Chapter 23: Spinal Injuries

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.

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 and spinal fracture–dislocations.⁴ During inspection of the face and trunk, it is important to keep in mind that certain injuries can be associated with significant visceral and axial skeletal injuries. Facial trauma and head injuries should alert the examining physician to the possibility of an injury to the cervical spine.² An abrasion under the strap of a restraint can be associated with significant injuries to the cervical spine and cervicothoracic junction. Lap belt contusions should heighten suspicion for flexion–distraction injuries to the thoracolumbar spine. These can be associated with visceral injury. Calcaneal fractures from significant decelerations, including falls from heights, are associated with axial-loading injuries of the thoracic and lumbar spine.⁵ Subsequent to a systematic inspection, a complete neurologic examination is performed (see later). The goal of a repeat assessment is to identify and provide initial treatment of potentially unstable spinal fractures from both a mechanical and a neurologic basis. This allows for a longitudinal comparison and documentation of the neurologic status and early determination of a potentially progressive neurologic deficit. Spinal injuries are identified and worked-up during the secondary survey, after life-saving measures. Of note, most spine injuries do not present with a neurological impairment. If a patient has signs of numbness, tingling sensation, or paralysis to any extremity, a serious injury to the spinal cord must be suspected. Impairment of bladder and bowel function are frequently missed on initial evaluation which speaks to the absolute necessity of a thorough neurological examination, as discussed later.⁶

The diagnostic work-up of spinal injuries includes plain radiographs, computerized tomography (CT) scans, and magnetic resonance imaging (MRI) for visualization of soft-tissue injuries to ligaments and intervertebral discs, epidural bleeding, dural tears, spinal cord contusions and lacerations, and intramedullary lesion expansion over time. Importantly, an MRI should be exclusively obtained in patients who are hemodynamically stable and adequately resuscitated. The initial work-up of multiply injured patients by multislice “whole-body” CT scans provides thin-section images of the entire spine, along with 2D and 3D reconstructions. Of note, in the past decade, the readily available whole-body CT scan has largely replaced the necessity of obtaining conventional radiographs of the entire spine to prevent missing additional vertebral fractures at a different level, which occur in approximately 10% of all cases.⁷

A thorough neurologic examination is mandatory in any trauma patient with suspected spinal injury. Cranial nerve abnormalities can be suggestive of occipito-cervical junction injuries. Four-extremity motor examination should focus on the C5-T1 and L2-S1 myotomes. Truncal and four-extremity sensory examination should document light-touch and pin-prick sensation throughout all dermatomes. Subjective numbness or tingling sensation or paralysis to any extremity imply presence of a serious injury to the spinal cord. The level and severity of a spinal cord injury can be determined by the use of a systematic chart published by the “American Spinal Injury Association” (ASIA).⁸ This chart illustrates the “key sensory points” which correspond to specific neurological levels in the spinal cord (Fig. 23-1).

When assessing the neurological impairment in an individual who sustained a spine injury, it is crucial to document the exact time of assessment, since a neurological deterioration may occur over time.⁶ The extent of neurologic injury is stratified into “complete” (ASIA grade A) or “incomplete” (ASIA grades B-D), with ASIA grade E reflecting a normal neurologic status (Fig. 23-1).⁹ Spinal cord injury is further stratified into paraplegia (paralysis of the lower extremities), resulting from thoracic and lumbar spine injuries, and quadriplegia (paralysis of all four extremities), which originates from cervical spine injuries. With incomplete injuries, the patient has some extent of preserved neurologic function below the level of injury, which is associated with a better outcome prediction compared to complete injuries, where the prognosis is dismal. The encompassing neurological examination should include reflex examination with a focus on triceps, brachioradialis, patellar, and achilles tendons. Hyper-reflexivity may be indicative of a spinal cord injury, while areflexia is reflective of spinal shock with temporary absence of all reflexes. Testing for pathological reflexes include Hoffman’s sign, Babinski sign, and presence of clonus in the case of impaired upper motor neuron down-regulation. A rectal examination is part of the mandatory examination and should document anal resting and voluntary tone, anal and perianal sensation (light-touch and pin-prick), and spinal reflexes (anal wink and bulbocavernosus reflex; the latter requires a Foley catheter placement in females). Obtunded patients should be observed for voluntary movements and withdrawal activity with objective assessments taken from reflex and rectal examinations. Return of the bulbocavernosus reflex is reflective of resolution of spinal shock. In contrast to spinal shock, neurogenic shock represents a hemodynamic entity characterized by hypotension and bradycardia resulting from impaired sympathetic outflow tracts in the injured spinal cord.

