Spine Trauma and Spinal Cord Injury

Key Points

Patients with spinal pain and spine fractures should receive a thorough neurologic
examination to look for spinal cord injury.

Spine fractures are associated with a high incidence of concurrent noncontiguous spine
fractures and spinal cord injuries.

The National Emergency X-radiography Utilization Study criteria or the Canadian
Cervical-Spine Rule criteria can be used to identify low-risk patients who do not need
cervical spine imaging.

Imaging with plain films versus computed tomography of the cervical spine should be
based on the pretest probability of a significant injury and the irradiation risk with
computed tomography.

Spinal shock, or transient physiologic transection of the spinal cord as a result of trauma,
is different from neurogenic shock, which is physiologic sympathectomy of the upper
spinal cord leading to peripheral vasodilation.

Patients with a spinal cord injury caused by blunt trauma are often given high-dose
corticosteroids within 8 hours of injury, although such therapy is controversial.
Epidemiology
The estimated annual cost of spine injuries, including inability to work and health care costs,
exceeds $5 billion in the United States.
1

In the emergency department (ED), all trauma victims are screened for vertebral fractures,
ligamentous disruptions, and spinal cord injuries because of the potentially devastating
neurologic consequences of overlooking these injuries. Patients with a delayed diagnosis of
spinal fracture are 7.5 times more likely to sustain secondary neurologic deficits.
2
Neurologic
deficits from spinal cord injury may be subtle and can easily be missed if not specifically
evaluated. Adding to these difficulties, plain film radiographs of the spine, though an adequate
screening tool for other fractures, can miss 23% to 42% of cervical spinal fractures
3 4
and 13% to
50% of lumbar fractures.
5 6

Pathophysiology
In the setting of spinal trauma, the bone, ligaments, spinal cord, and vascular structures may be
injured. Anatomically, the vertebral bony spine can be divided into structural columns. The
cervical spine is traditionally divided into two columnsanterior and posterior. The anterior
column consists of the load-bearing vertebral bodies, intervertebral disks, anterior longitudinal
ligament, and posterior longitudinal ligament ( Fig. 75.1 ). The posterior column consists of the
more posterior structures, including the pedicles, laminae, and transverse and spinous processes (
Fig. 75.2 ).
Fig. 75.1
Bony anatomy of a typical lower cervical vertebra (C3-C7): superior axial view with the anterior
aspect oriented upward and the posterior aspect oriented downward.
Fig. 75.2
Bony anatomy of a typical thoracic and lumbar vertebra (T1-L5): superior axial view with the
anterior aspect oriented upward and the posterior aspect oriented downward.
In contrast, the thoracic and lumbar vertebral spines are divided into three columns based on the
modified Denis modelanterior, middle, and posterior ( Fig. 75.3 ). The anterior column
consists of the anterior longitudinal ligament, the anterior two thirds of the vertebral body, and
the intervertebral disk. The middle column consists of the posterior longitudinal ligament, the
posterior third of the vertebral body, and the intervertebral disk. Any disruption of the middle
column predisposes a patient to significant spinal cord injury because the middle column abuts
the spinal canal. The posterior column consists of the remaining posterior structures.
Fig. 75.3
Schematic diagram illustrating the lateral view of the anatomic columns of the cervical and
thoracic/lumbar spine.
Note that the cervical spine's anterior column is composed of the same structures as the
thoracic/lumbar spine's anterior and middle columns.
The C1 and C2 vertebrae are anatomically unique ( Fig. 75.4 ). C1 (atlas) is a ring-link structure
without a vertebral body. It articulates superiorly with the occipital condyles. This articulation
allows 50% of normal neck flexion and extension. C2 (axis) projects the dens superiorly to
articulate with C1. The transverse ligament tethers the dens to the anterior arch of C1. This
atlantoaxial articulation allows 50% of normal neck rotation left and right.
Fig. 75.4
Bony anatomy of the upper cervical spine (C1 and C2): posterolateral view.
The C1 lateral masses articulate with the occipital condyles. The C2 dens projects cephalad,
articulates with the C1 anterior arch, and is stabilized by the C1 transverse ligament.
The spinal cord spans from the foramen magnum to the L1 level, whereupon the spinal cord
tapers into the conus medullaris and cauda equina, a collection of peripheral lower lumbar and
sacral nerve roots. Because the spinal cord is thickest in the cervical spine, there is relatively less
spinal canal space in the cervical levels than in the thoracic or lumbar spine. Thus spinal cord
injuries occur more frequently with cervical spine trauma than with thoracic or lumbar spine
trauma. The neurologic dermatomes can help localize the injury ( Table 75.1 ).
Table 75.1
Individual Spinal Sensory Dermatomes, Motor Function, and Reflex Arcs
SPINAL LEVEL SENSORY DISTRIBUTION MOTOR FUNCTION REFLEX
C2 Occiput

