a potential cervical spine injury may require endotracheal intubation before a definitive diagnosis can be made. By preventing neck hyperextension during direct laryngoscopy, in-line cervical spine immobilization during intubation maintains cervical spine neutrality (Fig. 75.10).

NEUROGENIC SHOCKNeurogenic shock results from a sympathectomy-induced reduction in blood pressure, heart rate, cardiac contractility, and cardiac output. Overly vigorous fluid resuscitation can be hazardous because of compromised cardiac output. Judicious use of vasopressors such as phenylephrine hydrochloride, dopamine, and norepinephrine is often indicated. Significant bradycardia should be treated hemodynamically with atropine.

Systolic blood pressure lower than 80 mm Hg is rarely due to neurogenic shock alone, and other causes of shock, primar-ily from hemorrhage, must be excluded. It should never be assumed that hypotension is due to spinal shock until hemor-rhage is excluded.

CORTICOSTEROID THERAPY FOR SPINAL CORD INJURYThough controversial, treatment of blunt spinal cord injury with high-dose methylprednisolone is common. This

RED FLAGS (PITFALLS)

Failure to identifyoccult injuries inhypoestheticareas.Forexample, in a patient with a midthoracic sensory leveldeficit, occult intraabdominal injuries may be hiddenbecausetheabdomenmaybeinsensate.

Failure to consider a spinal cord injury in a patient withnormal radiographic and computed tomographic (CT)findings.

FailuretorepeatplainfilmsorobtainCTimagingwhenplainfilmradiographsofthecervical,thoracic,orlumbarspineareinadequate.

Failuretoexcludeothercausesofhypotensioninatraumapatient before assuming that it is neurogenic shock. Asearchforoccultbloodlossshouldfirstbedone.

Failuretoconsideradistractinginjury,particularlyfractures,as a reason for a patient’s ability to localize neck andbackpain.

therapeutic recommendation is based on the findings of the National Acute Spinal Cord Injury Study (NASCIS), which demonstrated improved neurologic function in patients receiv-ing high-dose corticosteroids within 8 hours of injury. Improved neurologic function, however, was defined as a modest gain in motor scores but not functional improvement. In NASCIS, a loading dose of 30 mg/kg of methylpredniso-lone administered over a 15-minute period was followed by an infusion of 5.4 mg/kg/hr and continued for 24 hours (in patients treated within 3 hours of injury) or 48 hours (in patients treated 3 to 8 hours after injury).20,21 No benefit was found when steroids were administered more than 8 hours after injury.

Steroid therapy is not indicated for penetrating injuries and has not been adequately studied in children younger than 13 years or in patients with cauda equina or spinal root injury.

Finally, systemic corticosteroid therapy is not benign. Com-plications of steroid therapy include gastrointestinal hemor-rhage and wound infection in patients treated with corticos teroid infusions for 24 hours and higher rates of severe sepsis and severe pneumonia in those treated for 48 hours. The use of steroids for blunt traumatic spinal cord injury is far from the standard of care.22 More research is needed to verify or refute this controversial therapy.

SURGICAL MANAGEMENT OF SPINAL CORD INJURYTimely reduction of the displaced spinal column plus decom-pression of the spinal cord has been associated with recovery from otherwise devastating spinal cord injuries.23 The optimal timing of surgery following a spinal injury remains controversial. Some argue for immediate surgery, whereas others advocate delayed surgery because of the initial post-traumatic swelling. The sole absolute indication for immedi-ate surgery is progressively worsening neurologic status in patients with spinal fracture-dislocations who initially have incomplete or absent neurologic deficits.24


659

PRIORITY ACTIONS

Providepaincontrol.Maintainfullspinalprecautionsuntilthespinecanbecleared

radiographicallyorclinically.If intubating a trauma patient, an assistant should provide

in-line cervical spine immobilization until the cervicalspinecanbeassessedmoredefinitivelyatalatertime.

Performacarefulinitialneurologicexamination,especiallyinpatients who are about to undergo sedation or neuro-muscularblockade.

If a spinal fracture is suspected or detected, evaluate forassociatedinjuries:• For the cervical spine, examine for associated head

andfacialinjuries.• For the thoracic spine, examine for rib fractures and

pulmonary, cardiac, diaphragmatic, and mediastinalinjuries.

• Forthelumbarspine,examineforintraabdominalinju-ries,pelvicfractures,andcalcanealfractures.

• Forallspinallevels,examineforspinalcordinjury.Obtainurgentspineimagingifafractureorspinalcordinjury

issuspected.Obtainemergencymagneticresonanceimagingofthespine

ifaspinalcordinjuryissuspected.Consideradministeringcorticosteroidsifanadultpatienthas

sustained blunt spinal trauma and exhibits neurologicdeficitswithin8hoursofinjury.

Prolongedimmobilizationonarigidbackboardisuncomfort-able for the patient and places the patient at risk foraspirationandearlypressuresores.Aim to remove thebackboardassoonaspossibleandideallywithin2hoursof patient arrival. A standard hospital gurney providesadequatethoracicandlumbarstability.

Performserialneurologicexaminationsonpatientswithsus-pectedorknownspinal injuriestodocumentneurologicimprovement or deterioration. Neurologic deteriorationinvolving the cervical and upper thoracic levels mayrequire empiric endotracheal intubation for impendingrespiratoryfailure.

Once a spinal injury is detected, carefully reexamine theentirecervical, thoracic,and lumbarspine.Obtainplainfilmsorcomputedtomographyscansofany levelswithpainortendernessbecauseofthehighriskforasecondspinalinjury.