Neurologic Syndromes

Anterior Cord Syndrome

This represents an entity of incomplete spinal cord injury resulting from vascular compromise in the anterior spinal artery distribution and subsequent ischemic injury to the anterior two-thirds of the cord, which can occur after blunt trauma mechanisms or ischemic injuries (Fig. 23-2). Clinically, patients present with loss of motor function and pain and temperature sensation below the level of injury from involvement of the ventrally located lateral corticospinal and spinothalamic tracts. Patients typically retain proprioception and the ability to sense vibration and deep pressure from preservation of the posterior columns of the spinal cord. The chance of a relevant clinical recovery in anterior cord syndromes is poor due to the irreversible ischemic neuronal tissue damage.

Central Cord Syndrome

Traumatic central cord syndrome (TCCS) is associated with a contusion, ischemia or hemorrhage in the central portions of the spinal cord due to traumatic injury sustained in the cervical or upper thoracic spine. The syndrome is characterized by weakness in the arms with “burning hands” and relative sparing of lower extremity motor function, associated with variable sensory loss. TCCS typically results from a cervical hyperextension injury in patients with preexisting degenerative changes and narrowing of the spinal canal. Clinically, the upper extremities are more involved than the lower extremities due to the more central location of the upper extremity axons within the spinal cord tracts. Patients typically regain the ability to walk, but have more limited return of function to the upper extremities.

Brown-Séquard Syndrome

This entity represents an incomplete spinal cord syndrome resulting from a hemitransection of the spinal cord frequently resulting from penetrating injuries. The syndrome is characterized by unilateral damage to the corticospinal tract, spinothalamic tract, and dorsal columns. The clinical presentation consists of loss of ipsilateral light touch sensation, proprioception, and motor function and contralateral loss of pain and temperature sensation.

Posterior Cord Syndrome

This syndrome is rare and results from involvement of the dorsal columns with subsequent loss of proprioception and vibration and preserved motor function. The prognosis is variable with many patients experiencing difficulty walking due to the deficit in proprioceptive sensation.

Cervical Root Syndrome

This injury pattern is reflective of an isolated nerve root injury that causes a deficit in sensation and motor function secondary to an acute disc herniation or facet fracture, subluxation, or dislocation.

Conus Medullaris Syndrome

Injury to the conus medullaris, which is typically located at the level of the L1–L2 intervertebral space, can produce mixed upper and lower motor neuron findings. Isolated injury to the conus may result in loss of bowel and bladder control without sacral sparing. Nerve roots that “escape” the injury can allow preserved lower-extremity motor and sensory function despite injury to the distal tip of the spinal cord.

Cauda Equina Syndrome

The cauda equina extends distal to the conus and is composed of the lumbar and sacral nerve roots. Injury to the cauda equina results in lower motor neuron findings with sensory loss and motor dysfunction. Involvement of the lower sacral roots can result in bladder and bowel dysfunction.