C3 Thyroid cartilage

C4 Suprasternal notch Spontaneous respiration

C5 Infraclavicular area Shoulder shrugging Biceps
C6 Thumb Elbow flexion Triceps
C7 Index finger Elbow extension

C8 Little finger Finger flexion (with T1)

T4 Nipple line

T10 Umbilicus

L1 Inguinal ligament Hip flexion (with L2)

L2 Medial thigh Hip flexion

L3 Medial thigh Hip adduction

L4 Medial foot Hip abduction Patellar
L5 Web space between big toe and second toe Foot dorsiflexion

S1 Lateral foot Foot plantar flexion (with S2) Achilles
S2 Perianal area (with S3, S4) Foot plantar flexion

S3-4 Perianal area Rectal sphincter tone

The vertebral arteries branch off the subclavian arteries and course superiorly within the
transverse foramina of C2 to C6. These arteries then merge to form the basilar artery.
Presenting Signs and Symptoms
Patients with vertebral fractures usually have significant midline spinal tenderness on palpation.
High-risk findings include spinal soft tissue swelling, ecchymosis, and step-off misalignment of
the spine. Pain radiating along a dermatomal distribution suggests an associated radiculopathy.
Thoracic spine fractures are uncommon because the articulating ribs provide stability to the
spinal column; however, the thoracolumbar junction (encompassing the T10 to L2 vertebral
levels) is commonly injured because the spine curvature changes from the kyphotic thoracic
spine to the lordotic lumbar spine.
Patients with spinal cord injuries may have a spectrum of findings ranging from subtle
neurologic deficits to grossly obvious paralysis. Spinal cord injuries should be suspected in any
trauma victim who complains of neck or back pain, especially pain exacerbated by movement.
Neurologic symptoms suggesting spinal cord injury include numbness, tingling, paresthesias,
focal weakness, and paralysis. Other worrisome symptoms include urinary or fecal incontinence
and urinary retention. Unconscious patients and those with impaired consciousness secondary to
intoxication may harbor occult spinal cord injuries. Physical examination should focus on the
spine and areas where associated injuries may occur ( ).
Table 75.2
Physical Examination Findings Associated with Vertebral Fractures and Spinal Cord Injuries
INJURY PHYSICAL EXAMINATION AREA ASSOCIATED FINDINGS
Vertebral
fracture
Spine
Tenderness of the neck and/or back. Examine the
entire spine because vertebral fractures may occur
in multiples.
Neurologic See spinal cord injury below.
Chest
Thoracic spine fractures: Check for chest
tenderness, unequal breath sounds, and
arrhythmia, which are suggestive of an associated
intrathoracic injury or myocardial contusion.
Abdomen/pelvis
Thoracolumbar and lumbar spine fractures: Check
for abdominal or pelvic tenderness. For instance,
up to 50% of patients with a transverse process
fracture
7
and 33% of patients with a Chance
fracture
8
have concurrent intraabdominal
pathology. A transverse area of ecchymosis on the
lower abdominal wall (seat belt sign) increases the
INJURY PHYSICAL EXAMINATION AREA ASSOCIATED FINDINGS
chance of an abdominopelvic injury.
Extremity
Thoracolumbar and lumbar spine
fractures: Check for calcaneal
tenderness because 10% of calcaneal
fractures are associated with a low
thoracic or lumbar fracture.
Mechanistically, these areas are
fractured as a result of axial loading.