Whenperforming“clinicalclearance”ofapatient’scervicalspineorobtainingflexion-extensioncervicalspineplainfilms,donotpassivelyrangetheneckforthepatient.Thismay cause an iatrogenic spinal injury. Pain with activemovementwillprevent thepatient fromoverrangingtheneck.

TIPS AND TRICKS

In a series of patients with traumatic central cord syndrome, those who underwent early surgery (<24 hours after injury) and had an underlying disk herniation or fracture-dislocation exhibited significantly greater overall motor improvement than did those who underwent late surgery (>24 hours after injury).25 Unfortunately, early decompressive surgery does not uniformly improve outcome following spinal cord injury.

FOLLOW-UP, NEXT STEPS IN CARE, AND PATIENT EDUCATION

Most patients with traumatic spinal fractures are admitted to the hospital because they fulfill at least one of four admission criteria: (1) intractable pain, (2) fracture involvement of more than one column, (3) a functionally unstable fracture pattern, and (4) the presence or potential for development of a spinal cord injury.

Patients who can be discharged home include those with normal neurologic function and (1) an isolated, stable poste-rior column fracture (spinous process, transverse process) in the cervical, thoracic, or lumbar spine or (2) a stable wedge fracture in the thoracic or lumbar spine.

Patients with confirmed or suspected spinal cord injury should be scheduled for early consultation with a neurosur-geon or orthopedist. This may require transfer of the patient to a spine specialty center.

The level of the spinal cord injury, associated neurologic deficits, and other traumatic injuries will determine whether the patient should be admitted to the intensive care unit, neu-rosurgical observation unit, or general ward. Circular beds, rotating frames, and serial inflation devices are used to protect the patient from pressure sores.

Discharged patients without a fracture or spinal cord injury require only conservative management. Discharged patients with a stable spinal fracture require only conservative man-agement with or without an immobilization device, such as a cervical collar or thoracolumbar sacral orthosis back brace. Soft collars and back braces are not recommended because they predispose patients to stiffness of the neck and back, respectively.

Discharged patients with persistent neck pain who are still at risk for an unstable ligamentous injury should wear a semi-rigid cervical collar (e.g., Philadelphia or Miami J collar) for 7 to 10 days until adequate flexion-extension plain films can be obtained. Discharge instructions should include informa-tion about the warning signs of spinal cord injury.

DOCUMENTATION

Documentneckandbacktenderness,alongwiththeneuro-logicexamination,inalltraumapatients.

Inspinalcordinjurypatients,marktheinitiallevelofsensorydeficittomonitorprogressionofthepatient’sneurologicstatus.

Forpatientswithneurologicdeficits,performanddocumentthebulbocavernosusreflexandsacral-sparingexamina-tiontoassessforspinalshock.


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3. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349: 2510-8.

REFERENCES

References can be found on Expert Consult @ www.expertconsult.com.

SUGGESTED READINGS1. Bracken MB, Shepard MJ, Holford TR, et al. Administration of

methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-604.

2. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9.

http://www.expertconsult.com


660.e1

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and spinal cord injuries. J Emerg Med 1993;11:63-57.2. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed

spine fractures. J Trauma 1987;27:980-6.3. Nunez Jr DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervical spine trauma:

how much more do we learn by routinely using helical CT? Radiographics 1996;16:1307-18.

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5. Hauser CJ, Visvikis G, Hinrichs C, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma 2003; 55:228-34.

6. Lucey BC, Stuhlfaut JW, Hochberg AR, et al. Evaluation of blunt abdominal trauma using PACS-based 2D and 3D MDCT reformations of the lumbar spine and pelvis. AJR Am J Roentgenol 2005;185:1435-40.

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8. Tyroch AH, McGuire EL, McLean SF, et al. The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review. Am Surg 2005;71:434-8.

9. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9.

10. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349: 2510-8.

11. Mahadevan SV, Navarro M. The evaluation and clearance of the cervical spine in adult trauma patients: clinical concepts, controversies, and advances. Trauma Rep 2004;5:1-12.

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13. Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effective analysis. Radiology 1999;212:117-25.

14. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277-84.

15. Mettler Jr FA, Huda W, Yoshizumi TT, et al. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008;248:254-63.

16. Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38:12.

17. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760-5.

18. Ballock RT, Mackersie R, Abitbol JJ, et al. Can burst fractures be predicted from plain radiographs? J Bone Joint Surg Br 1992;74:147-50.

19. Goldberg W, Mueller C, Panacek E, et al. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 2001;38:17-21.

20. Bracken MB, Holford TR. Effects of timing of methylprednisolone or naloxone administration on recovery of segmental and long-tract neurological function in NASCIS 2. J Neurosurg 1993;79:500-7.

21. Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-604.

22. Spencer MT, Bazarian JJ. Evidence-based emergency medicine/systematic review abstract. Are corticosteroids effective in traumatic spinal cord injury? Ann Emerg Med 2003;41:410-3.

23. Brunette DD, Rockswold GL. Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J Trauma 1987;27:445-7.

24. Lindsey RW, Pneumaticos SG, Gugala ZG. Management techniques in spinal injuries. In: Browner BD, Jupiter JB, Levine AM, et al, editors. Skeletal trauma: basic science, management, and reconstruction. 3rd ed. Philadelphia: Saunders; 2003. pp. 746-7.

25. Guest J, Eleraky MA, Apostolides PJ, et al. Traumatic central cord syndrome: results of surgical management. J Neurosurg 2002;97:25-32.

75 - spine trauma and spinal cord injury - semantic … · 645 spine trauma and 75 spinal cord...

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