11/25/2018

1/47

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 258: Spine Trauma Steven Go

INTRODUCTION AND EPIDEMIOLOGY

Trauma to the spine can cause a vertebral spinal column injury, a spinal cord injury, or both. A few studies have tried to estimate the annual

incidence of spinal column injury in the general population with results ranging from 11.8 to 64 cases per 100,000,1,2 but no current figuresare available for the U.S. population. In contrast, the estimated annual incidence of spinal cord injury in the United States is 40 cases per

million or 12,000 new cases per year, with 81% male victims, a mean age of 42.6 years, and a 67% Caucasian predominance.3 Since 2010, theleading causes of spinal cord injury are vehicular (37%), falls (29%), and violence (14%). Lifetime costs for spinal cord injury victims vary

according to age at time of injury, severity of injury, and socioeconomic status; however, estimates range in millions of dollars per patient.3

FUNCTIONAL ANATOMY

VERTEBRAL COLUMN

The vertebral column is composed of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 (usually fused) coccygeal. The axialvertebrae (C1 and C2) are anatomically unique in that they are designed for rotary motion. The odontoid (dens) of the axis (C2) is held againstthe atlas (C1) by the strong transverse ligament. The remaining vertebrae share some common anatomical features (Figure 258-1). A typicalsubaxial vertebra is composed of an anterior body and a posterior vertebral arch. The vertebral arch is comprised of two pedicles, twolaminae, and seven processes (one spinous, two transverse, and four articular). These articulations enable the spine to engage in flexion,extension, lateral flexion, rotation, or circumduction (combination of all movements). The orientation of these articular facet joints changes atdi�erent levels of the spine and accounts for variations in motion of specific regions of the vertebral column. Due to its inherent flexibility, the

cervical spine is the most commonly injured region of the spinal column, with most injuries occurring at the C2 level and from C5 to C7.4 Thesecond most common region of injury is in the thoracolumbar transition zone.

FIGURE 258-1.

Vertebral anatomy. Each vertebra consists of a vertebral body and posterior element. Vertebrae are stabilized by an anterior longitudinalligament, posterior ligament, and interspinous ligament.

11/25/2018

2/47

A series of ligaments serves to maintain alignment of the spinal column. The anterior and posterior longitudinal ligaments run along thevertebral bodies. Surrounding the vertebral arch are the ligamentum flavum and the supraspinous, interspinous, intertransverse, andcapsular ligaments. Between adjacent vertebral bodies are the intervertebral disks, consisting of a peripheral annulus fibrosus and a centralnucleus pulposus. The intervertebral disks act as shock absorbers to distribute axial load. When compressive forces exceed the absorptivecapacity of the disk, the annulus fibrosus ruptures. This allows the nucleus pulposus to protrude into the vertebral canal, and this may resultin spinal nerve or spinal cord compression.

SPINAL CORD

The spinal cord is a cylindrical structure that begins at the foramen magnum, where it is continuous with the medulla oblongata of the brainand extends down the spinal canal to the first and second lumbar vertebrae. The spinal cord gives rise to 31 pairs of spinal nerves: 8 cervical,12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve emerges through the intervertebral foramen corresponding to theappropriate spinal cord level. The lower nerve roots form an array of nerves called the cauda equina.

PATHOPHYSIOLOGY

SPINAL COLUMN INJURIES

Given their multiple axes of motion, the bony vertebrae can be injured via several mechanisms and present with a number of di�erent injury

patterns (Table 258-1).5,6,7,8,9,10

11/25/2018

3/47

TABLE 258-1

Major Spinal Column Injuries

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Flexion Anterior

subluxation

(hyperflexion

sprain) (usually

stable, but

depends on the

integrity of

posterior

ligaments)

Cervical

[Photo contributors: Mark Silverberg, MD/Steven Pulitzer, MD. Reproduced with

permission from Shah BR, Lucchesi M, Amodio J (eds): Atlas of Pediatric Emergency

Medicine, 2ed, © 2013, McGraw-Hill Education, New York, NY. Figure 20-57.]

Anterior

subluxation

produces

ligamentous

failure and may

have no

associated

fractures. Plain

films can be

normal.

However,

significant

ligamentous

injury can

display anterior

so� tissue

swelling, a

widening of the

spinous

processes at the

level of injury

("fanning"),

posterior

widening of the

intervertebral

space, and

cervical disk

space

alignment ≥11

degrees

between

adjacent

spaces.

11/25/2018

4/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Atlantoaxial

dislocation

(unstable)

Cervical

[Used with permission of Jake Block, MD.]

Transverse

ligament

rupture without

an associated

fracture can

occur in older

patients from a

direct blow to

the occiput.

Radiographic

diagnosis relies

on measuring

the predental

space, which is

the space

between the

posterior aspect

of the anterior

arch of C1 and

the anterior

border of the

odontoid. A

predental space

of >3 mm on a

lateral

radiograph (2

mm for CT

images) implies

damage to the

transverse

ligament; >5

mm implies

rupture of the

transverse

ligament.

11/25/2018

5/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Bilateral

interfacetal

dislocation

(unstable)

Cervical Bilateral

interfacetal

dislocation

(locked facets)

occurs when

the articular

masses of one

vertebra

dislocate

anteriorly and

superiorly from

the articular

surfaces of the

adjacent

vertebra below.

Disruption of all

ligamentous

structures

occurs. On

radiographs,

the vertebral

body is

dislocated

anteriorly ≥50%

of its width.

These injuries

usually present

with neurologic

deficits due to

compromise of

the

intervertebral

foramen, unless

the dislocation

is only partial

(perched

facets).

11/25/2018

6/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Simple wedge

(compression)

fracture (usually

stable)

Cervical;

TL

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-22 Part A.]

Most common

thoracic

fracture (52%).5

A vertebral

wedge fracture

typically

involves a

fracture of the

superior end

plate of the

vertebral body

while sparing

the inferior end

plate. An

isolated simple

wedge fracture

is stable, but

the presence of

significant

posterior

ligamentous

disruption can

make the injury

unstable. A

simple wedge

fracture is

di�erentiated

from a burst

fracture by the

absence of a

vertical fracture

of the vertebral

body and lack

of bulging of

the posterior

vertebral

border.

11/25/2018

7/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Spinous process

avulsion (clay

shoveler's)

fracture (stable)

Cervical

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-10 Part A.]

This is an

avulsion o� the

end of one of

the lower

cervical spinous

processes

(classically C7).

It is thought to

be caused by

strong muscle

contractions

pulling on the

bone via the

ligamentous

complex. It is

not associated

with neurologic

compromise.

11/25/2018

8/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Flexion teardrop

fracture (highly

unstable)

Cervical

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-1.]

Extreme

hyperflexion

causes

complete

disruption of

the spinal

ligaments at the

level of injury.

The "teardrop"

is the

anteroinferior

portion of the

vertebral body

that is

separated and

displaced from

the vertebral

body by the

anterior spinal

ligament.

"Fanning" of

the spinous

processes may

be present, with

or without

fracture. A

sagittal fracture

through the

vertebral body

may be seen on

CT. Anterior

spinal cord

syndrome is

associated with

this injury

11/25/2018

9/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Flexion-

rotation

Unilateral facet

dislocation

(stable unless

associated with

an articular mass

fracture)

Cervical

[Reproduced with permission from Simon RR, Sherman Scott C (eds): Emergency

Orthopedics, 6th ed. McGraw-Hill, Inc., 2011. Fig 9-21B.]

A unilateral

facet

dislocation

occurs when

the articular

mass and

inferior facet on

one side of the

vertebra are

anteriorly

dislocated. On a

lateral

radiograph, the

involved

vertebral body

will be

displaced <50%

of its width. On

the anterior

view, the

spinous process

at the level of

the rotation will

be pointing

toward the side

that is

dislocated.

11/25/2018

10/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Fracture of

lateral mass (can

be unstable)

Cervical

Comminuted fracture of the lateral mass of C4 extending into the right lamina.

Typically

presents with

severe neck

pain and

sometimes

radicular

symptoms. May

be associated

with Brown-

Séquard

syndrome or

vertebral artery

injury;

therefore, some

experts feel that

magnetic

resonance

angiography

should be done

in all patients

with this

lesion.6 A pillar

fracture is a

type of lateral

mass fracture

that consists of

an isolated

vertical or

oblique fracture

through the

lateral mass.

The adjacent

lamina and

pedicle remain

intact. The

fractured

articular mass is

displaced

posteriorly and

may be visible

as a double

outline on the

lateral

radiograph.

Flexion- Anterior TL These injuries

11/25/2018

11/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

distraction compression

with associated

transverse

fracture through

vertebral body

(unstable)

Arrow points to splaying of the posterior elements.

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-27C.]

are associated

with seatbelt

injuries,

especially when

lap belts alone

are used.

Radiographic

findings include

posterior

vertebral wall

fracture,

increased

height of the

posterior

vertebra, and

"fanning" of the

spinous

processes. The

Chance fracture

variant presents

with minor

anterior

vertebral

compression

and significant

distraction of

the middle and

posterior

ligamentous

structure. It

o�en occurs

from T11 to L2

(TL transition

zone). These

injuries are

o�en

misdiagnosed

as an anterior

compression

fracture. They

may require CT

to visualize and

are o�en

associated with

intra-

11/25/2018

12/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

abdominal

injuries.

Vertical

compression

Je�erson burst

fracture of atlas

(potentially

unstable)

Cervical

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-13.]

Vertical

compression

forces the

occipital

condyles

downward and

produces a

burst fracture

by driving the

lateral masses

of C1 apart. This

is best seen as

outward

displacement of

the lateral

masses on the

open-mouth

odontoid

radiograph or

on CT. If

displacement of

both lateral

masses

(measured as

o�set from the

superior corner

of the C2

vertebral body

on each side) is

>7 mm when

added together,

rupture of the

transverse

ligament is

likely, and the

spine is

unstable.

11/25/2018

13/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Burst fracture

(unstable)

Cervical;

TL

Arrow shows posterior displacement of posterior vertebral body cortex.

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-31B.]

A burst fracture

occurs when a

vertebra is

crushed by an

axial load,

causing

fragments to

displace in all

directions. The

lateral

radiograph may

show an

obvious

fracture of the

end plates, but

sometimes all

that is seen is a

bowing or

disruption of

the posterior

cortex of the

a�ected

vertebra. The

anterior

radiographic

view may show

a vertical

fracture

through the

vertebral body

and widening of

the

interpedicular

distance. The

burst fracture is

usually obvious

on CT. The

spinal cord may

be injured if a

retropulsed

fragment enters

the spinal

canal.

11/25/2018

14/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Extension Hyperextension

dislocation

(unstable)

Cervical

[Reproduced with permission from Schwartz DT (ed): Emergency Radiology: Case

Studies. McGraw-Hill, Inc., 2008. Sect V: Cervical Spine Radiology; Fig 6.]