Spinal cord
injury
Neurologic, motor (anterior column)
Assess motor function on a scale of 0 to 5 (see
Table 75.3). motor level is defined as the most
caudal segment with at least 3/5 strength. Injuries
to the first eight cervical segments result in
tetraplegia (previously known as quadriplegia);
lesions below the T1 level result in paraplegia.
Neurologic, sensory (spinothalamic
tract)
Assess sensory function via pinprick and light
touch on the following scale: 0 = absent; 1 =
impaired; 2 = normal. The sensory level is defined
as the most caudal segment of the spinal cord with
normal sensory function. The highest intact
sensory level should be marked on the patient's
spine to monitor for progression.
Neurologic, sensory (dorsal column)
Assess vibratory sensory function on a scale of 0 to
2 by using a tuning fork over bony prominences.
Assess position sense (proprioception) by flexing
and extending the great toe.
Neurology, deep tendon reflex
On a scale of 0 to 4, assess the deep tendon
reflexes in the upper (biceps, triceps) and lower
(patellar, Achilles) extremities (see Table 75.4).
Anogenital
Assess rectal tone, sacral sensation, signs of
urinary or fecal retention or incontinence, and
priapism. Also check the anogenital reflexes: an
anal wink (S2-S4) is present if the anal sphincter
contracts in response to stroking the perianal skin
area. The bulbocavernosus reflex (S3-S4) is elicited
INJURY PHYSICAL EXAMINATION AREA ASSOCIATED FINDINGS
by squeezing the glans penis or clitoris (or pulling
on an inserted Foley catheter), which results in
reflexive contraction of the anal sphincter.
Head-to-toe
examination
A spinal cord injury may mask a
patient's ability to perceive and
localize pain. Imaging of high-risk
areas, such as the abdomen, and
areas of bruising or swelling may be
required to exclude occult injuries.

Table 75.3
Graded Assessment of Motor Function
GRADE ASSESSMENT ON PHYSICAL EXAMINATION
0 No active contraction
1 Trace visible or palpable contraction
2 Movement with gravity eliminated
3 Movement against gravity
4 Movement against gravity and resistance
5 Normal power
Table 75.4
Graded Assessment of Deep Tendon Reflexes
GRADE ASSESSMENT ON PHYSICAL EXAMINATION
0 Reflexes absent
1 Reflexes diminished but present
2 Normal reflexes
GRADE ASSESSMENT ON PHYSICAL EXAMINATION
3 Reflexes increased
4 Clonus present
Spinal shock is a neurologic phenomenon resulting from physiologic transection of the spinal
cord. It results in flaccid paralysis and loss of reflexes below the level of the spinal cord lesion.
Spinal shock is temporary, commonly lasting for 24 to 48 hours, although it can persist for
weeks. Patients suffering from spinal shock may appear (clinically) to have a complete spinal
cord injury only to miraculously recover once the spinal shock has passed. Termination of
spinal shock is identified by return of segmental reflexes; anogenital reflexes are the earliest to
recover.
Neurogenic shock may occur in patients with cervical or high thoracic spinal cord injuries. It is a
neurocardiovascular phenomenon resulting from impairment of the descending sympathetic
pathways in the spinal cord. As a result, vasomotor tone is lost and visceral and peripheral
vasodilation and hypotension ensue. Diminished sympathetic innervation to the heart also occurs
and results in relative bradycardia despite the presence of hypotension.
Differential Diagnosis and Medical Decision Making
Indications for Cervical Spine Imaging
In the year 2000, in the hope of reducing the number of low-risk patients undergoing cervical
spine plain film radiography, a multicenter study by the National Emergency X-radiography
Utilization Study (NEXUS) group validated a set of five low-risk criteria for determining which
patients do not require radiographic imaging if all the criteria are met ( Box 75.1 ). This clinical
decision tool demonstrated a sensitivity of 99.6% and a specificity of 12.9% for detecting
clinically significant cervical spine fractures. It was thus extrapolated that 4309 (12.6%) of the
34,069 patients enrolled could have avoided plain film radiography.
9

