- All patients with multiple trauma should be suspected of having a spinal injury
- Failure to detect usually results from failure to suspect
- Cervical spine and thoraco-lumbar junction are the commonest site of injury
- The percentage of nerve injuries seen in patients with spinal fractures are:
| Cervical spine |
40% |
| Thoracic spine |
10% |
| Thoraco-lumbar junction |
35% |
| Lumbar spine |
3% |
- All injuries should be assumed to be unstable until proven otherwise
Management
- At scene of accident
- Maintain in-lime spinal immobilisation
- Requires supporting of neck with stiff collar and sandbags
- Patient should be transported on spinal board
- Primary survey
- Intubation required maintenance of in-line immobilisation
- Pharyngeal stimulation with airway can caused vagal discharge and cardiac arrest
- Consider pre-medication with atropine
- Cervical spine injuries reduce sympathetic outflow
- Patients may be both hypotensive and bradycardic
- NB - Not a feature of hypovolaemia therefore suspect spinal cord injury
- May require both atropine and inotropic support
- Aggressive fluid resuscitation can induce pulmonary oedema
- Secondary survey
- Patients may develop respiratory failure due to
- In tetraplegic patients
- Intercostal paralysis
- Partial phrenic nerve palsy
- Impaired ability to cough
- Ventilation-perfusion mismatch
- In paraplegic patients
- Variable intercostal nerve paralysis
- Associated chest injuries
- May develop as a late feature due to ascending oedema in the cervical cord
- Abdomen may be flaccid with absent sensation
- Features of peritonism may be absent
- Priapism may develop
Assessing level of injury
| Muscle group |
Nerve supply |
Reflex |
| Diaphragm |
C3, C4, C5 |
|
| Shoulder abductors |
C5 |
|
| Elbow flexors |
C5, C6 |
Biceps jerk |
| Supinators / pronators |
C6 |
Supinator jerk |
| Wrist extensors |
C6
|
|
|
Wrist flexors
|
C7 |
|
| Elbow extensors |
C7 |
Triceps jerk |
| Finger extensors |
C7
|
|
| Finger flexors |
C8 |
|
| Intrinsic hand muscles |
T1 |
|
| Hip flexors |
L1, L2
|
|
| Hip adductors |
L2, L3 |
|
| Knee extensors |
L3, L4 |
Knee jerk |
| Ankle dorsiflexors |
L4, L5 |
|
| Toe extensors |
L5 |
|
| Knee flexors |
L4, L5, S1 |
|
| Ankle plantar flexors |
S1, S2 |
Ankle jerk |
| Toe flexors |
S1, S2 |
|
| Anal sphincter |
S2, S3, S4 |
Bulbocavernosus reflex |
|
|
Anal reflex |
Partial cord lesions
- Function preserved distal to level or cord injury
- May be missed if do not fit classical injury pattern
- Central cord lesion - flaccid paralysis of upper limbs
- Anterior cord lesion - loss of temperature and sensation
- Posterior cord lesion - loss of vibration sensation and proprioception
- Brown - Sequard syndrome - loss of ipsilateral power and contralateral pain and temperature
Radiological assessment of cervical spine
- 20% patients with spinal cord injury have no radiological evidence of bony injury
- Lateral cervical spine x-ray should be taken during primary survey
- Should ensure that the junction between C7 and T1 is seen
- Anterio-posterior and odontoid peg views should be taken during secondary survey
- If unable to see the C7 / T1 junction consider a 'swimmer's view'
- On lateral cervical spine films need to assess:
- Anterior vertebral alignment
- Posterior vertebral alignment
- Posterior facet joint margins
- Anterior border of spinous processes
- Posterior border of spinous processes
- Integrity of vertebral bodies, laminae, pedicles and arches
- Pre-vertebral space
- Retropharyngeal space should be < 6 mm
- Retrotracheal space should be < 22 mm
- Interspinous gaps
Classification of cervical spine fractures
- Hyperflexion injuries
- Anterior subluxation
- Bilateral locked facet joints
- Teardrop fracture
- Spinous process fractures (Clay shoveller's fracture)
- Hyperextension injuries
- Fracture of the anterior or posterior arch of C1
- Anterior-inferior vertebral chip facture
- Laminar fracture
- Axial compression
- Burst factures
- Fracture of the pedicle of C2
- Flexion rotation injuries
- Unilateral facet dislocation
Radiological signs of spinal instability
- Compression of vertebral body >25%
- Kyphotic angle of >10%
- Facet joint widening
- Teardrop fracture
- Base of odontoid peg fracture
- Atlanto-axial gap > 3 mm
- Atlanto-occipital dislocation
Bibliography
Al-Khateeb H, Oussedik S. The management and treatment of
cervical spine injuries. Hosp Med 2005; 66:
389-395
Bracken M B. Steroids for acute spinal cord injury. Cochrane Database Syst Rev 2002;
CD001046.
Driscoll P A, Ross R, Nicholson D A. Cervical spine I. Br Med J 1993;
307: 785-789.
Driscoll P A, Ross R, Nicholson D A. Cervical spine II. Br Med J 1993;
307: 855-859.
Proctor M R. Spinal cord injury. Crit Care Med 2002; 30 (Suppl): S489-S499
McDonald J W, Sadowsky C. Spinal-cord injury. Lancet 2002; 359: 417-425.
Woolard A, Oussedik S. Injuries to the lumbar spine:
identification and management. Hosp Med 2005: 66;
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