Extreme

hyperextension

can cause a

complete tear

of the anterior

longitudinal

ligament and

intervertebral

disk, with

disruption of

the posterior

ligamentous

complex. On the

lateral

radiographic

view, the

vertebrae may

appear normal

if the

dislocation

spontaneously

reduces or if the

injury is masked

by a cervical

immobilization

collar.

Prevertebral

so� tissue

swelling may be

the only

radiographic

finding present.

Anterior disk

space widening

or fracture of

the

anteroinferior

end plate of the

vertebral body

may occur.

Patients usually

present with a

central cord

syndrome.

11/25/2018

15/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Hyperextension

teardrop fracture

or extension

corner avulsion

fracture

(unstable in

extension)

Cervical Hyperextension

may cause the

anterior

longitudinal

ligament to

avulse a

fragment o� the

anteroinferior

corner of the

vertebral body.

The height of

the avulsed

fragment

usually exceeds

its width. This

fracture is more

common in

older patients

with

osteoporosis.

Fracture of

posterior arch of

atlas (stable)

Cervical

Arrowhead indicates the posterior arch fracture. There is also a displaced dens

fracture (arrow).

[Reproduced with permission from Galli, et al: Emergency Orthopedics: The Spine.

New York, NY: McGraw-Hill;1989]

Fracture occurs

from wedging

of the posterior

arch between

the occipital

bone and the

C2 vertebra. A

CT is indicated

to rule out an

associated

Je�erson

fracture or a

dens fracture.

11/25/2018

16/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Laminar fracture

(usually stable)

Cervical

Bilateral laminar fractures. [Reproduced with permission from Simon RR, Sherman

SC (eds): Emergency Orthopedics, 6th ed. McGraw-Hill, Inc., 2011. Fig 9-26B.]

Laminar

fractures may

be associated

with spinous

process

fractures. They

may not be

evident on plain

radiographs

and usually

require CT for

diagnosis.

11/25/2018

17/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Traumatic

spondylolisthesis

(hangman's

fracture)

(unstable)

Cervical The hangman's

fracture is a

fracture of both

pedicles of C2,

with the

anterior

displacement of

C2 on C3. This

was associated

with the neck

hyperextension

from judicial

hangings,

where the

noose knot is

placed under

the subject's

chin and snaps

the head

backward.

Suicidal

hangings do not

usually cause

extreme

hyperextension

and are not

associated with

the hangman's

fracture.

Because the

spinal canal at

the level of C2 is

large, a

hangman's

fracture does

not cause

neurologic

injury.

11/25/2018

18/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Injuries

caused by a

combination

of

mechanisms

or poorly

understood

mechanisms

Occipital condyle

fractures (usually

stable)

Cervical

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 11-11B.]

Occipital

condyle

fractures are

rarely visible on

plain

radiographs

and usually

require CT

imaging for

detection.

Presentation is

rather variable

due to

proximity of

multiple

neurovascular

structures.7

Neurologic

impairment is

common and

usually involves

lower cranial

nerve deficits

and/or limb

weakness.

Atlanto-occipital

dissociation

(AOD) (highly

unstable)

Cervical Secondary to

high-energy

impact.

Historically,

strongly

associated with

mortality8;

however,

modern

patients may

survive due to

better

prehospital

care/transport.

The classic

presentation is

paralysis of

upper

extremities with

lack of lower

11/25/2018

19/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

[Photo contributors: Konstantinos Agoritsas, MD/Steven Pulitzer, MD. Reproduced

with permission from Shah BR, Lucchesi M, Amodio J (eds): Atlas of Pediatric

Emergency Medicine, 2nd ed. © 2013, McGraw-Hill Education, New York, NY. Fig 20-

52.]

extremity

paralysis or

weakness

(cruciate

paralysis).9

However,

presentation

can be variable

with a common

presentation

being lower

cranial nerve

deficits. CT may

be required for

detection. In

radiographs in

the normal

patient, the

distance

between the

basion and the

superior cortex

of the dens

(basion-dental

interval [BDI])

should be ≤10

mm in adults

(≤8.5 mm on

CT). In addition,

the distance

from the basion

to the posterior

border of the

body of C2

(basion-atlantal

interval [BAI])

should be ≤12

mm anterior

displacement or

≤4 mm

posterior

displacement

on a lateral

radiograph. If

there are

abnormalities

11/25/2018

20/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

in both the BDI

and BAI, this

strongly

suggests the

existence of

AOD.10

Odontoid (dens)

fractures (type II

and III are

unstable)

Cervical

Type 1 odontoid fracture. [Reproduced with permission from Block J, Jordanov MI,

Stack LB, Thurman RJ (eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc.,

2013. Fig 11-18.]

Frequently

involves other

injuries to the

cervical spine

and

multisystem

trauma.

Conscious

patients will

usually describe

immediate and

severe high

cervical pain

with muscle

spasm. The pain

may radiate to

the occiput.

Neurologic

injury is present

in 18% to 25%

of cases with

odontoid

fractures,

ranging from

minimal

sensory or

motor loss to

quadriplegia.

Odontoid

fractures are

classified

according to the

level of injury.

CT can miss

odontoid

fractures if the

fracture line is

aligned with the

11/25/2018

21/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Type 2 odontoid fracture. [Reproduced with permission from Block J, Jordanov MI,

Stack LB, Thurman RJ (eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc.,

2013. Fig 11-19C.]

Type 3 odontoid fracture. [Reproduced with permission from Block J, Jordanov MI,

Stack LB, Thurman RJ (eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc.,

2013. Fig 11-20C.]

cut of the CT (en

face).

11/25/2018

22/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Translational

fracture-

dislocation

(unstable)

TL

T10-T11 fracture-dislocation.

This is a high-

energy

disruption of all

three columns

of spine and is

readily

apparent both

on radiographs

and CT. Patients

commonly

present with

severe

neurologic

findings. These

fractures are

most o�en

unstable;

however, in the

absence of

destabilizing rib

cage fractures,

lesions above

T7 can be

stable.

11/25/2018

23/47

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Sacrum and

coccyx

fractures

Sacral fracture

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 8-16A.]

Usually

associated with

pelvic

fracture(s).

Transverse

fractures

through the

body can injure

the cauda

equina.

Longitudinal

fractures can

cause

radiculopathies.

Central sacral

fracture can

present with

bowel/bladder

incontinence.

11/25/2018

24/47

Abbreviations: C1 = first cervical vertebra; C2 = second cervical vertebra; C3 = third cervical vertebra; C7 = seventh cervical vertebra; T1 = first thoracic

vertebra; T7 = seventh thoracic vertebra; TL = thoracolumbar.

Mechanism

of InjuryInjury

Spinal

Column

Regions

Typically

A�ected

Image Notes

Coccyx fracture

[Reproduced with permission from Block J, Jordanov MI, Stack LB, Thurman RJ

(eds): The Atlas of Emergency Radiology. McGraw-Hill, Inc., 2013. Fig 8-24.]

Coccygeal

injuries are

usually

associated with

a direct fall onto

the buttocks,

with resultant

coccyx pain

exacerbated by

sitting or

straining.

Localized

tenderness can

be elicited with

coccyx

palpation

during a rectal

exam, but this is

not required for

diagnosis.

Imaging is not

needed to

diagnose

coccygeal

fractures.

Treatment is

symptomatic

with analgesics

and use of a

rubber

doughnut

pillow.

The variable anatomic qualities of the regions of the spinal column cause characteristic injury patterns in each region. The exposure andextreme mobility of the cervical spine (C1-C7) make it particularly vulnerable to injury, because it is the most flexible and mobile portion ofthe spinal column. The cervicothoracic junction (C7-T1) is one of the transitional zones of the spinal column, which are locations where thevertebral morphology changes. This designation is important because transitional zones sustain the greatest amount of stress during motionand are most vulnerable to injury. In contrast to the cervical spine, the thoracic spine (T1-T10) is a rigid segment, with its sti�ness enhancedby articulation with the rib cage. Therefore, not only is injury to the thoracic spine less common than in other regions, but this also meansthat the presence of a thoracic vertebral injury indicates the patient was subjected to severe traumatic forces and is at high risk forintrathoracic injuries. Moreover, the spinal canal in the thoracic region is also narrower than in other regions. This increases the risk of cordinjury, which is o�en complete when it occurs. The thoracolumbar junction (T11-L2) is a transitional zone between the highly fixed thoracic

11/25/2018

25/47

and relatively mobile lumbar spine. In addition to this change in bone anatomy, the thoracolumbar junction serves as the level of transitionfrom the end of the spinal cord (about L1) to the nerve roots of the cauda equina. Relative to the thoracic spine, the width of the spinal canalin the thoracolumbar region is greater. Therefore, despite a large number of vertebral injuries at the thoracolumbar junction, most do nothave neurologic deficits, or, if present, they are partial or incomplete. Relative to the thoracic and thoracolumbar regions, the lower lumbarspine (L3-L5) is more mobile. Because of the width of the spinal canal in the lumbar region and the ending of the spinal cord at the L1 level,isolated fractures of the lower lumbar spine rarely injure the spinal cord or result in neurologic injury. The sacrum and coccyx form the lowerportion of the spinal column. The vertebral foramina of the sacrum together form the sacral canal that contains the nerve roots of the lumbar,sacral, and coccygeal spinal nerves and the filum terminale. The coccyx, which articulates with the sacrum, consists of four vertebrae fusedtogether. When neurologic injuries occur, they are usually complete cauda equina lesions or isolated nerve root deficits. Sacral fractures thatinvolve the central sacral canal can produce bowel or bladder dysfunction.

FRACTURE STABILITY

Much has been written regarding determining whether or not a particular injury is "stable." Spinal stability is defined as the ability of thespine to limit patterns of displacement under physiologic loads so as not to damage or irritate the spinal cord or nerve roots. Severalparadigms have been created, including the Denis column system, which splits the spinal column into anterior, middle, and posterior

elements.11 A spine injury is considered unstable if at least two columns of a particular region are involved. Although this schema and other

instability scoring systems have been published,12,13,14 determining spinal stability a�er an acute injury in the ED is particularly di�icult. Thisis because these injuries o�en occur in the setting of polytrauma, altered mental status, and severe pain, which may result in suboptimalinitial imaging. In addition, many EDs lack quick access to emergent MRI to evaluate the spinal ligaments. Therefore, assume any spinefracture is unstable and maintain appropriate precautions until expert consultation can be obtained from a spine surgeon.