Acute Management Strategies

The initial management principles for trauma patients with associated spinal injuries consist of protection of airway and breathing/ventilation, ensuring adequate oxygenation, control of blood loss, and maintenance of adequate blood pressure according to the established guidelines by the “Advanced Trauma Life Support” (ATLS^®) protocol.^3,10 Presence of an unstable spinal injury must be suspected in any patient who sustains a high-energy trauma mechanism, independent of a neurological impairment. Per ATLS^® protocol, the entire spine remains protected during the primary survey, by the use of a long spine-board and a cervical collar. Hard backboards must be removed as soon as safely possible due to the high risk of developing pressure sores and decubitus ulcers after prolonged immobilization. A cervical collar is kept in place until formal spine clearance (see protocols in following discussion), which usually requires additional radiographic workup. When securing the airway, care is required during intubation to prevent hyperextension of the neck that might cause an iatrogenic injury to the cervical spine or spinal cord. Endotracheal intubation must be performed with in-line cervical traction or by fiber-optic assistance. Maintenance of oxygenation and avoiding hypotension are key to minimizing the potential for second hit insults to the vulnerable spinal cord. In a selected subset of patients with spinal cord injuries, hypotension may result from neurogenic shock due to disruption of sympathetic output to the cardiovascular system.¹¹ Neurogenic shock is characterized by bradycardia in the presence of hypotension. These patients typically require the use of inotropic and chronotropic support to maintain adequate systolic blood pressures. Patients with spinal cord injuries above the level of C5 are more likely to require intubation and mechanical ventilation.¹¹

One of the most important tasks for the treating spine surgeon is to determine the presence or absence of spinal stability. Most spine surgeons agree with the general definition that spinal stability refers to the ability of the spine to maintain its alignment and protect the neural structures during normal physiologic loads.¹² Biomechanically, spinal instability refers to an abnormal response to applied loads and can be characterized by motion in spinal segments beyond the normal constraints. In a clinical scenario, defining “spinal stability” remains challenging and a topic of ongoing debate. The working definition of spinal stability takes into consideration that under physiological loads (the influence of gravity on body mass) the spine will not experience increasing deformity, onset of neurological impairment, or a drastic increase in patients’ subjective level of pain.¹² Reciprocally, unstable spine injuries are at risk for progressive deformity and neurologic compromise (or both) which may represent the basis for considering surgical spine stabilization and decompression of the spinal cord. If spinal stability can be confirmed without the need for surgical intervention, patients should be cleared from log-roll precautions followed by early mobilization with or without adjunctive bracing. If spinal injuries are deemed unstable, early surgical treatment should be considered to prevent complications related to prolonged bed rest and immobilization (pressure sores, pulmonary and thromboembolic complications, etc).

Spinal fractures, traumatic dislocations, and fracture-dislocations are best classified by the comprehensive AO/OTA classification system which is based on the alphanumeric classification published by Magerl et al. in 1994 (Fig. 23-3).¹³

The AO/OTA classification codes the anatomic spine region by a number (cervical: 51; thoracic: 52; lumbar: 53), and the injury pattern/severity by an alphanumeric combination (A,B,C and 1,2,3).¹⁴ The clinical implication of classifying spinal injuries by the AO/OTA system is that the alphanumeric code reflects injury severity and guides treatment (operative vs nonoperative) based on spinal stability. In brief, A-type spinal injuries represent axial loading trauma mechanisms leading to compression fractures (A1), vertebral split fractures (A2) or burst fractures (A3). In contrast, B-type injuries reflect unstable fractures and fracture-dislocations originating from flexion/distraction (B1,B2) or hyperextension (B3) trauma mechanisms. Finally, C-type injuries are by definition rotationally unstable and include rotational wedge/split/burst fractures (C1), flexion/distraction or hyperextension injuries with rotation (C2), or complete rotational shearing injuries (C3). The incidence of associated neurological (spinal cord) injury increases with the alpha-numeric fracture classification, from near 0% in stable A1-type compression fractures, to near 100% in C3-type injuries (Fig. 23-3).⁶ The C3-type is representative of the worst spinal injury pattern (so-called “Holdsworth” injury, “slice” fracture, or “traumatic spondyloptosis”) and associated with a near-100% risk of spinal cord injury or spinal cord transection.¹⁵

The extent of vertebral displacement (spondylolisthesis) is classified by the Meyerding grading system (Fig. 23-4).¹⁶ This classification is based on radiographic measurements on lateral views of the according spine segment. The Meyerding classification describes four grades of severity of spondylolisthesis, based on the calculated percentage of vertebral slip:

• 0–25% (grade I)

• 25–50% (grade II)

• 50–75% (grade III)

• 75–100% (grade IV)