Box 75.1 NEXUS Low-Risk Criteria for a Cervical Spine Injury
A patient does not require cervical spine radiographic imaging if all five of the following low-risk
conditions are met:
1
No posterior midline neck pain or tenderness
2
No focal neurologic deficit
3
Normal level of alertness
4
No evidence of intoxication
5
No clinically apparent, painful distracting injury *
NEXUS, National Emergency X-radiography Utilization Study.
Following development of the NEXUS criteria, the Canadian Cervical-Spine Rule (CCR) was
developed ( Fig. 75.5 ). The validated sensitivity and specificity for this decision rule were
99.4% and 45.1%, respectively.
10

Fig. 75.5
Canadian Cervical-Spine Rule (CCR) algorithm for clinical clearance of the cervical spine.
The green box signifies a low-risk, negative work-up and clinical cervical spine clearance.
Orange boxes signify a moderate-risk condition, and the red box signifies a high-risk condition,
both of which require plain film radiography. ED, emergency department; GCS, Glasgow Coma
Scale; RR, respiratory rate; SBP, systolic blood pressure.
(Data from 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 J Med 2003;349:2510-8.)
The CCR study excluded the following subjects: patients younger than 16 years; patients with an
abnormal Glasgow Coma Scale score, abnormal vital signs, injuries more than 48 hours old,
penetrating trauma, paralysis, and history of vertebral disease; patients seen previously for the
same injury; and pregnant patients. Because these cases were not studied, the CCR guidelines
should not be applied to such patients.
Choosing the Imaging Modality to Evaluate the Cervical Spine ( Fig. 75.6)
When patients have at least one high-risk criterion for a spinal fracture, imaging begins with
either plain films or computed tomography (CT) scans. The pros and cons of both imaging
approaches are listed in Table 75.5 .
Fig. 75.6
Diagnostic algorithm for a patient with neck pain resulting from blunt trauma.
CCR, Canadian Cervical-Spine Rule; CT, computed tomography; MRI, magnetic resonance
imaging; NEXUS, National Emergency X-radiography Utilization Study.
Table 75.5
Advantages and Disadvantages of Plain Film Imaging and Computed Tomography of the
Cervical Spine

PLAIN FILM RADIOGRAPHY COMPUTED TOMOGRAPHY

PLAIN FILM RADIOGRAPHY COMPUTED TOMOGRAPHY
Advantages
Less irradiation of the thyroid, breast, and lens Can
be performed at the bedside
98% sensitivity in detecting fractures
More cost-effective than plain films
Less delay in patient management,
especially if the patient is already
going to CT scanner for imaging of
another body part
Disadvantages
Only 53% sensitivity in detecting fractures Three-
view films are inadequate >50% of the time,
especially films of the cervicocranial and
cervicothoracic junction Inefficient use of radiology
personnel, who are often repeating films because
of image inadequacy A suspicious fracture or one
detected on plain films requires additional
evaluation by CT for confirmation and further
delineation
More irradiation of the thyroid,
breast, and lens Requires the patient
to be hemodynamically stable
because of being transported out of
the emergency department to the
CT scanner
Patients with symptoms suggestive of a spinal cord injury should undergo CT and magnetic
resonance imaging (MRI) of suspicious areas of the spine. Although plain films and CT do not
directly reveal spinal cord injuries, they may supply indirect evidence of such injuries. Spinal
cord injury without radiographic abnormality (SCIWORA) is a traumatic myelopathy in which
no abnormalities can be identified on plain films or CT.
Computed Tomography
With increasing evidence in the literature showing that CT is much more sensitive (98%) than
plain film radiography (53%) in detecting cervical spine fractures, future recommendations will
probably recommend cervical spine CT as the first-line diagnostic approach for most patients
because of the neurologic significance of a missed cervical spine injury.
11
Conventional
radiography is especially difficult to interpret in the high cervical spine (occiput, C1, C2) and
cervicothoracic junction (C6, C7, T1), where coincidentally most cervical spine fractures occur.
12
It is important to obtain sagittal CT reconstructions, in addition to the traditional axial views,
to adequately assess spinal alignment.
Cost analyses have shown that cervical spine CT scans are actually less expensive than
conventional radiography in high-risk patients. These studies factored personnel time, delays in
patient management while obtaining films, and the neurologic sequelae of initially missing a
cervical spine injury. Cost savings are especially evident if the patient is already undergoing CT
imaging of other body parts, such as head scanning for a closed head injury. With multidetector
scanners being more readily available, an additional cervical spine scan would add less than 5
minutes of scan time at a relatively small cost.
13