SPINAL CORD INJURIES

Damage to the spinal cord is the result of two types of injury. First is the primary injury from mechanical forces from traumatic impact. Thisinsult sets into motion a series of vascular and chemical processes that lead to secondary injury. The initial phase is characterized byhemorrhage into the cord and formation of edema at the injured site and surrounding region. Local spinal cord ischemia ensues secondary tovasospasm and thrombosis of the small arterioles within the gray and white matter. Extension of edema may further compromise blood flowand increase ischemia. A secondary tissue degeneration phase begins within hours of injury. This is associated with neural membrane

dysfunction, driven by a pathologic excitation of sodium ion channels, an influx of calcium ions, and the release of glutamine.15 Cell deathensues from a combination of mechanisms including electrolyte imbalances, cell edema, and the formation and release of oxidative

substances.15

SPINAL CORD LESIONS

The severity of spinal cord injury determines the prognosis for recovery of function, so it is important to distinguish between complete andincomplete spinal cord injuries. The American Spinal Injury Association defines a complete neurologic lesion as the absence of sensory andmotor function below the level of injury. This includes loss of function to the level of the lowest sacral segment. In contrast, a lesion isincomplete if sensory, motor, or both functions are partially present below the neurologic level of injury. This may consist only of sacralsensation at the anal mucocutaneous junction or voluntary contraction of the external anal sphincter upon digital examination. Completelesions have a minimal chance of functional motor recovery. Patients with incomplete lesions are expected to have at least some degree ofrecovery. The di�erentiation between complete and incomplete spinal cord damage may be complicated by the presence of spinal shock.Patients in spinal shock lose all reflex activities below the area of injury, and lesions cannot be deemed truly complete until spinal shock hasresolved.

A significant number of descending and ascending tracts have been identified in the spinal cord (Figure 258-2). The three most important ofthese in terms of neuroanatomic localization of cord lesions are the corticospinal tracts, spinothalamic tracts, and dorsal (posterior) columns.

FIGURE 258-2.

The anatomy of a cross section of cervical spinal cord. [Reproduced with permission from Simon RR, Sherman SC (eds): EmergencyOrthopedics, 6th ed. McGraw-Hill, Inc., 2011. Fig 9-5.]

11/25/2018

26/47

The corticospinal tract is a descending motor pathway. Its fibers originate from the cerebral cortex through the internal capsule and themiddle of the crus cerebri. The tract then breaks up into bundles in the pons and finally collects into a discrete bundle, forming the pyramid ofthe medulla. In the lower medulla, approximately 90% of the fibers cross to the side opposite that of their origin and descend through thespinal cord as the lateral corticospinal tract. These fibers synapse on lower motor neurons in the spinal cord. The 10% of corticospinal fibersthat do not cross in the medulla descend in the anterior funiculus of the cervical and upper thoracic cord levels as the ventral corticospinaltract. Damage to the corticospinal tract neurons (upper motor neurons) in the spinal cord results in ipsilateral clinical findings such as muscleweakness, spasticity, increased deep tendon reflexes, and a Babinski's sign.

The two major ascending pathways that transmit sensory information are the spinothalamic tracts and the dorsal columns. Thespinothalamic tract transmits pain and temperature sensation. As the axons of the first neurons enter the spinal cord, most ascend one or twolevels before entering the dorsal gray matter of the spinal cord, where they synapse with the second neuron of the spinothalamic tract. Thesecond neuron immediately crosses the midline in the anterior commissure of the spinal cord and ascends in the anterolateral funiculus asthe lateral spinothalamic tract. When the spinothalamic tract is damaged, the patient experiences loss of pain and temperature sensation inthe contralateral half of the body. The (pain and temperature) sensory loss begins one or two segments below the level of the damage.

The dorsal columns transmit vibration and proprioceptive information. Neurons enter the spinal cord proximal to pain and temperatureneurons. They di�er from pain and temperature neurons in that they do not immediately synapse in the spinal cord. Instead, these axonsenter the ipsilateral dorsal column and do not synapse until they reach the gracile or cuneate nuclei of the medulla. From these nuclei, fiberscross the midline and ascend in the medial lemniscus to the thalamus. Injury to one side of the dorsal columns will result in ipsilateral loss ofvibration and position sense. The sensory loss begins at the level of the lesion. Light touch is transmitted through both the spinothalamictracts and the dorsal columns. Therefore, light touch is not completely lost unless there is damage to both the spinothalamic tracts and thedorsal columns.

Each spinal nerve is named for its adjacent vertebral body (see Figure 258-3). In the cervical region, there is an additional pair of spinal nerveroots compared to the number of vertebral bodies. The first seven spinal nerves are named for the first seven cervical vertebrae, each exitingthrough the intervertebral foramen above its corresponding vertebral body. The spinal nerve exiting below C7, however, is referred to as theC8 spinal nerve, although no eighth cervical vertebra exists. All subsequent nerve roots, beginning with T1, exit below the vertebral body forwhich they are named.

FIGURE 258-3.

Spinal cord level. The spinal cord level of injury can be delineated by physical examination, including a detailed neurologic examination.

11/25/2018

27/47

During fetal development, the downward growth of the vertebral column is greater than that of the spinal cord. Because the adult spinal cordends as the conus medullaris at the level of the lower border of the first lumbar vertebra, the lumbar and sacral nerve roots must continueinferiorly below the termination of the spinal cord to exit from their respective intervertebral foramina. These nerve roots form the caudaequina. A potential consequence of this arrangement is that injury to a single lower vertebra can involve multiple nerve roots in the caudaequina. For example, an injury at the L3 vertebra can involve the L3 nerve root as well as the lower nerve roots that are progressing to a levelcaudal to the L3 vertebra.

PREHOSPITAL CARE

The prehospital treatment of patients with spinal injury involves recognition of patients at risk, appropriate immobilization, and triage to anappropriate facility (see chapters 1, "Emergency Medical Services" and 2, "Prehospital Equipment"). Presume that patients with anappropriate traumatic mechanism who have complaints of neck or back pain, tenderness on prehospital exam, neurologic complaints,significant injury above the clavicles, or altered sensorium that precludes accurate evaluation of the spine to have a spinal cord injury, andtake appropriate spinal precautions. Transport of the patient to a center that is capable of rapid diagnostics and therapeutics is important tooptimize outcome following spinal injury.

Prehospital care for spinal injuries traditionally involves immobilization of the entire spine at the scene with a rigid cervical collar (or similardevices) plus a long backboard. However, there is little evidence that cervical collars and/or long spine boards reduce neurologic injury,

spinal instability, or mortality.16,17 In contrast, cervical collars and long backboards can induce complications such as pressure sores,18,19

patient discomfort,20 and respiratory compromise.21 In light of these data, some experts have recommended retaining the cervical collar but

transporting the patient on a gurney with a scoop stretcher22 or other so�, padded devices23 to avoid the rigid spine board. Some authors

have even proposed abandoning the routine use of cervical collars.24 Nevertheless, in the absence of controlled data regarding the safety of

11/25/2018

28/47

such measures, current neurosurgery guidelines25 still recommend usage of the rigid cervical collar and long spine board. In contrast, spinalimmobilization is no longer recommended for fully conscious, neurologically intact patients with isolated penetrating neck injury because

collars can delay resuscitation and obscure neck injuries.26,27

INITIAL ED STABILIZATION

AIRWAY

ED evaluation of the patient with potential spinal injury should not di�er substantially from that of any patient with multiple injuries, with thefirst priority being the airway. The higher the level of spinal injury, the more likely is the need for early airway intervention. For example,unstable spine lesions above C3 can cause immediate respiratory arrest, and lesions a�ecting C3-C5 can a�ect the phrenic nerve anddiaphragm function. For this reason, some experts recommend that any patient with an injury at C5 or above should have the airway securedby endotracheal intubation. Delayed respiratory compromise can occur if spinal cord edema from more caudal lesions progresses rostrally tocause phrenic nerve paralysis. Many patients can initially support ventilatory function using intercostal muscles or abdominal breathing, butthey eventually tire and subsequently develop respiratory failure. Therefore, be vigilant for respiratory compromise in patients with highcervical injuries. If safety allows, perform a brief focused neurologic assessment before sedation and intubation.

Maintain in-line spinal stabilization while intubating, because human cadaver studies demonstrate less cervical motion and glottisvisualization with in-line stabilization than with cervical collars in place, and movement of an unstable cervical spine can worsen or produce

spinal cord injury.28 Video-assisted intubation improves intubation success over direct laryngoscopy, but manual in-line stabilization is still

necessary to minimize cervical extension.28

HYPOTENSION

Hypotension in patients with spinal cord injuries may be due to neurogenic shock, blood loss, cardiac injury, tension pneumothorax, or otherinjuries. Although hypotension and relative bradycardia are classic signs of neurogenic shock, bradycardia can also be associated with

intraperitoneal bleeding or prior medication with calcium channel blockers or β-blockers. In one study,29 74% of hypotensive patients withpenetrating spinal cord injury had major blood loss causing hypotension. Therefore, presume blood loss as the cause of hypotension in spinalinjury patients until proven otherwise. Hypotension is initially treated with IV crystalloid.

SPINE IMMOBILIZATION

Long spine boards are associated with pressure sores, so remove them as soon as possible. Log rolling is the traditional method for boardremoval, because it requires only a few sta� and allows visualization of the patient's back and performance of a rectal examination. Some

experts recommend the "6+ li� and slide maneuver" because it produces less spine motion than log rolling.30 The 6+ maneuver consists firstof unstrapping the patient from the board. Next, one person maintains in-line stabilization at the head, while six others positioned at thechest, pelvis, and lower extremities levels li� the patient as a unit 10 to 20 cm above the board. Another person slides the board out fromunder the patient, and the patient is then lowered to the bed, maintaining spinal alignment. Disadvantages are the need for many sta�

members to perform this maneuver and inability to visualize the patient's back.31

Hard cervical collars are associated with patient discomfort and pressure sores of the neck.32 Therefore, promptly clear the cervical spine ifpossible (see "Clinical Decision Rules in Cervical Spine Imaging" and "Cervical Spine Imaging" below). Do not overtighten the cervical collar

on head-injured patients, because jugular venous compression can raise intracranial pressure,33 although Stifneck® and Miami J® collars may

be better than other rigid collars in this regard.34

CLINICAL FEATURES

HISTORY

If the patient is able to give a history, focus on key historical points as they pertain to spine injury. Specifically, seek the presence or absence

of the historical elements included in imaging decision rules (see Tables 4,35 5,36 and 637). Evaluate for symptoms of midline spine pain,painful distracting injury, paresthesias, loss of function, change in mental status (including loss of consciousness), or other neurologic

11/25/2018

29/47

symptoms (especially urinary or fecal incontinence or priapism). Pay particular attention to any symptoms indicating present or impendingrespiratory compromise, including dyspnea, palpitations, abdominal breathing, and anxiety, which may indicate a high cervical spine injury.