A traumatic dislocation of the spine (traumatic spondyloptosis) is almost exclusively related to high-energy acceleration/deceleration trauma mechanisms. The cervical spine is particularly vulnerable due to its flexible fixation between the head and the thorax. Rigidity at these two points (the occipito-cervical junction and the cervico-thoracic junction) causes vulnerability to occur at the intervening cervical segment between. For the same reason, the thoraco-lumbar junction is particularly vulnerable to traumatic fractures and fracture-dislocations (Fig. 23-5).¹⁶

Additional classification systems for vertebral fractures include classic “three-column” classification by Denis, the Allen/Ferguson fracture classification, the White and Panjabi system, and the “load sharing classification” system for assessment of stable versus unstable burst fractures.^17,18,19 In addition, the “subaxial injury classification” (SLIC) system for cervical injuries (Table 23-1) and the “thoracolumbar injury classification and severity score” (TLICS) for thoracic and lumbar fractures (Table 23-2) offer guidance in the decision-making for operative versus nonoperative management of spinal injuries.^20,21 While these two widely used classification systems are helpful for guiding treatment, the respective scoring relies on availability of MRI for prediction of discoligamentous complex integrity.

During patient rescue, transport, and initial assessment and management every attempt should be made to minimize the movement of the spinal column. The presence of neurological symptoms (see earlier) is presumptive evidence of a spinal cord injury associated with spinal column instability. Spinal precautions are aimed at avoiding secondary damage to the spinal cord by excessive bending or twisting in presence of potentially unstable injury patterns. Clearance of the cervical spine has represented a conundrum for many decades, due to the potential medicolegal implications related to missed spinal injuries, and the risk of complications associated with prolonged spinal immobilization.²²

The published literature provides a multiplicity of decision-making protocols for clearance of the cervical spine in the trauma patient. Among these, the NEXUS (“National Emergency X-Radiography Utilization Study”) criteria for patients at low risk for a significant cervical spine injury (Fig. 23-6) have been widely applied for spinal assessment without the requirement for adjunctive radiographic imaging.^23,24

Symptomatic patients require advanced imaging studies starting with CT scans. The latter is frequently available from the initial whole-body CT diagnostic work-up of the trauma patient. The clearance of obtunded patients remains controversial and no universal standard is currently available due to a lack of consensus in the community. Many trauma centers clear the cervical spine in obtunded patients in presence of a normal CT scan. In case of equivocal findings on CT scan, escalation to an MRI may be justified and indicated by the individual spine surgeon’s recommendation.²⁵

The “Canadian Cervical Spine Rules” provide a helpful clinical decision-making pathway for obtunded patients with inability of obtaining a reliable clinical evaluation (Fig. 23-7).

The authors recommend to use a pragmatic approach for clearance of the cervical spine in the trauma patient, based on stratification in four distinct cohorts:

1. Awake, asymptomatic patients.

2. Awake, symptomatic patients.

3. Temporarily non-assessable.

4. Obtunded/comatose patients.

In analogy to the recommendations established by Anderson et al.,²⁶ we allocate these patient cohorts to three distinct spinal clearance algorithms:

1. Asymptomatic patients—Clinical Pathway. (Fig. 23-8)

2. Symptomatic patients—Imaging Pathway. (Fig. 23-9)

3. Obtunded patients and temporarily non-assessable patients – Obtunded Pathway. (Fig. 23-10)

1. Asymptomatic patients are cleared per ATLS protocol or NEXUS guidelines by pure clinical assessment without imaging. This reflects the awake, alert, sober, and neurologically normal patient who has no tenderness to palpation and exhibits unrestricted and pain-free active and passive range of motion in the cervical spine. If any subjective symptoms present during evaluation, patients are placed into the symptomatic group.

2. Symptomatic patients require further radiographic workup (see earlier) to determine spinal stability. Early consultation of a spine surgery service is recommended for this patient cohort.

3. Temporarily non-assessable patients due to altered mental status, intoxication or presence of distracting injuries are kept in rigid cervical immobilization until clearance can occur secondary to return of normal mental status and control of distracting injuries. This entails placing this patient cohort into a 24–48 hour “holding-period” until a formal re-assessment is possible according to protocol for awake patients (cohorts 1 and 2).