The risk for cancer from irradiation serves as the major deterrent against universally performing
CT in all patients with neck trauma. It is estimated that up to 2% of cancers in the United States
are attributable to CT studies.
14
The thyroid gland, breast tissue, and lens are exposed to
especially high levels of radiation in cervical spine CT, thus placing the patient at high risk for
the development of thyroid cancer, breast cancer, and cataracts. Patients receive an effective dose
of 0.2 millisievert (mSv) and 6 mSv for cervical spine plain films and CT, respectively. In
contrast, the effective dose of a posteroanterior and lateral chest radiograph is just 0.1 mSv.
15
The overall lifetime carcinogenic risk from CT imaging, however, varies depending on the
patient's age at the time of irradiation. Younger patients have greater risk, partly because they
have more years of life left for the development of cancer. Furthermore, children are more
radiosensitive. If irradiated after 40 years of age, the risk reaches its nadir, with an estimated
lifetime attributable risk for death from cancer of less than 0.2%.
14

Because of such concerns for radiation exposure, low-risk patients should undergo conventional
radiography. Only patients with radiographic evidence of an injury on plain films should
subsequently undergo CT scanning. For moderate- to high-risk patients, cervical spine CT should
be the first-line imaging modality, especially for patients scheduled for CT scanning of another
body part.
Flexion-Extension Plain Film Radiography
A normal cervical CT image adequately excludes a cervical spine fracture but cannot sufficiently
evaluate ligamentous instability. In patients who have sustained significant flexion, extension, or
rotational injury to the neck and have persistent neck pain, ligamentous stability should be
assessed within 10 days either in the ED or by a neurosurgeon or orthopedic spine specialist.
In the ED, patients who are awake and alert and can actively flex and extend their neck 30
degrees may undergo flexion-extension plain film radiography to evaluate for spinal stability.
Vertebral body subluxation or focal widening of the spinous processes suggests an unstable
ligamentous injury. Because no serious adverse outcomes have resulted from voluntary neck
movement by an awake, alert patient without neurologic deficits, manual manipulation of the
patient's neck should be avoided during flexion-extension radiography.
Many acutely injured patients have such severe associated cervical muscle spasms that they have
limited neck mobility. As a result, flexion-extension films are often inadequate, and these
patients should be immobilized in a semirigid cervical collar (e.g., a Philadelphia or Miami J
collar) and undergo delayed flexion-extension plain film radiography after 7 to 10 days, when
the cervical muscle spasm diminishes.
Magnetic Resonance Imaging
MRI is the best available modality for detection and characterization of spinal cord injury, but it
is less sensitive than CT for cervical spine fractures. In an acute trauma patient with potential
spinal injury, indications for emergency MRI include (1) complete or incomplete neurologic
deficits suspicious for a spinal cord injury, (2) deterioration of spinal cord neurologic function,
and (3) signs of unstable ligamentous injury. Abnormal MRI findings may include the presence
of spinal canal compromise, disk herniation, and spinal cord edema or hemorrhage.
Older and Osteopenic Patients
Patients older than 65 years old and those taking corticosteroids on a long-term basis are
probably osteopenic. They can sustain spinal fractures with mild trauma, such as a fall from a
standing position, and often exhibit minimal associated pain. Specifically, patients older than 65
years have an increased risk for cervical spine fracture (relative risk of 2.09).
16
In addition, acute
back pain in chronic corticosteroid users is correlated with 99% specificity for a spinal
compression fracture.
17
Thus, imaging should be performed in these potentially osteopenic
patients in the setting of neck or back pain.
Clinical Clearance of the Cervical Spine
Not all patients require cervical spine imaging. To clinically clear a cervical spine, the patient's
neck should be reevaluated for tenderness. First, unfasten the cervical collar. Next, palpate the
posterior aspect of the patient's neck while applying the other hand to the patient's forehead to
prevent spontaneous and reflexive head lifting. In the absence of significant midline tenderness,
remove your hands and instruct the patient to actively lift the head off the gurney and place the
neck through a range of motion by looking right, left, caudad, and cephalad. Do not assist the
patient.
If the patient is able to move spontaneously and easily without pain or neurologic symptoms, the
patient's neck is considered to be clinically cleared and the collar may be removed.
Facts and Formulas
Ten percent of spinal fractures have a second noncontiguous fracture along the vertebral
spine.
Ten percent of patients with a calcaneal fracture have an associated thoracic or lumbar
fracture.
The most commonly fractured cervical spine level is C2, especially in the elderly.
Approximately 20% of computed tomographyconfirmed burst fractures in the thoracic
and lumbar spine appear as wedge fractures on plain film radiography.
18