PHYSICAL EXAMINATION

Once the patient is stabilized and other life-threatening injuries have been excluded or treated, perform a detailed neurologic assessment. Anappropriately detailed initial neurologic examination is important to allow for comparison later should the patient deteriorate. Assess thepatient's mental status and note any clinical evidence of intoxication. Physical examination should focus on delineating the level of the spinalcord injury (Figure 258-3). Document the presence or absence of midline neck or back tenderness. Test motor function for muscle groups(Table 258-2). Determine the level of sensory loss (Figure 258-4), and investigate proprioception or vibratory function to examine posteriorcolumn function. Test for "saddle anesthesia," which is sensory deficit in the region of the buttocks, perineum, and inner aspect of the thighs.Test deep tendon reflexes along with anogenital reflexes because "sacral sparing" with preservation of anogenital reflexes denotes anincomplete spinal cord level, even if the patient has complete sensory and motor loss. To test the bulbocavernosus reflex, squeeze the penisto determine whether the anal sphincter simultaneously contracts. Assess rectal tone at the same time. Test the cremasteric reflex by strokingthe medial thigh with a blunt instrument. If the scrotum rises, some spinal cord integrity exists. Document rectal tone and sensation aroundthe anus. An "anal wink reflex" (contraction of the anal musculature when the perianal region is stimulated with a pin) indicates some sacralsparing. Conversely, priapism implies a complete spinal cord injury. In 2013, the American Spinal Injury Association published a revised

version of the International Standards for Neurological Classification of Spinal Cord Injury.38 This scoring system is used by spine surgeons to

document their initial examination and has prognostic value39; however, the scale is rather lengthy and is not practical for ED initialassessment.

TABLE 258-2

Motor Grading System

Grade Movement

0 No active contraction

1 Trace visible or palpable contraction

2 Movement with gravity eliminated

3 Movement against gravity

4 Movement against gravity plus resistance

5 Normal power

FIGURE 258-4.

Dermatomes for sensory examination.

11/25/2018

30/47

INCOMPLETE SPINAL CORD SYNDROMES

There are three major incomplete spinal cord syndromes identified by predictable physical examination findings, although overlap in findingsmay occur (Table 258-3).

11/25/2018

31/47

*Outcome improves when the e�ects of secondary injury are prevented or reversed.

TABLE 258-3

Four Major Incomplete Spinal Cord Syndromes

Syndrome Mechanisms SymptomsGeneral

Prognosis*

Anterior

cord

Direct anterior cord

compression

Complete paralysis below the lesion with loss of pain and temperature sensation Poor

Flexion of cervical

spine

Thrombosis of anterior

spinal artery

Preservation of proprioception and vibratory function

Central

cord

Hyperextension

injuries

Quadriparesis—greater in the upper extremities than the lower extremities. Some loss of

pain and temperature sensation, also greater in the upper extremities

Good

Disruption of blood

flow to the spinal cord

Cervical spinal stenosis

Brown-

Séquard

Transverse

hemisection of the

spinal cord

Ipsilateral spastic paresis, loss of proprioception and vibratory sensation, and contralateral

loss of pain and temperature sensation

Good

Unilateral cord

compression

ANTERIOR CORD SYNDROME

The anterior cord syndrome results from damage to the corticospinal and spinothalamic pathways, with preservation of posterior columnfunction. This is manifested by loss of motor function and pain and temperature sensation distal to the lesion. Only vibration, position, andtacticle sensation are preserved. This syndrome may occur following direct injury to the anterior spinal cord. Flexion of the cervical spine mayresult in cord contusion or bone injury with secondary cord injury. Alternatively, thrombosis of the anterior spinal artery can cause ischemicinjury to the anterior cord. Anterior cord injury can also be produced by an extrinsic mass that is amenable to surgical decompression. Theoverall prognosis for recovery of function is poor.

CENTRAL CORD SYNDROME

The central cord syndrome is usually seen in older patients with preexisting cervical spondylosis who sustain a hyperextension injury. Asnamed, this injury preferentially involves the central portion of the cord more than the peripheral. The centrally located fibers of thecorticospinal and spinothalamic tracts are a�ected. The neural tracts providing function to the upper extremities are most medial in positioncompared with the thoracic, lower extremity, and sacral fibers that have a more lateral distribution. Clinically, patients with a central cordsyndrome present with decreased strength and, to a lesser degree, decreased pain and temperature sensation, more in the upper than thelower extremities. Vibration and position sensation are usually preserved. Spastic paraparesis or spastic quadriparesis can also be seen. Themajority will have bowel and bladder control, although this may be impaired in the more severe cases.

BROWN-SÉQUARD SYNDROME

11/25/2018

32/47

The Brown-Séquard syndrome results from hemisection of the cord. It is manifested by ipsilateral loss of motor function, proprioception, andvibratory sensation, and contralateral loss of pain and temperature sensation. The most common cause of this syndrome is penetrating

injury.40 It can also be caused by lateral cord compression secondary to disk protrusion, hematomas, spine fractures, infections, infarctions,or tumors.

CAUDA EQUINA SYNDROME

Cauda equina syndrome is not a true spinal cord syndrome because the cauda equina is composed entirely of lumbar, sacral, and coccygealnerve roots; therefore, injuries to this region produce peripheral nerve injuries. Symptoms and signs may include bowel and/or bladderdysfunction, decreased rectal tone, "saddle anesthesia" (sensory deficit over the perineum, buttocks, and inner thighs), variable motor andsensory loss in the lower extremities, decreased lower extremity reflexes, and sciatica. Bowel or bladder incontinence is not a universal

finding, because rectal tone can be spared,41 and if the patient presents early, the patient's bladder may not yet be full enough to cause

overflow incontinence. Careful history and physical examination, including identification of saddle anesthesia,42 are helpful to suggest the

diagnosis, but no one symptom or sign has 100% predictive value for this entity.42 Therefore, perform an MRI of the lumbosacral spinal cord ifclinical suspicion warrants. See the section "Epidural Compression Syndrome" in chapter 279, "Neck and Back Pain," for further discussion ofcauda equina syndrome.

NEUROGENIC SHOCK

Neurogenic shock is a type of distributive shock that can occur with CNS or spinal cord injury that probably occurs in less than 20% of spinal

cord–injured patients.43 Loss of peripheral sympathetic innervation results in extreme vasodilatation secondary to loss of sympatheticarterial tone. This causes blood pooling in the distal circulation with resultant hypotension. If the T1 through T4 cord levels are compromised,loss of sympathetic innervation to the heart leaves unopposed vagal parasympathetic cardiac innervation. This results in bradycardia or anabsence of reflex tachycardia. In general, patients with neurogenic shock are warm, peripherally vasodilated, and hypotensive with a relativebradycardia. Patients tend to tolerate hypotension relatively well, because peripheral oxygen delivery is presumably normal. Loss ofsympathetic tone and subsequent inability to redirect blood from the periphery to the core may cause excessive heat loss and hypothermia.

The diagnosis of neurogenic shock is one of exclusion. Certain clues, such as bradycardia and warm, dry skin, may be evident, buthypotension in the trauma patient can never be presumed to be caused by neurogenic shock until other possible sources of hypotension are

excluded.29

SPINAL SHOCK

Spinal shock is not neurogenic shock; the two terms have very di�erent meanings and are not interchangeable. Spinal shock is the temporaryloss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injury. The typical presentation involves

flaccidity, loss of reflexes, and loss of voluntary movement.44 The lower the level of the spinal cord injury, the more likely it is that all distalreflexes will be absent. Loss of neurologic function that occurs with spinal shock can cause an incomplete spinal cord injury to mimic acomplete cord injury. Therefore, cord lesions cannot be called complete until spinal shock has resolved. The delayed plantar and

bulbocavernosus reflexes are among the first to return as spinal shock resolves.45 The duration of spinal shock is variable; it generally lasts for

days to weeks but can persist for months.46

DIAGNOSIS

Although spinal column and spinal cord injuries can sometimes be diagnosed clinically, diagnostic imaging is necessary to confirm thediagnosis and direct definitive care. However, judicious use of imaging is desirable to avoid unnecessary costs and ionizing radiationexposure to patients. Therefore, the challenge is identifying the appropriate patients to image and selecting the appropriate imagingmodality.

CLINICAL DECISION RULES IN CERVICAL SPINE IMAGING

In some cases, it is obvious who needs cervical spine imaging. For example, patients with head or neck trauma who are not fully alert(Glasgow coma scale score of <15) should undergo imaging of their cervical spine because the frequency of cervical spine injury in association

11/25/2018

33/47

*Defined as Glasgow coma scale score <15; disorientation to person, place, time, or events; inability to remember three objects at 5 minutes; delayed or

inappropriate response to external stimuli.

†Any injury thought "to have the potential to impair the patient's ability to appreciate other injuries."

with traumatic brain injury ranges from 1.7% to 8%.47 However, in less obvious cases, the decision to perform imaging is not quite so clearcut.

An unstructured clinical exam is not adequately sensitive for the detection of cervical spine injuries,48 so guidelines can assist clinicaljudgment in deciding whom to image. In alert, stable adult trauma patients who have no neurologic deficits (i.e., low-risk trauma patients),two major clinical decision rules have been defined to avoid unnecessary radiography.

The first decision rule was derived by the National Emergency X-Radiography Utilization Study (NEXUS), which determined that plain cervical

spine imaging is unnecessary in patients who lack any one of five clinical criteria (Table 258-4).35 In the study population of 34,069 patients,the NEXUS criteria were 99.6% sensitive (95% confidence interval [CI], 98.6% to 100%) for detecting prospectively defined clinically significantcervical spine injuries, but only 12.9% specific (95% CI, 12.8% to 13.0%), with a negative predictive value of 99.9% (95% CI, 99.8% to 100%).The original NEXUS trial excluded patients >60 years old, but the criteria were subsequently shown to be 100% sensitive (95% CI, 97.1% to

100%) and 14.7% specific (95% CI, 14.6% to 14.7%) for clinically significant injuries in 2943 patients ≥65 years of age.49 In a subsequentprospective trial (n = 2785) investigating NEXUS's performance in patients ≥65 years of age, NEXUS was only 65.9% sensitive (vs 84.2% in

younger patients) for cervical spine injuries detected on CT.50 However, this trial contained several sources of bias (use of conveniencesample, a very high incidence of cervical spine injuries in the elderly group [12.8% vs 4.6% in the previous trial], and every elderly patientincluded was a trauma team activation). This latter study did not clarify whether the fractures detected on CT were clinically significant or ifany intervention was required.

TABLE 258-4

NEXUS Criteria

Absence of midline cervical tenderness

Normal level of alertness and consciousness*

No evidence of intoxication

Absence of focal neurologic deficit

Absence of painful distracting injury†

The Canadian Cervical Spine Rule for Radiography (CCR) was developed for alert, stable trauma patients to reduce practice variation and

ine�iciency in the ED use of plain cervical spine radiography.36 The Canadian rule consists of three assessments, which are asked in

sequential order (Table 258-5).36 To proceed to the next assessment, the answer to the previous assessment must be "Yes." If the answer toany assessments is "No," then imaging is immediately performed. In the original study sample of 8924 patients, the CCR was 100% sensitive

(95% CI, 98% to 100%) and 42.5% specific (95% CI, 40% to 44%) for identifying patients with "clinically important" cervical spine injuries.36

The CCR has also been validated in both larger hospital-based studies51 and prehospital studies,52 but has been criticized for its complexity

relative to NEXUS.53

11/25/2018

34/47

*Defined as fall from a height of >3 feet; an axial loading injury; high-speed motor vehicle crash, rollover, or ejection; motorized recreational vehicle or

bicycle collision.