4. Obtunded/comatose patients rely purely upon imaging modalities to rule-out unstable spinal injuries. This includes patients with severe traumatic brain injury (GCS≤8) or other reasons for mechanical ventilation and sedation/anesthesia, for example, in multiply injured patients under ongoing resuscitation (polytrauma).

Clearance of spinal precautions entails that spinal stability has either been ascertained, for example, for stable A1-type compression fractures of the thoracic or lumbar spine (Fig. 23-3) or enforced by surgical measures, for example, by placement of a Halo fixator for unstable cervical spine injuries or spinal fixation/fusion for unstable thoracic and lumbar injuries.

Contrary to the NEXUS or ATLS guidelines outlined above for cervical spine clearance in awake patients, decision-making strategies for determining presence and severity of thoracic and lumbar spine injuries relies largely on imaging by CT scan and MRI (see AO/OTA classification, Fig. 23-3, and TLICS score, Table 23-2). A recently published study by the “AAST TL-Spine Multicenter Study Group” revealed that clinical examination alone is insufficient for determining the need for imaging in patients at risk for a thoracic or lumbar spine injury.²⁷

Despite current science unequivocally demonstrating a lack of effectiveness of high-dose methylprednisolone in the acute management of patients with spinal cord injuries, the issue remains a topic of daily debate and uncertainty among the involved care providers in the trauma bay. From a historic perspective, the consideration of high-dose steroids originated from presumed benefits in patients with brain tumors and head injuries in the 1960s and 1970s. After publication of the second “National Acute Spinal Cord Injury Study” (NASCIS-2) in 1990, the application of high-dose methylprednisolone for patients with acute SCI became a globally accepted standard of care for more than a decade.^28,29 A critical analysis of the NASCIS data, however, placed the use of high-dose steroids under scrutiny due to questionable benefits and the potential for inflicting unintentional harm, such as placing the patients at increased risk for pulmonary infections.³⁰ The large-scale prospective randomized multicenter “CRASH” trial (Corticosteroid randomization after significant head injury) confirmed the notion of the unjustified experimental nature of high-dose steroids in the acute management of neurological injuries. The CRASH trial was unexpectedly aborted after enrollment of about 10,000 patients, based on the unexpected finding of a drastically increased mortality in patients treated with methylprednisolone, compared to the placebo control group.³¹ The extrapolation of the negative results from this large-scale trial implied that the uncritical administration of corticosteroids in the 1980s and earlier may have been the cause of preventable post-injury mortality.³² In absence of new prospective randomized trials on the role of steroids in spinal cord injury, current guidelines and clinical recommendations consider the routine use of steroids for patients with acute spinal cord injury obsolete.^3,33 A few selected neurological entities, such as spinal contusions or traumatic central cord syndrome (CCS) may allow consideration for a short course of steroids at the individual treating spine surgeon’s discretion.

Thromboembolic Prophylaxis

Prophylaxis against venous thromboembolism (VTE) is a crucial consideration in patients with unstable spine fractures and spinal cord injuries. The published literature showed a generally low VTE rate in patients with stable spinal fractures and absence of neurological injuries (<2%). In contrast, a venography-controlled study in patients with acute spinal cord injuries reported deep vein clots in the calf around 80%, and symptomatic VTE has been reported in up to 10% of spinal cord-injured patients.³⁴ All trauma patients with associated spinal injuries should have mechanical prophylaxis instituted as soon as possible with graduated compression stockings and/or sequential compression devices. Pharmacologic prophylaxis with unfractionated heparin or low-molecular-weight heparin (LMWH) should be initiated as soon as the acute risk for additional bleeding in the trauma patient is adequately controlled.³⁵ LMWH appears to be more effective for the VTE prevention and associated with fewer bleeding complications than unfractionated heparin in patients with spine injuries.³⁴ The duration of pharmacologic VTE prophylaxis is determined by the patient’s mobility status and should be typically continued for 2 weeks in patients without neurological injuries, and for 6–12 weeks in presence of spinal cord injury. If patients are poor candidates or have a contraindication to pharmacological VTE prophylaxis due to increased risk of bleeding complications, then the early placement of a removable inferior vena cava (IVC) filter should be strongly considered as an alternative option.³⁵ Low-risk patients, such as an ambulatory patient with an isolated stable A1-type thoracolumbar compression fracture (Fig. 23-3), do not require pharmacologic prophylaxis.³⁵