High-dose methylprednisolone is administered as a 30-mg/kg bolus and then as a 5.4-
mg/kg/hr infusion for 24 hours (if started within 3 hours of injury) or for 48 hours (if
started within 8 hours of injury).
Consider early endotracheal intubation in spinal cord injury patients with a negative
inspiratory force of less than 25 cm H
2
O or a vital capacity of less than 15 mL/kg.
Classic Fracture Patterns ( Tables 75.6 to 75.8; Figs. 75.7 to 75.9)
Cervical Spine Injuries
Based on the NEXUS study of 818 patients with cervical spine injury, fractures occurred most
commonly at the level of C2 (24% of all fractures), C6 (20%), and C7 (19%). Anatomically, the
most commonly fractured part of the cervical spine was the vertebral body, which accounted for
30% of fractures at the C3 to C7 levels. It was more common than fractures of the spinous
process (21%), lamina (16%), and articular process (15%). Subluxations occurred most
commonly at the C5-C6 (25%) and C6-C7 (23%) levels.
19

Table 75.6
Classic Upper Cervical Spine Injury Patterns (C1-C2)
*

INJURY MECHANISM STABILITY FIGURE COMMENTS
Atlantooccipital
dislocation
Flexion Unstable 75.7, A
Often instantly fatal More common in children
because of small, horizontally oriented occipital
condyles Dislocation can be anterior (most
common), superiorly distracted, or posterior
Anterior
atlantoaxial
dislocation
Flexion Unstable 75.7, B
Associated with rupture of the transverse
ligament Most commonly occurs in patients with
rheumatoid arthritis and ankylosing spondylitis
from ligament laxity Widening of the predental
space seen on lateral plain films
Jefferson fracture
(C1 burst fracture)
Axial
compression
Unstable 75.7, C
33% with associated C2 fracture Low incidence of
neurologic injury because of a wide C1 spinal
canal Usually involves fractures of both the
anterior and posterior C1 arches, often with 3 or 4
fracture fragments Complication: transverse
ligament rupture, especially if the C1 lateral
masses are 7 mm wider than expected (MRI
recommended); vertebral artery injury (CT
angiography recommended)
C1 posterior arch
fracture
Extension Stable 75.7, C
An associated C2 fracture (occurs 50% of time)
makes a posterior arch fracture unstable On plain
films, no displacement of lateral masses on the
odontoid view and no prevertebral soft tissue
swelling, unlike a Jefferson burst fracture
INJURY MECHANISM STABILITY FIGURE COMMENTS
C2 dens fracture Flexion Variable 75.7, D
Type I (stable): Avulsion of the dens with an intact
transverse ligament Type II (unstable): Fracture at
the base of the dens; 10% have an associated
rupture of the transverse ligamentMRI provides
a definitive diagnosis of ligament rupture Type III
(stable): Fracture of the dens extending into the
vertebral body
Hangman's fracture
(C2
spondylolisthesis)
Extension Unstable 75.7, E
Bilateral C2 pedicle fractures At risk for disruption
of the PLL, C2 anterior subluxation, and C2-C3 disk
rupture Low risk for spinal cord injury because of
C2 anterior subluxation, which widens the spinal
canal
Extension teardrop
fracture
Extension Unstable 75.7, F
Small triangular avulsion of the anteroinferior
vertebral body at the insertion point of the ALL
Occurs most frequently at the C2 level but can
occur in the lower cervical spine Complication:
central cord syndrome as a result of the
ligamentum flavum buckling during
hyperextension Requires CT differentiation from a
very unstable flexion teardrop fracture (see
flexion teardrop fracture in Table 75.7)
*
Listed in progressive order from the occiput, to C1, to C2.
Table 75.7
Classic Lower Cervical Spine Injury Patterns (C3-C7)
INJURY MECHANISM STABILITY FIGURE COMMENTS
Articular mass
fracture
Flexion-
rotation
Stable 75.8, A
Associated with transverse process and vertebral