TABLE 258-5

Canadian Cervical Spine Rule for Radiography: Cervical Spine Imaging Unnecessary in Patients Meeting These Three Criteria

Assessment Definitions

Assessment #1:

There are no high-risk factors that mandate radiography.

High-risk factors include:

Age 65 years or older

A dangerous mechanism of injury*

The presence of paresthesias in the extremities

Assessment #2:

There are low-risk factors that allow a safe assessment of range of motion.

Low-risk factors include:

Simple rear-end motor vehicle crashes

Patient able to sit up in the ED

Patient ambulatory at any time

Delayed onset of neck pain

Absence of midline cervical tenderness

Assessment #3:

The patient is able to actively rotate his/her neck (regardless of pain).

Can rotate neck 45 degrees to the le� and to the right

There is one published direct prospective comparison of NEXUS and CCR (n = 8283) that reported that CCR was more accurate for detectingcervical spine injury compared to NEXUS, with superior sensitivity (99% vs 91%), specificity (45% vs 37%), positive likelihood ratio (1.81 vs

1.44), and negative likelihood ratio (0.01 vs 0.25).54 However, some have questioned the methodology of this comparison as being biased in

favor of CCR.55,56 A meta-analysis of 15 studies (79,526 patients) concluded that the CCR appeared to have better diagnostic accuracy than

NEXUS57; however, the quality of methods of the included studies were termed "modest," and further more rigorous studies were suggestedto be done. In both rules, the more subjective parts ("absence of painful distracting injury" and "no evidence of intoxication" for NEXUS;"dangerous mechanism of injury" and assessment of range of motion for CCR) are the most common misinterpretation of the rules, which

obviously a�ects their performance.57

Both NEXUS and CCR were developed in an era prior to the routine use of CT as a primary tool to evaluate the cervical spine in blunt traumapatients. Consequently, studies have been done to compare both decision rules using CT scan as the gold standard. In a 2011 study of 2606blunt trauma patients, NEXUS was found to only be 82.8% sensitive and 45.7% specific for spine injury. Of the 26 missed injuries, 19 patients

required further intervention, including 2 who went to the operating room and 1 needing a Halo.58 The same group compared CCR to CT scan

(3201 blunt trauma patients), finding excellent sensitivity of 100% but only 0.60% specificity.59 Nevertheless, the use of NEXUS has been

recommended for use in several national guidelines and trauma societies.60,61

In summary, many experts feel that because both NEXUS and CCR have been widely validated and have demonstrated adequate sensitivity,

either rule may be used to determine which low-risk patients should undergo plain or CT cervical spine imaging.57

CERVICAL SPINE IMAGING

Plain Radiography

Standard radiography for the identification of bony cervical injury includes three views of the cervical spine: lateral, anterior-posterior, and

odontoid. A single lateral cervical spine film will identify only about 90% of injuries to bone and ligaments.24 The anterior-posterior and open-mouth odontoid views will identify many of the remaining abnormalities. It is important to image all seven cervical vertebrae, along with the

11/25/2018

35/47

superior border of the first thoracic vertebra, given the propensity for injuries at the cervical-thoracic junction. Therefore, a "swimmers view"may be necessary to visualize this junction clearly, but this o�en requires an assistant to pull down the shoulders during the radiograph. Themain advantages of plain radiography are that it can be done at the bedside, exposes the patient to only small amounts of ionizing radiation,and has a relatively low cost. One of the main disadvantages of plain films is that they are poor for imaging C1 and C2. In addition,visualization of the entire cervical spine by plain films is o�en problematic in obese, elderly, or extremely muscular patients, especially with acervical collar in place.

Cervical Spine CT

The practice in many trauma centers is to obtain CT as the initial imaging modality to evaluate the cervical spine. Multidetector CT is more

sensitive and specific than plain radiography for evaluating the cervical spine in trauma patients and can be performed quickly.62,63 CT canbe used to visualize the entire cervical spine and is particularly useful at the craniocervical and cervicothoracic regions, where the sensitivityof plain films is most limited. In addition, a 3-year retrospective review found that plain radiography did not add any clinically useful

information to a cervical spine CT.64 Furthermore, a cost analysis showed CT to be cost-e�ective to screen for cervical spine injuries in

moderate- to high-risk patients.65 The Eastern Association for the Surgery of Trauma recommends CT as the primary diagnostic tool for

suspected cervical spine injury.60 In addition, if plain radiography is chosen as the primary imaging modality, a CT should be ordered if aninjury is detected or suspected or if the initial plain radiograph is inadequate.

Imaging for Cervical Ligamentous Injury

In patients with pure ligamentous injuries, the ligaments are disrupted, but the spine spontaneously reduces to a normal position. Theresulting instability risks subsequent neurologic injury if the spine moves. Signs and symptoms include persistent neck pain/midlinetenderness, extremity paresthesias, or focal neurologic findings despite normal plain radiographs and/or CT.

Although flexion and extension radiographs have been traditionally used to try to detect ligamentous instability, numerous studies havedemonstrated their lack of sensitivity and ine�iciency (30% to 80% of flexion and extension radiographs are inadequate), and they provide no

further information beyond a CT.66,67,68,69,70 Therefore, flexion and extension radiographs should not be ordered when more advancedimaging is available.

MRI is the imaging modality of choice if a ligamentous injury is strongly suspected because MRI has excellent sensitivity for so� tissue

injuries.71,72 However, there are practical limitations on its use, including the requirement for the patient to be stable, availability, cost, andpatient tolerance for the procedure. If emergent MRI is not feasible, reliable patients with persistent pain but normal CT can be discharged ina firm foam collar with outpatient follow-up in 3 to 5 days. Most patients' symptoms will resolve over a few days. A patient with persistentpain at follow-up will likely require additional imaging. Unreliable patients with severe persistent pain and normal CT images should beconsidered for an MRI study, although this is rarely indicated as part of the initial investigation. In fact, some data have suggested that newer-

generation CTs are su�icient to detect significant injuries without MRI even in obtunded patients.73,74 However, the results of these studiescannot currently be externally generalized to awake, symptomatic patients.

Thoracic and Lumbar Spine Imaging

As of this writing, there are no well-validated clinical decision rules for imaging in possible thoracolumbar spine injuries. However, Table 258-

6 provides practice guidelines for imaging in blunt trauma victims who are suspected of having thoracolumbar injuries.37,75

11/25/2018

36/47

Abbreviation: CT = multidetector CT.

TABLE 258-6

Eastern Association for the Surgery of Trauma Guidelines for Thoracic and Lumbar Imaging a�er Trauma

Level I (convincingly

justifiable based on

scientific evidence)

When imaging is deemed necessary, CT scans with axial collimation should be used to screen for and diagnose injury,

because CT scans are superior to plain films in identifying thoracolumbar spine fractures.

Level II (reasonably

justifiable based on

scientific evidence and

expert opinion)

Patients with back pain, thoracolumbar spine tenderness on examination, neurologic deficits referable to the

thoracolumbar spine, altered mental status, intoxication, distracting injuries, or known or suspected high-energy

mechanisms should be screened for thoracolumbar spine injury with CT scan.

In blunt trauma patients with a known or suspected injury to the cervical spine, or any other region of the spine,

thorough evaluation of the entire spine by CT scan should be strongly considered due to a high incidence of spinal

injury at multiple levels within this population.

Patients without complaints of thoracolumbar spine pain who have normal mental status, as well as normal neurologic

and physical examinations, may be excluded from thoracolumbar spine injury by clinical examination alone, without

radiographic imaging, provided that there is no suspicion of high-energy mechanism or intoxication with alcohol or

drugs.

Level III (supported by

available data, but

scientific evidence

lacking)

MRI should be considered in consultation with the spine service for CT findings suggestive of neurologic involvement

and of gross neurologic deficits.

As with the cervical spine, CT has largely supplanted plain radiography in the imaging of thoracic and lumbar injuries with significant blunttrauma. CT scanning is indicated in almost all patients with proven bony spinal injury, subluxations, neurologic deficits (but no apparentabnormalities on plain films), or severe neck or back pain (with normal plain films) and when the thoracic and lumbar spine should beexamined to define the anatomy of a fracture and the extent of impingement on the spinal canal. Rather than obtaining separate plainradiographs or dedicated CT images, the thoracic and abdominal CT scans obtained to evaluate the multiple trauma patient can be used toreconstruct images of the thoracic and lumbar spine, although some authors have suggested that spinal image reconstruction is not

necessary because the spine can be seen on the visceral CT scans.76,77 CT can reveal the anatomy of an osseous injury, grade the extent ofspinal canal impingement by bone fragments, and assess the stability of an injury. If an associated spinal cord or nerve root injury issuspected, MRI is the imaging study of choice.

It is less clear how to screen for thoracolumbar injuries in patients who have less severe mechanisms of injuries. Although it has been shown

repeatedly that CT is more sensitive for thoracolumbar injuries in severely injured patients,37 there has been no prospective controlledcomparison between plain radiography and CT in more mildly injured patients. Nevertheless, some published guidelines suggest CT should

be considered the standard screening modality for thoracolumbar injuries.37

Spinal Cord and Neural Tissue Imaging

MRI is not as sensitive as CT for detecting or delineating bone injuries but is superb at defining neural, muscular, and so� tissue injury. MRI isthe diagnostic test of choice for describing the anatomy of nerve injury. Entities such as herniated disks or spinal cord contusions can also bedelineated on MRI. MRI is indicated in patients with neurologic findings with no clear explanation a�er plain films and/or CT scanning. If thepatient is stable and MRI is unavailable, transfer to a tertiary care facility with MRI capabilities is appropriate.

Concurrent Spine Injury Imaging

11/25/2018

37/47

The determination of a spinal column injury at one level should prompt imaging of the entire remainder of the spine with CT because

approximately 20% of patients with a spine fracture in one segment will have a noncontiguous second fracture at another segment.78,79

Spine Imaging in Obtunded Patients

While experts recommend that all obtunded patients with significant blunt trauma should have their entire spine imaged, consensus doesnot yet exist on what imaging is necessary to clear the spine in obtunded patients. Specifically, it is controversial whether a negative CT of the

spine is adequate or if a subsequent MRI needs to be done,80 although at this writing, the trend in the literature suggests that a negative CT is

su�icient.73,74 In the absence of definitive data, maintain spinal precautions in the obtunded trauma patient in the ED, and defer any spineclearance to local expert consultants.

TREATMENT AND DISPOSITION OF SPINAL COLUMN INJURIES

The goals of treatment are to prevent secondary injury, alleviate cord compression, and establish spinal stability. Maintain spinalimmobilization and keep movement to a minimum. Obtain emergent consultation with a spine surgeon (neurosurgeon or orthopedic surgeondepending on the particular facility) on all spinal column fractures or ligamentous injuries, regardless of neurologic compromise.