Timing of Tracheostomy

One of the unresolved challenges in the management of ventilator-dependent trauma patients with associated unstable spine fractures and spinal cord injuries consists in defining the ideal timing of conversion to a tracheostomy.³⁶ The conundrum consists of coordinating the timing of early tracheostomy (the intent of which is to reduce the inherent risk of ventilator-associated pneumonia) and the timing of cervical spine fixation (if indicated for the management of unstable cervical injuries). Spine surgeons are generally worried that a preceding tracheostomy may increase the risk of a surgical site infection for a delayed anterior cervical spine fusion (ACDF). This concern appears unjustified based on the existing literature which demonstrates that ACDF surgery is safely performed in presence of a prior tracheostomy, without an increased risk of a postoperative infection. As the dual incisions are typically located several centimeters apart, the tracheostomy wound can be safely draped off during the preparation for the ACDF procedure and does not appear to pose a risk of cross-contamination. In fact, these two procedures can be safely performed during the same operating-room visit under the same anesthetic. At our own institution, the requirement for prolonged mechanical ventilation in patients is discussed as part of the overall surgical plan in the management of patients with spine fractures and spinal cord injuries. Our protocol attempts to coordinate the early timing of tracheostomy with the timing for the spinal fusion. This proactive approach, tailored at decreasing the risk of preventable pulmonary infections and adverse outcomes in a highly vulnerable patient population, requires close cooperation between spine surgeons and the general surgery trauma team.³⁷

Timing of Spinal Surgery

Unstable spine fractures, dislocations and fracture-dislocations must be recognized early and treated in a timely fashion. This entails early closed-reduction and application of halo fixators for unstable cervical spine injuries, and the early open-reduction and spinal fixation/fusion for unstable thoracic and lumbar injuries and for irreducible cervical spine dislocations. The example of an institutional protocol for the surgical management of thoracic and lumbar fractures/fracture-dislocations is shown in Fig. 23-11.¹⁶

The widely disseminated practice of internally fixating unstable thoracic and lumbar fractures in polytrauma patients consist of either (1) a conservative approach of “delayed spine fixation” (after full resuscitation), or (2) a more proactive approach of “early total care.” Early total care often includes invasive anterior approaches, vertebral corpectomy, spinal canal decompression, and anterior spinal column stabilization/fusion. Many spine surgeons are discouraged from early spinal surgery based on the notion that multiply injured patients are frequently “too sick” to safely undergo surgical procedures within the first few days after major trauma.³⁸ The problem associated with this conservative philosophy is that these vulnerable patients remain bedridden on log-roll precautions, which precludes from a coherent and proactive management of severe associated injuries to the head, chest, abdomen, and pelvis. In a landmark article, Croce and colleagues performed a retrospective analysis of a prospective database on 291 consecutive patients with unstable spine fractures requiring surgical fixation. Patients were matched for injury severity and stratified by level of spine injury into two distinct cohorts, depending on the timing of fracture fixation: “early” fixation (within 3 days, n=142) versus “late” fixation (>3 days, n=149).³⁹ The authors found that the early fixation of thoracic spine fractures resulted in a lower incidence of pneumonia, fewer ventilator-dependent days, a shorter ICU stay, and reduced hospital charges.³⁹ This notion was confirmed by a systematic review of the published literature by Rutges et al. who provided a comparison between different time-points of surgical stabilization of thoracic or lumbar spine fractures.⁴⁰ The authors concluded that the early intervention for fracture stabilization in the thoracolumbar spine is safe, advantageous, and associated with a significantly decreased incidence of postoperative complications.⁴⁰