body fractures Uncommon
Burst fracture
Axial
compression
Stable 75.8, B
Compressive fracture of the anterior and posterior
vertebral body Intact ALL and PLL Complication: spinal
cord injury because of a retropulsed vertebral body
fragment (especially anterior cord syndrome)
INJURY MECHANISM STABILITY FIGURE COMMENTS
Clay shoveler's
(spinous
process)
fracture
Flexion Stable 75.8, B
Spinous process fracture from forceful neck flexion
Most commonly occurs in the lower cervical levels,
usually C7 Not associated with neurologic injury
Extension
teardrop
fracture
Extension Unstable 75.7, F Most commonly occurs at C2 See Table 75.6
Facet
dislocation,
bilateral
Flexion Unstable 75.8, C
Significant anterior displacement (>50%) of the spine
when bilateral inferior facets displace anterior to the
superior facets below At risk for injuring the disk,
vertebral arteries, and spinal cord
Facet
dislocation,
unilateral
Flexion-
rotation
Stable 75.8, D
Usually causes 25-50% anterior displacement of the
spine Complication: vertebral artery injury (CT
angiography recommended)
Flexion
teardrop
fracture
Flexion and
axial loading
Unstable 75.8, E
One of the most unstable fractures in the lower
cervical spine because it involves both columns
Fracture and anterior displacement of the
anteroinferior vertebral body (appears similar to an
extension teardrop fracture except that it is much
more unstable) Unique findings for flexion (versus
extension) teardrop fractures include same-level
fractures and displacement of posterior structures
Rupture of both ALL and PLL complexes Usually
occurs at C5 or C6 Can result from diving into shallow
water or a football tackling injury Often associated
with spinal cord injury and tetraplegia
Subluxation,
anterior
Flexion Unstable 75.8, F
Anterior slipping of a vertebra over another Ruptured
PLL such that the anterior and posterior vertebral
lines are disrupted Complication: vertebral artery
dissection (CT angiography recommended) May be
evident only during flexion views by conventional
radiography when the interspinous distance widens
and the vertebral body subluxates anteriorly
Transverse
Lateral flexion Stable 75.8, A
Complication: vertebral artery injury because it
INJURY MECHANISM STABILITY FIGURE COMMENTS
process
fracture
travels within the transverse foramina (CT
angiography recommended); associated cervical
radiculopathy and brachial plexus injuries in 10% of
cases
Wedge
fracture
Flexion Stable 75.8, G
Compression fracture of only the anterosuperior
vertebral body end plate Disruption of the anterior
vertebral line Intact posterior vertebral body and
posterior vertebral line
Table 75.8
Classic Thoracic and Lumbar Spine Injury Patterns
INJURY MECHANISM STABILITY FIGURE COMMENTS
Wedge
fracture
Flexion
Stable,
usually
75.8, G
Most common fracture in the thoracic spine Isolated
anterior column fracture Disruption of the anterior
vertebral line with an intact posterior vertebral line
(classic) Maintain a low threshold to obtain spine CT for
differentiation of a wedge from a burst fracture (up to
22% of burst fractures appear to have an intact
posterior vertebral line)
Burst
fracture
Axial loading Variable 75.8, B
Fracture of the anterior and middle columns Disruption
of the anterior and posterior vertebral lines (classic)
65% have associated spinal cord injury because of
middle column compromise
Chance
fracture
Flexion-
distraction
Unstable 75.9, A
Fracture through the anterior, middle, and posterior
columns, progressing from posterior to anterior Usually
located at the T12-L2 junction Classically caused by a
lap belt hyperflexion mechanism in a motor vehicle
collision 33-89% associated with intraabdominal injury
Spinal cord injury is uncommon because of the
distraction mechanism
Transverse
process
fracture