CERVICAL SPINE FRACTURES

The majority of cervical spinal fractures will require admission for definitive treatment or for the care of associated injuries. Until transfer ofcare to a surgeon, spine precautions should be maintained, associated injuries stabilized, and the patient carefully monitored for respiratoryor neurologic deterioration.

THORACIC AND LUMBAR SPINE FRACTURES

Thoracolumbar fractures are also high risk for associated spinal cord or other traumatic injuries, such as aortic, intrathoracic, or intra-abdominal visceral injuries. Although many of these injuries will require admission, there are two types of thoracolumbar factures that maybe amenable to outpatient therapy.

Compression fractures, also known as "wedge" or "anterior" compression fractures, comprised approximately 52% of thoracolumbar

fractures in one published series.81 These fractures occur as a result of a hyperflexion during an axial load that crushes the anterior portion ofthe vertebra. If the percentage of loss of vertebral height is <40%, the patient may be a candidate for outpatient therapy, and this should bediscussed on a case-by-case basis by the spine surgeon. However, if the loss of vertebral height is ≥50% or if the angle between the damagedvertebra and the rest of the spinal column is >25% to 30%, the compression fracture is generally considered unstable.

In addition, make certain that an apparent compression fracture seen on plain radiographs is not a burst fracture, which is a compression-type fracture that involves the posterior half of the vertebrae. Burst fractures may result in retropulsed fragments that can impinge on thespinal canal and cause neurologic injury. In two studies, the incidence of misdiagnosis of burst fractures on plain radiographs ranged from

20% to 23%.82,83 Another fracture that is sometimes misdiagnosed as a wedge compression fracture on plain radiograph is the Chancefracture. This fracture occurs via a flexion-distraction mechanism and involves minor anterior vertebral compression and significantdistraction of the middle and posterior ligamentous structures. Typical radiographic findings reveal a transverse fracture lucency in thevertebral body, an increased height of the posterior vertebral body, fracture of the posterior wall of the vertebral body, and posterior openingof the disk space. Finally, minor to moderate trauma can cause pathologic fractures secondary to preexisting neoplastic, infectious, orosteoporotic processes in the spine. Because the above mentioned fractures can be easily misdiagnosed with plain radiography alone, some

experts recommend that compression fractures of the thoracolumbar spine on plain radiographs be further evaluated with CT.84

If, a�er a thorough evaluation, a stable wedge compression fracture with no neurologic compromise is diagnosed, the patient may be treatedas an outpatient with analgesia, heat, massage, rest, and appropriate follow-up for consideration of physical therapy.

SACRUM AND COCCYX FRACTURES

Injuries of the sacral spine and nerve roots are very unusual. When they occur, they are frequently associated with fractures of the pelvis. Ingeneral, transverse fractures through the body are most significant in that they cause injury to part or all of the cauda equina. Longitudinalfractures may cause radiculopathy. Sacral fractures that involve the central sacral canal can produce bowel or bladder dysfunction.

11/25/2018

38/47

One notable exception to the need for emergent consultation is an isolated coccyx fracture. Coccygeal injuries are usually associated with adirect fall onto the buttocks, with resultant coccyx pain exacerbated by sitting or straining. Imaging is not needed to diagnose coccygealfractures. Treatment is symptomatic with analgesics and use of a rubber doughnut pillow.

SPECIAL CONSIDERATIONS

CORTICOSTEROIDS

High-dose methylprednisolone remains a controversial treatment in acute blunt spinal cord injury and should not be given routinely. Themajor neuroprotective mechanism by which high-dose methylprednisolone is believed to work is in its inhibition of free radical–induced lipidperoxidation. Other proposed beneficial actions include its ability to increase levels of spinal cord blood flow, increase extracellular calcium,and prevent loss of potassium from injured cord tissue. Methylprednisolone is advocated in preference to other steroids because it crossescell membranes more rapidly and completely.

In the 1990s, the National Acute Spinal Cord Injury Study (NASCIS) group published three prospective, double-blind studies to evaluate the

e�icacy of methylprednisolone in blunt spinal cord injury: NASCIS I, II, and III.85,86,87 NASCIS I compared high-dose methylprednisolone and alower-dose methylprednisolone regimen (n = 330). NASCIS I showed no evidence in recovery of function between the groups. NASCIS IIcompared a higher dose of methylprednisolone (Table 258-7), naloxone, and placebo (n = 427). This trial was also negative, but based on posthoc subgroup analysis, NASCIS II showed modest improvements in motor function when steroids were administered within 8 hours of injury.NASCIS III compared high-dose methylprednisolone for 24 hours, high-dose methylprednisolone for 48 hours, and tirilazad mesylate for 24hours (n = 499). NASCIS III was also a negative trial, but post hoc analysis found that patients who received the 48-hour methylprednisoloneregimen within 3 to 8 hours of their injury showed motor improvement. In all three trials, patients who received high-dosemethylprednisolone and longer duration protocols were more likely to develop complications such as severe sepsis, severe pneumonia,wound infection and delayed healing, pulmonary embolism and deep vein thrombosis, GI bleeding, and death. A recent Cochrane systematicreview (written by the lead author of the NASCIS trials) essentially confirmed the conclusions of NASCIS II and III that high-dosemethylprednisolone was beneficial when administered within 8 hours of injury, but these patients were also more likely to develop

complications.88 The systematic review also recommended that more randomized trials be done urgently.

TABLE 258-7

The National Acute Spinal Cord Injury Study II High-Dose Methylprednisolone Protocol

Indications Blunt trauma

Neurologic deficit referable to the spinal cord

Treatment must be started within 8 h of injury

Treatment Methylprednisolone, 30 milligrams/kg IV bolus over 15 min

Followed by a 45-min pause

Methylprednisolone, 5.4 milligrams/kg/h IV is then infused for 23 h

The results of the NASCIS clinical trials have been criticized as not providing su�icient clinical evidence to support the use of steroids in acutespinal cord injury. Examples of bias cited include the use of post hoc subgroup analysis, the artificiality of the 3- and 8-hour time limits, and adi�erence in the severity of injury in particular treatment groups. Reassessment, meta-analysis, and studies by other authors have

questioned the validity of the NASCIS trials and the e�ectiveness of high-dose steroid therapy in these patients.89,90,91 Consequently, the2013 updated guidelines for the management of acute spinal cord injuries endorsed by the American Association of Neurological Surgeonsand the Congress of Neurological Surgeons stated that "there is no consistent or compelling medical evidence of any class to justify theadministration of methylprednisolone for acute spinal cord injury," and that "methylprednisolone should not be routinely used in the

treatment of patients with acute spinal cord injury."92 Moreover, the U.S. Food and Drug Administration has not approved corticosteroids for

acute spinal cord injury.93

Nevertheless, the use of methylprednisolone persists in some centers. Therefore, given the continued controversy over its use,94,95 thedecision to start corticosteroids should only be made in conjunction with the surgeon who will ultimately be caring for the patient, and not

11/25/2018

39/47

1. 

2. 

3. 

4. 

5. 

6. 

given routinely.

It is important to realize that the NASCIS trial protocol was evaluated only in patients with blunt spinal cord injury, while penetrating injurieswere excluded from these studies. In fact, high-dose methylprednisolone therapy has not been found to be e�icacious in penetrating spinal

cord injury.96 In addition, because corticosteroids worsen outcomes in brain-injured patients, they should be avoided in this population as

well.97

CARDIOVASCULAR COMPLICATIONS

If neurogenic shock is present, initiate an infusion of IV crystalloid to correct this relative hypovolemia. If IV fluids are not adequate tomaintain organ perfusion, positive inotropic pressor agents may be beneficial adjuncts to improve cardiac output and raise perfusionpressure. In terms of target systolic blood pressure and mean arterial pressure, the evidence in the literature is limited at best. However, it hasbeen recommended that systolic blood pressure should be kept greater than 90 mm Hg, with the mean arterial pressure kept at 85 to 90 mm

Hg.98 The aggressive use of fluids in neurogenic shock should be performed with careful monitoring, because there is danger of excessivefluid replacement, resulting in heart failure and pulmonary edema. There is no definitive evidence that any particular vasopressor is superior

to another for this indication.99

Bradycardia, when present, usually occurs within the first few hours or days a�er spinal cord injury because of a predominance of vagal toneto the heart. In cases of hemodynamically significant bradycardia, atropine may be needed. Rare occurrences of atrioventricular conductionblock with significant bradycardia require a pacemaker.

PENETRATING INJURY

Penetrating injuries to the neck are discussed in chapter 260, "Trauma to the Neck." For spinal gunshot wounds with a transabdominal ortransintestinal trajectory, administer prophylactic broad-spectrum IV antibiotics in the ED. Corticosteroids are contraindicated in patientswith any type of penetrating spinal injuries, and emergent consultation with a spine surgeon is indicated.

Acknowledgments: The author gratefully acknowledges the prior contributions of Bonny J. Baron, Kevin J. McSherry, James L. Larson, Jr.,and Thomas M. Scalea, the authors of this chapter in the previous edition. The author would also like to thank Lawrence R. Ricci, DO, for hisinvaluable assistance with locating images.

REFERENCES

Fredo  HL, Rizvi  SA, Lied  B, Ronning  P, Helseth  E: The epidemiology of traumatic cervical spine fractures: a prospective population studyfrom Norway. Scand J Trauma Resusc Emerg Med 20: 85, 2012.

[PubMed: 23259662]  

Hu  R, Mustard  CA, Burns C" Epidemiology of incident spinal fracture in a complete population. Spine 21: 492, 1996. [PubMed: 8658254]  

https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202013.pdf (National Spinal Cord Injury Statistical Center: Spinalcord injury facts and figures at a glance, 2013.) Accessed June 18, 2014.

Greenbaum  J, Walters  N, Levy  PD: An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergencydepartment. J Emerg Med 36: 64, 2009.

[PubMed: 18783909]  

Holmes  JF, Miller  PQ, Panacek  EA, Lin  S, Horne  NS, Mower  WR: Epidemiology of thoracolumbar spine injury in blunt trauma. Acad EmergMed 8: 866, 2001.

[PubMed: 11535478]  

Rabb  CH, Lopez  J, Beauchamp  K, Witt  P, Bolles  G, Dwyer  A: Unilateral cervical facet fractures with subluxation: injury patterns andtreatment. J Spinal Disord Tech 20: 416, 2007.

[PubMed: 17970181]  

11/25/2018

40/47

7. 

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

19. 

20. 

21. 

Syre  P, Petrov  D, Malhotra  NR: Management of upper cervical spine injuries: a review. J Neurosurg Sci 57: 219, 2013. [PubMed: 23877268]  

Amorosa  LF, Vaccaro  AR: Current concepts in cervical spine trauma. Instr Course Lect 63: 255, 2014. [PubMed: 24720311]  

Dickman  CA, Hadley  MN, Pappas  CT, Sonntag  VK, Geisler  FH: Cruciate paralysis: a clinical and radiographic analysis of injuries to thecervicomedullary junction. J Neurosurg 73: 850, 1990.

