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

  • Complete and thorough spinal evaluation and neurologic examination are mandatory in all critically injured patients.

  • 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.

  • Computed tomography is the standard initial diagnostic trauma workup in patients requiring imaging. Magnetic resonance imaging is indicated on a case-by-case basis after formal spine surgery consultation.

  • 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 spinal injuries is essential. This requires either spinal clearance or spinal stabilization by surgical means.

  • Spinal clearance should be provided within 24 hours of admission to minimize the risk of preventable immobilization-related 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.

  • The use of steroids is considered obsolete in the management of acute traumatic spinal cord injury.


The scope of this chapter is to provide the trauma surgeon a pragmatic approach on how to coordinate the care of the multiply injured patient who presents with associated spinal injuries. The chapter focuses on current strategies for initial assessment and management of spinal injuries relevant to trauma surgeons with respect to the decision making for the integrated care of the critically injured patient. Pertinent issues include the conundrum of how to recognize an unstable spine injury, when and how to clear the cervical spine, the role of steroids in the management of spinal cord injury, the optimal timing of tracheostomy in spinal cord–injured patients, and the coordination of care for associated spine injuries in the multiply injured patient. Understanding these critical aspects related to the care of spinal injuries will allow optimization of the coordination of care for these highly vulnerable patients at risk of sustaining delayed “second-hit” insults and adverse outcomes.


The presence of an associated spinal injury must be assumed in any multiply injured patient until proven otherwise.1 Of note, approximately 10% to 15% 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 neurologic 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 application of a cervical collar, exact documentation and timing of the findings, and ...

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