However, due to the lack of unequivocal scientific evidence from prospective randomized trials, there is a lack of consensus regarding the “optimal” timing of spine fracture fixation in multiply injured patients.⁴¹ Intuitive advantages of early spine fixation relates to preventing complications associated with prolonged bed rest and the inability to adequately position and mobilize severely injured patients in the intensive care unit (ICU). Unequivocally, multiply injured patients require unrestricted options for mobilization and positioning in the ICU, including the upright seated position for treatment of head injuries and the prone position for respiratory therapy of pulmonary complications, such as the acute respiratory distress syndrome. Finally, unstable and unreduced spinal fractures contribute to the “antigenic load” of major trauma by contributing to stress, pain, ongoing bleeding, and systemic release of inflammatory mediators.^42,43 This translates into an increased overall trauma burden within the organism and can turn the physiological “host defense response” into a pathological “host defense failure.” These reasons provide a strong argument for the early clearance of bed rest and log-roll precautions in multiply injured patients.^10,42 Recent evidence suggest that any unstable thoracic or lumbar spine fracture or dislocation should be reduced and fixated within 24 hours of admission.^44,45,46 This notion is particularly applicable in the care of multiply injured patients at risk of sustaining “second hit” insults and post-injury complications, including pressure sores, pulmonary infections and thromboembolic complications.^47,48

A proactive approach of “spine damage control” has been described and validated in the recent literature with the intent of mitigating the risk of adverse outcomes in polytrauma patients with associated unstable thoracic or lumbar spine fractures at risk of adverse outcomes.^49,50,51 The concept of “spine damage control” entails a staged procedure of immediate posterior fracture reduction and instrumentation within 24 hours (“day 1 surgery”), followed by scheduled 360° completion corpectomy and fusion during a physiological “time-window of opportunity” (>3 days after trauma).³⁸ Proceeding with the second stage is done if an adjunctive anterior decompression and fusion is indicated for neurological or biomechanical reasons. This concept differs from the more common elective strategy of staged spine fixation by initial posterior fixation and delayed anterior completion in two ways. First, by its timeliness (posterior fixation within 24 hours) and second, by its expanded applicability to all unstable thoracolumbar fractures, including exclusive anterior column burst fractures. The analogy of management strategies for femur shaft fractures and unstable thoracolumbar spine fractures in multiply injured patients is schematically depicted in Fig. 23-12.³⁸

Our group recently published the results from our early institutional experience of applying the “spine damage control” protocol at our trauma center at Denver Health.⁴⁶ A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and injury severity score (ISS) >15 were prospectively enrolled during a 3-year time window. Early “spine damage control” within 24 hours was performed in 42 patients, whereas 70 matched patients in the control group underwent definitive operative spine fixation at a delayed time-point. The mean time to initial spine fixation was significantly decreased in the “spine damage control” group (8.9±1.7 hours vs 98.7±22.4 hours, P<0.01). The early spine fixation cohort also showed a reduced length of operative time (2.4±0.7 hours vs 3.9±1.3 hours), length of hospital stay (14.1±2.9 days vs 32.6±7.8 days), and number of ventilator-dependent days (2.2±1.5 days vs 9.1±2.4 days), compared to the delayed spine fixation control group. Most importantly, the post-injury and postoperative complication rate was significantly decreased after “spine damage control,” including a reduced incidence of wound complications and surgical site infections (2.4% vs 7.1%), urinary tract infections (4.8% vs 21.4%), pulmonary complications (14.3% vs 25.7%), and pressure sores (2.4% vs 8.6%). Our early experience implies that a proactive concept of early stabilization of unstable thoracic and lumbar fractures in multiply injured patients represents a safe and effective treatment strategy that should be considered for implementation in other trauma centers.⁴⁶ A representative example of an early “spine damage control” procedure in a polytrauma patient with a severe multilevel segmental fracture-dislocation of the thoracolumbar spine is shown in Fig. 23-13 and Fig. 23-14.

Surgical Considerations

In general, surgery for unstable spinal injuries attempts to accomplish three main goals which the authors term the “Holy Trinity of the Spine.”²²

1. To provide and maintain anatomic alignment of spinal segments.

2. To provide an early and “rock-solid” stability to the unstable spine.

3. To decompress neurological structures (spinal cord, spinal nerve-roots, cauda equina, conus medullaris), if indicated.