[PubMed: 2230968]  

Harris  JH  Jr, Carson  GC, Wagner  LK: Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebralrelationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 162: 881, 1994.

[PubMed: 8141012]  

Denis  F: The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8: 817, 1983. [PubMed: 6670016]  

Vaccaro  AR, Oner  C, Kepler  CK  et al.: AOSpine thoracolumbar spine injury classification system: fracture description, neurological status,and key modifiers. Spine 38: 2028, 2013.

[PubMed: 23970107]  

Lewkonia  P, Paolucci  EO, Thomas  K: Reliability of the thoracolumbar injury classification and severity score and comparison with thedenis classification for injury to the thoracic and lumbar spine. Spine 37: 2161, 2012.

[PubMed: 22648029]  

Aarabi  B, Walters  BC, Dhall  SS  et al.: Subaxial cervical spine injury classification systems. Neurosurgery 72 (Suppl 2): 170, 2013. [PubMed: 23417189]

Grossman  RG, Fehlings  MG, Frankowski  RF  et al.: A prospective, multicenter, phase I matched-comparison group trial of safety,pharmacokinetics, and preliminary e�icacy of riluzole in patients with traumatic spinal cord injury. J Neurotrauma 31: 239, 2014.

[PubMed: 23859435]  

Horodyski  M, DiPaola  CP, Conrad  BP, Rechtine  GR 2nd: Cervical collars are insu�icient for immobilizing an unstable cervical spine injury.J Emerg Med 41: 513, 2011.

[PubMed: 21397431]  

Kwan  I, Bunn  F, Roberts  I: Spinal immobilisation for trauma patients. Cochrane Database Syst Rev 2: CD002803, 2001. [PubMed: 11406043]  

Tescher  AN, Rindflesch  AB, Youdas  JW  et al.: Range-of-motion restriction and craniofacial tissue-interface pressure from four cervicalcollars. J Trauma 63: 1120, 2007.

[PubMed: 17993960]  

Linares  HA, Mawson  AR, Suarez  E, Biundo  JJ: Association between pressure sores and immobilization in the immediate post-injuryperiod. Orthopedics 10: 571, 1987.

[PubMed: 3575181]  

Luscombe  MD, Williams  JL: Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J 20: 476,2003.

[PubMed: 12954698]  

Totten  VY, Sugarman  DB: Respiratory e�ects of spinal immobilization. Prehosp Emerg Care 3: 347, 1999. [PubMed: 10534038]  

11/25/2018

41/47

22. 

23. 

24. 

25. 

26. 

27. 

28. 

29. 

30. 

31. 

32. 

33. 

34. 

35. 

36. 

Del Rossi  G, Rechtine  GR, Conrad  BP, Horodyski  M: Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med 28:751, 2010.

[PubMed: 20837250]  

Hemmes  B, Poeze  M, Brink  PR: Reduced tissue-interface pressure and increased comfort on a newly developed so�-layered longspineboard. J Trauma 68: 593, 2010.

[PubMed: 19918198]  

Sundstrom  T, Asbjornsen  H, Habiba  S, Sunde  GA, Wester  K: Prehospital use of cervical collars in trauma patients: a critical review. JNeurotrauma 31: 531, 2014.

[PubMed: 23962031]  

Theodore  N, Hadley  MN, Aarabi  B  et al.: Prehospital cervical spinal immobilization a�er trauma. Neurosurgery 72 (Suppl 2): 22, 2013. [PubMed: 23417176]

Connell  RA, Graham  CA, Munro  PT: Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury 34:912, 2003.

[PubMed: 14636733]  

Haut  ER, Kalish  BT, Efron  DT  et al.: Spine immobilization in penetrating trauma: more harm than good? J Trauma 68: 115, 2010. [PubMed: 20065766]  

Azia  M: Use of video-assisted intubation devices in the management of patients with trauma. Anesthesiol Clin 31: 157, 2013. [PubMed: 23351541]  

Zipnick  RI, Scalea  TM, Trooskin  SZ  et al.: Hemodynamic responses to penetrating spinal cord injuries. J Trauma 35: 578, 1993. [PubMed: 8411282]  

Horodyski  M, Conrad  BP, Del Rossi  G, DiPaola  CP, Rechtine  GR 2nd: Removing a patient from the spine board: is the li� and slide saferthan the log roll? J Trauma 70: 1282, 2011.

[PubMed: 21610441]  

Conrad  BP, Rossi  GD, Horodyski  MB, Prasarn  ML, Alemi  Y, Rechtine  GR: Eliminating log rolling as a spine trauma order. Surg Neurol Int 3(Suppl 3): S188, 2012.

[PubMed: 22905325]  

Powers  J, Daniels  D, McGuire  C, Hilbish  C: The incidence of skin breakdown associated with use of cervical collars. J Trauma Nurs 13:198, 2006.

[PubMed: 17263104]  

Ho  AM, Fung  KY, Joynt  GM, Karmakar  MK, Peng  Z: Rigid cervical collar and intracranial pressure of patients with severe head injury. JTrauma 53: 1185, 2002.

[PubMed: 12478051]  

Karason  S, Reynisson  K, Sigvaldason  K, Sigurdsson  GH: Evaluation of clinical e�icacy and safety of cervical trauma collars: di�erences inimmobilization, e�ect on jugular venous pressure and patient comfort. Scand J Trauma Resusc Emerg Med 22: 37, 2014.

[PubMed: 24906207]  

Ho�man  JR, Mower  WR, Wolfson  AB, Todd  KH, Zucker  MI: Validity of a set of clinical criteria to rule out injury to the cervical spine inpatients with blunt trauma: National Emergency X-Radiography Utilization Study Group. N Engl J Med 343: 94, 2000.

[PubMed: 10891516]  

Stiell  IG, Wells  GA, Vandemheen  KL  et al.: The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286: 1841,2001.

11/25/2018

42/47

37. 

38. 

39. 

40. 

41. 

42. 

43. 

44. 

45. 

46. 

47. 

48. 

49. 

50. 

[PubMed: 11597285]  

Sixta  S, Moore  FO, Ditillo  MF  et al.: Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery ofTrauma practice management guideline. J Trauma Acute Care Surg 73 (5 Suppl 4): S326, 2012.  [PubMed: 23114489]

http://www.asia-spinalinjury.org/elearning/ISNCSCI.php (American Spinal Injury Association: ASIA Learning Center Materials:International Standards for Neurological Classification of Spinal Cord Injury Exam Worksheet. 2014.) Accessed August 22, 2014.

Scivoletto  G, Tamburella  F, Laurenza  L, Torre  M, Molinari  M: Who is going to walk? A review of the factors influencing walking recoverya�er spinal cord injury. Front Hum Neurosci 8: 141, 2014.

[PubMed: 24659962]  

Amendola  L, Corghi  A, Cappuccio  M, De Iure  F: Two cases of Brown-Sequard syndrome in penetrating spinal cord injuries. Eur Rev MedPharmacol Sci 18 (1 Suppl): 2, 2014.

[PubMed: 24825034]  

Gooding  BW, Higgins  MA, Calthorpe  DA: Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome? Br JNeurosurg 27: 156, 2013.

[PubMed: 23113877]  

Balasubramanian  K, Kalsi  P, Greenough  CG, Kuskoor Seetharam  MP: Reliability of clinical assessment in diagnosing cauda equinasyndrome. Br J Neurosurg 24: 383, 2010.

[PubMed: 20726746]  

Guly  HR, Bouamra  O, Lecky  FE: The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergencydepartment. Resuscitation 76: 57, 2008.

[PubMed: 17688997]  

Ditunno  JF, Little  JW, Tessler  A, Burns  AS: Spinal shock revisited: a four-phase model. Spinal Cord 42: 383, 2004. [PubMed: 15037862]  

Ko  HY, Ditunno  JF  Jr, Graziani  V, Little  JW: The pattern of reflex recovery during spinal shock. Spinal Cord 37: 402, 1999. [PubMed: 10432259]  

D'Amico  JM, Condli�e  EG, Martins  KJ, Bennett  DJ, Gorassini  MA: Recovery of neuronal and network excitability a�er spinal cord injuryand implications for spasticity. Front Integr Neurosci 8: 36, 2014.

[PubMed: 24860447]  

Fujii  T, Faul  M, Sasser  S: Risk factors for cervical spine injury among patients with traumatic brain injury. J Emerg Trauma Shock 6: 252,2013.

[PubMed: 24339657]  

Bandiera  G, Stiell  IG, Wells  GA  et al.: The Canadian C-spine rule performs better than unstructured physician judgment. Ann Emerg Med42: 395, 2003.

[PubMed: 12944893]  

Touger  M, Gennis  P, Nathanson  N  et al.: Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunttrauma. Ann Emerg Med 40: 287, 2002.

[PubMed: 12192352]  

Goode  T, Young  A, Wilson  SP, Katzen  J, Wolfe  LG, Duane  TM: Evaluation of cervical spine fracture in the elderly: can we trust our physicalexamination? Am Surg 80: 182, 2014.

[PubMed: 24480220]  

11/25/2018

43/47

51. 

52. 

53. 

54. 

55. 

56. 

57. 

58. 

59. 

60. 

61. 

62. 

63. 

64. 

Stiell  IG, Clement  CM, Grimshaw  J  et al.: Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.BMJ 339: b4146, 2009.

[PubMed: 19875425]  

Vaillancourt  C, Stiell  IG, Beaudoin  T  et al.: The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med54: 663, 2009.

[PubMed: 19394111]  

Mower  WR, Ho�man  JL: Comparison of the Canadian C-Spine rule and NEXUS decision instrument in evaluating blunt trauma patientsfor cervical spine injury. Ann Emerg Med 43: 515, 2004.

[PubMed: 15039696]  

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 JMed 349: 2510, 2003.

[PubMed: 14695411]  

Yealy  DM, Auble  TE: Choosing between clinical prediction rules. N Engl J Med 349: 2553, 2003. [PubMed: 14695417]  

Mower  WR, Wolfson  AB, Ho�man  JR, Todd  KH: The Canadian C-spine rule. N Engl J Med 350: 1467, 2004. [PubMed: 15070802]  

Michale�  ZA, Maher  CG, Verhagen  AP, Rebbeck  T, Lin  CW: Accuracy of the Canadian C-spine rule and NEXUS to screen for clinicallyimportant cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 184: E867, 2012.

[PubMed: 23048086]  

Duane  TM, Mayglothling  J, Wilson  SP  et al.: National Emergency X-Radiography Utilization Study criteria is inadequate to rule outfracture a�er significant blunt trauma compared with computed tomography. J Trauma 70: 829, 2011.

[PubMed: 21610391]  

Duane  TM, Wilson  SP, Mayglothling  J  et al.: Canadian Cervical Spine rule compared with computed tomography: a prospective analysis.J Trauma 71: 352, 2011.

[PubMed: 21825938]  

Como  JJ, Diaz  JJ, Dunham  CM  et al.: Practice management guidelines for identification of cervical spine injuries following trauma:update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma 67: 651, 2009.

