Chapter 23: Spinal Injuries

INTRODUCTION

The anatomy of the spine, epidemiology and management strategies for isolated spine injuries has been well defined in the pertinent literature and many other textbooks. The scope of this chapter is to provide the trauma surgeon a pragmatic approach, along with clinical guidance, on coordinating the care of the vulnerable cohort of multiply injured patients with associated spinal injuries. Current strategies for initial assessment and management are discussed with a focus on aspects of critical decision-making of importance to the trauma surgeon. These include the questions of how to recognize an unstable spine injury; when and how to clear the cervical spine; current role of steroids in the management of spinal cord injury; timing of tracheostomy in spinal cord-injured patients; and the optimal timing of spinal surgery in the multiply injured patient.

Understanding the pertinent aspects of care for this vulnerable cohort of critically injured patients “at risk” will allow for the trauma surgeon to “speak the same language” as the consulting spine surgeon and to allow coordinating the optimal modality and timing of spinal surgery to mitigate the risk of “second hit” insults and post-injury complications.

INITIAL ASSESSMENT AND DIAGNOSTIC WORKUP

The presence of an associated spinal injury must be assumed in any multiply injured patient until proven otherwise.¹ Of note, approximately 10–15% percent of all trauma patients with severe head injuries have an associated cervical spine injury.² It is important to understand that most spine injuries do not present with a neurological impairment. Pain or tenderness anywhere along the spine, from the occiput to the sacrum, should raise the concern for a spinal injury. The key imperative in the acute management of a trauma patient with a suspected spine injury consists of complete spinal immobilization including the application of a cervical collar, exact documentation and timing of the findings, and immediate evacuation to a designated trauma center.³ A cervical collar must be applied in all trauma patients until cervical spine injuries are either confirmed as absent (see spinal clearance protocols below) or identified and treated appropriately. The unstable spine is at risk for injury from careless manipulation. Therefore, strict log-roll precautions should be maintained until spinal injuries are excluded or spinal stability is restored.⁴ The long spine board must be removed at the earliest time-point once a thorough assessment of the spine has been completed, in order to avoid pressure sores from prolonged immobilization.³ The entire posterior spine should be inspected and palpated for local tenderness and deformities while adhering to log-roll precautions. This requires a team of 4–5 health care personnel to log-roll a patient with simultaneous in-line cervical stabilization. The paraspinal soft tissues should be inspected for evidence of swelling, malalignment, or bruising. Systematic palpation of the spinous processes of the entire spinal column can help to identify and localize a spinal injury as significant gapping between processes can occur in flexion/distraction injuries ...