Cervical injuries

The preferred treatment modality for unstable cervical spine fractures consists of an anterior decompression (including corpectomy) and fusion with anterior plating (ACDF) in conjunction with a bone graft substitute or cage. Unstable three-column fractures and fracture-dislocations with posterior facet dislocations may require a posterior approach or combined posterior/anterior approach with 360° fusion. Posterior cervical spine fixation is typically accomplished by placement of multilevel lateral mass screws with or without adjunctive bone grafting for spinal fusion.

Thoracic and lumbar injuries

Unstable vertebral fractures with or without neurological injuries are generally managed through anterior approaches (transthoracic or retroperitoneal) by anterior decompression with corpectomy and fusion using expandable cages and graft constructs, with or without adjunctive anterior column instrumentation with plates/screws or rods/screws. As described earlier, a standardized “spine damage control” procedure should be considered in multiply injured patients by initial posterior fracture reduction, fixation, and decompression by laminectomy, if indicated. This modality allows early mobilization and positioning of multiply injured patients as needed for intensive care. Definitive treatment consists of a delayed, staged anterior corpectomy and anterior column fusion (360°), if indicated (Fig. 23-15).

“Chance” fractures of the B2-type (Fig. 23-3) are managed exclusively by a posterior approach with definitive internal fixation using pedicle screws, with instrumentation two levels above and two levels below the fracture site. Three-column injuries frequently require a combined posterior/anterior 360° fusion, as outlined earlier.

Of note, the placement of surgical drains is rarely indicated in the acute surgical management of spinal injuries. Exceptions where drains are beneficial include placement of retroperitoneal drains after extensive anterior approaches and chest tubes for transthoracic approaches. In contrast, the prophylactic placement of drains around the cervical spine for anterior or posterior approaches, and for posterior thoracic or lumbar approaches does not appear to convey any benefit. Perceived benefits include the theoretical decreased risk of postoperative hematoma formation. However, it can be argued that keeping drains increases the risk of surgical site infections. Furthermore, side-effects from prolonged antibiotic therapy can occur if the surgeon requests antibiotics be continued while surgical drains remain in place. This request does not appear to be justified from a quality of care or patient safety perspective.

• ✓ The presence of an unstable spinal injury is presumed in all trauma patients until proven otherwise.

• ✓ Complete and thorough neurological examination is mandatory. Critically injured patients need total spinal evaluation from “occiput to coccyx.” This includes physical examination and advanced imaging studies. Computed tomography is available as part of the initial diagnostic trauma workup in most cases. Magnetic resonance imaging is indicated on a case-by-case basis after formal spine surgery consultation.

• ✓ Strict log-roll precautions and cervical rigid-collar immobilization should be continued until unstable injuries are ruled-out or identified and managed by early proactive surgical treatment protocols.

• ✓ An accurate classification of spine injuries using validated classification systems facilitates surgical decision-making and serves as a basis to guide treatment.

• ✓ Early mobilization of critically injured patients with spine injuries is essential. This requires either spinal clearance or spinal stabilization by surgical means.

• ✓ “Spinal clearance” should be provided early in the management of trauma patients to enable removal of unnecessary braces and immobilizers, and to minimize the risk of preventable post-injury complications.

• ✓ A standardized “spine damage control” protocol allows stabilization of unstable thoracic and lumbar spine fractures within 24 hours and subsequent mobilization of patients without restrictions.

• ✓ Unstable cervical spine injuries benefit from halo-vest application or Gardner-Wells tong traction until definitive surgical fixation is performed.

• ✓ Spinal cord injured patients benefit from standardized institutional practice protocols to facilitate quality care and early transfer to neuro-rehabilitation centers after spinal stabilization and resuscitation from associated injuries.

• ✓ The uncritical use of steroids is considered obsolete in the management of acute traumatic spinal cord injury, with the exception of rare selected circumstances.

• ✓ The timing of tracheostomy in patients requiring prolonged mechanical ventilation should be coordinated with early cervical spine fixation, if indicated.

• ✓ Surgical drains are rarely indicated after fixation of acute spine injuries and may contribute to adverse postoperative sequelae and prolonged unnecessary antibiotic prophylaxis.

• ✓ A multidisciplinary approach is needed to ensure proper care of critically injured patients with concomitant spinal injury. Timely transparent communication is paramount for the successful multidisciplinary management of this highly vulnerable patient cohort.