[PubMed: 19741415]  

Ryken  TC, Hadley  MN, Walters  BC  et al.: Radiographic assessment. Neurosurgery 72 (Suppl 2): 54, 2013. [PubMed: 23417179]  

Bailitz  J, Starr  F, Beecro�  M  et al.: CT should replace three-view radiographs as the initial screening test in patients at high, moderate,and low risk for blunt cervical spine injury: a prospective comparison. J Trauma 66: 1605, 2009.

[PubMed: 19509621]  

Gale  SC, Gracias  VH, Reilly  PM, Schwab  CW: The ine�iciency of plain radiography to evaluate the cervical spine a�er blunt trauma. JTrauma 59: 1121, 2005.

[PubMed: 16385289]  

Hashem  R, Evans  CC, Farrokhyar  F, Kahnamoui  K: Plain radiography does not add any clinically significant advantage to multidetectorrow computed tomography in diagnosing cervical spine injuries in blunt trauma patients. J Trauma 66: 423, 2009.

[PubMed: 19204517]  

11/25/2018

44/47

65. 

66. 

67. 

68. 

69. 

70. 

71. 

72. 

73. 

74. 

75. 

76. 

77. 

Grogan  EL, Morris  JA  Jr, Dittus  RS  et al.: Cervical spine evaluation in urban trauma centers: lowering institutional costs andcomplications through helical CT scan. J Am Coll Surg 200: 160, 2005.

[PubMed: 15664088]  

Insko  EK, Gracias  VH, Gupta  R, Goettler  CE, Gaieski  DF, Dalinka  MK: Utility of flexion and extension radiographs of the cervical spine inthe acute evaluation of blunt trauma. J Trauma 53: 426, 2002.

[PubMed: 12352475]  

Khan  SN, Erickson  G, Sena  MJ, Gupta  MC: Use of flexion and extension radiographs of the cervical spine to rule out acute instability inpatients with negative computed tomography scans. J Orthop Trauma 25: 51, 2011.

[PubMed: 21085024]  

McCracken  B, Klineberg  E, Pickard  B, Wisner  DH: Flexion and extension radiographic evaluation for the clearance of potential cervicalspine injures in trauma patients. Eur Spine J 22: 1467, 2013.

[PubMed: 23404352]  

Goodnight  TJ, Helmer  SD, Dort  JM, Nold  RJ, Smith  RS: A comparison of flexion and extension radiographs with computed tomographyof the cervical spine in blunt trauma. Am Surg 74: 855, 2008.

[PubMed: 18807677]  

Tran  B, Saxe  JM, Ekeh  AP: Are flexion extension films necessary for cervical spine clearance in patients with neck pain a�er negativecervical CT scan? J Surg Res 184: 411, 2013.

[PubMed: 23809183]  

Chew  BG, Swartz  C, Quigley  MR, Altman  DT, Da�ner  RH, Wilberger  JE: Cervical spine clearance in the traumatically injured patient: ismultidetector CT scanning su�icient alone? Clinical article. J Neurosurg Spine 19: 576, 2013.

[PubMed: 24033302]  

Mnaker  J, Stein  DM, Philp  AS, Scalea  TM: 40-slice multidetector CT: is MRI still necessar American Spinal Injury Association AmericanSpinal Injury Association y for cervical spine clearance a�er blunt trauma? Am Surg 76: 157, 2010.

[PubMed: 20336892]  

Khanna  P, Chau  C, Dublin  A, Kim  K, Wisner  D: The value of cervical magnetic resonance imaging in the evaluation of the obtunded orcomatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J TraumaAcute Care Surg 72: 699, 2012.

[PubMed: 22491556]  

Satahoo  SS, Davis  JS, Garcia  GD  et al.: Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient'scervical spine? J Surg Res 187: 225, 2014.

[PubMed: 24157265]  

O'Connor  E, Walsham  J: Review article: indications for thoracolumbar imaging in blunt trauma patients: a review of current literature.Emerg Med Australas 21: 94, 2009.

[PubMed: 19422405]  

Mancini  DJ, Burchard  KW, Pekala  JS: Optimal thoracic and lumbar spine imaging for trauma: are thoracic and lumbar spine reformatsalways indicated? J Trauma 69: 119, 2010.

[PubMed: 20622586]  

Gross  EA: Computed tomographic screening for thoracic and lumbar fractures: is spine reformatting necessary? Am J Emerg Med 28: 73,2010.

[PubMed: 20006205]  

11/25/2018

45/47

78. 

79. 

80. 

81. 

82. 

83. 

84. 

85. 

86. 

87. 

88. 

89. 

90. 

91. 

Sharma  OP, Oswanski  MF, Yazdi  JS, Jindal  S, Taylor  M: Assessment for additional spinal trauma in patients with cervical spine injury. AmSurg 73: 70, 2007.

[PubMed: 17249461]  

Miller  CP, Brubacher  JW, Biswas  D, Lawrence  BD, Whang  PG, Grauer  JN: The incidence of noncontiguous spinal fractures and othertraumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center. Spine 36: 1532, 2011.

[PubMed: 21242872]  

Schoenfeld  AJ, Bono  CM, McGuire  KJ, Warholic  N, Harris  MB: Computed tomography alone versus computed tomography and magneticresonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 68: 109, 2010.

[PubMed: 20065765]  

Holmes  JF, Miller  PQ, Panacek  EA, Lin  S, Horne  NS, Mower  WR: Epidemiology of thoracolumbar spine injury in blunt trauma. AcadEmerg Med 8: 866, 2001.

[PubMed: 11535478]  

Dai  LY: Imaging diagnosis of thoracolumbar burst fractures. Chin Med Sci J 19: 142, 2004. [PubMed: 15250254]  

Ballock  RT, Mackersie  R, Abitbol  JJ, Cervilla  V, Resnick  D, Garfin  SR: Can burst fractures be predicted from plain radiographs? J BoneJoint Surg Br 74: 147, 1992.

[PubMed: 1732246]  

Dai  LY, Wang  XY, Jiang  LS  et al.: Plain radiography versus computed tomography scans in the diagnosis and management ofthoracolumbar burst fractures. Spine 33: E548, 2008.

[PubMed: 18628696]  

Bracken  MB, Collins  WF, Freeman  DF  et al.: E�icacy of methylprednisolone in acute spinal cord injury. JAMA 251: 45, 1984. [PubMed: 6361287]  

Bracken  MB, Shepard  MJ, Collins  WF  et al.: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acutespinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322: 1405, 1990.

[PubMed: 2278545]  

Bracken  MB, Shepard  MJ, Holford  TR  et al.: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours inthe treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury randomized controlled trial. National AcuteSpinal Cord Injury Study. JAMA 277: 1597, 1997.

[PubMed: 9168289]  

Bracken  MB: Steroids for acute spinal cord injury. Cochrane Database Syst Rev 1: CD001046, 2012. [PubMed: 22258943]

Sayer  FT, Kronvall  E, Nilsson  OG: Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structuredanalysis of published literature. Spine J 6: 335, 2006.

[PubMed: 16651231]  

Ito  Y, Sugimoto  Y, Tomioka  M, Kai  N, Tanaka  M: Does high dose methylprednisolone sodium succinate really improve neurological statusin patient with acute cervical cord injury? A prospective study about neurological recovery and early complications. Spine 34: 2121, 2009.

[PubMed: 19713878]  

Suberviola  B, Gonzalez-Castro  A, Llorca  J, Ortiz-Melon  F, Minambres  E: Early complications of high-dose methylprednisolone in acutespinal cord injury patients. Injury 39: 748, 2008.

[PubMed: 18541241]  

11/25/2018

46/47

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 

Hurlbert  RJ, Hadley  MN, Walters  BC  et al.: Pharmacological therapy for acute spinal cord injury. Neurosurgery 72 (Suppl 2): 93, 2013. [PubMed: 23417182]  

http://www.ninds.nih.gov/disorders/sci/detail_sci.htm#258013233 (NINDS: Spinal Cord Injury: Hope Through Research. 2014.) AccessedSeptember 9, 2014.

Hurlbert  RJ: Methylprednisolone for the treatment of acute spinal cord injury: point. Neurosurgery 61 (Suppl 1): 32, 2014. [PubMed: 25032528]  

Fehlings  MG, Wilson  JR, Cho  N: Methylprednisolone for the treatment of acute spinal cord injury: counterpoint. Neurosurgery 61 (Suppl1): 36, 2014.

[PubMed: 25032529]  

Levy  ML, Gans  W, Wijesinghe  HS, SooHoo  WE, Adkins  RH, Stillerman  CB: Use of methylprednisolone as an adjunct in the managementof patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 39: 1141, 1996.

[PubMed: 8938768]  

Alderson  P, Roberts  I: Corticosteroids for acute traumatic brain injury. Cochrane Database Syst Rev 1: CD000196, 2005. [PubMed: 15674869]  

Ryken  TC, Hurlbert  RJ, Hadley  MN  et al.: The acute cardiopulmonary management of patients with cervical spinal cord injuries.Neurosurgery 72 (Suppl 2): 84, 2013.

[PubMed: 23417181]

Ploumis  A, Yadlapalli  N, Fehlings  MG, Kwon  BK, Vaccaro  AR: A systematic review of the evidence supporting a role for vasopressorsupport in acute SCI. Spinal Cord 48: 356, 2010.

[PubMed: 19935758]  

PRACTICE GUIDELINES AND USEFUL WEB RESOURCES

2013 American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines for the Management of Acute CervicalSpine and Spinal Cord Injuries. (These are the current practice guidelines from the American Association of Neurological Surgeons/Congressof Neurological Surgeons Joint Guidelines Committee. The chapters regarding prehospital care, initial clinical assessment, and radiographicassessment are particularly relevant to the emergency physician. Online and full-text access is free.)—http://neurosurgerycns.wordpress.com/2013/02/20/guidelines-for-the-management-of-acute-cervical-spine-and-spinal-cord-injury/

Eastern Association for the Surgery of Trauma Practice Management Guidelines (This site contains relevant practice guidelines for cervicaland thoracolumbar spinal injuries.)—http://www.east.org/resources/treatment-guidelines

National Spinal Cord Injury Statistics Center (This webpage contains a link to both a two-page summary and a more detailed report of themost current epidemiologic data regarding spinal cord injuries in the United States in PDF FORM.)—https://www.nscisc.uab.edu/

National Spinal Cord Injury Association—http://www.spinalcord.org; and National Institute of Neurological Disorders and Stroke—http://www.ninds.nih.gov/disorders/sci/sci.htm (These sites have patient information regarding spinal cord injury. The National Institute ofNeurological Disorders and Stroke site includes links to current trials regarding spinal cord injury.)

McGraw HillCopyright © McGraw-Hill Education

All rights reserved. Your IP address is 65.51.87.97

Terms of Use   •  Privacy Policy   •  Notice   •  Accessibility

11/25/2018

47/47

Access Provided by: Brookdale University Medical CenterSilverchair