Stable 75.9, B
Most common fracture in the lumbar spine Classically
has a vertical fracture orientation A horizontal
transverse process fracture orientation suggests a
distraction injury (Chance fracture) More than 50% of
INJURY MECHANISM STABILITY FIGURE COMMENTS
transverse process fractures are missed by
conventional radiography and detected on spine CT
Clinically insignificant, but a risk factor for other injury
patterns 50% associated with an intraabdominal injury
30% associated with a pelvic fracture (especially an L5
transverse process fracture) L2 transverse process
fracture is associated with renal artery thrombosis
Fracture-
dislocation
Compression
or distraction
Unstable 75.9, C
Significant spinal misalignment and vertebral column
discontinuity Fracture through the anterior, middle,
and posterior columns Extremely high incidence of
spinal cord injury
Fig. 75.7
A, Cross-sectional sagittal view of anterior atlantooccipital dislocation with associated spinal
cord injury. B, Posterolateral view of anterior atlantoaxial dislocation from rupture of the
transverse ligament. C, Posterolateral view of a C1 Jefferson burst fracture through the anterior
and posterior arch and an isolated C1 posterior arch fracture. D, Posterolateral view of the three
types of C2 dens fractures. E, Sagittal view of a hangman's fracture with bilateral C2 pedicle
fracture. PLL, Posterior longitudinal ligament. F, Sagittal view of a C2 extension teardrop
fracture. ALL, Anterior longitudinal ligament.
Fig. 75.8
A, Superior axial view of an articular pillar fracture and transverse process fracture. B, Sagittal
view of a C4 burst fracture and C5 clay shoveler's (spinous process) fracture. C, Sagittal view of
bilateral C4 facet dislocation. D, Sagittal view of unilateral C4 facet dislocation. E, Sagittal view
of a C5 teardrop fracture. F, Sagittal view of C4 anterior subluxation. G, Sagittal view of a C5
wedge fracture.
Fig. 75.9
A, Sagittal view of an L2 Chance (flexion-distraction) fracture. B, Superior axial view of a
transverse process fracture in a typical lumbar spine. C, Sagittal view of an L1-L2 fracture-
dislocation injury, which is at high risk for a spinal cord injury because of discontinuity of the
spinal canal.
Thoracic and Lumbar Spine Injuries
Similar to patients undergoing cervical spine assessment, low-risk patients may selectively be
cleared clinically without radiographic imaging. Although no large studies of thoracic and
lumbar spine injuries equivalent to the NEXUS and CCR projects have been conducted,
recommendations can be extrapolated from the relevant literature.
Based on the NEXUS criteria, patients with (1) significant back pain or tenderness, (2) clinical
evidence of drug- or alcohol-related intoxication, (3) lower extremity neurologic deficits, (4)
Glasgow Coma Scale score lower than 15, or (5) a distracting injury cannot be cleared clinically
for a thoracic or lumbar fracture. Patients with alcohol intoxication, for example, should not be
cleared clinically until they are sober and found to fulfill no other high-risk criteria.
Furthermore, based on the CCR criteria and the American Healthcare Research and Quality red
flag indications for imaging, injured patients who are (1) older than 65 years with any degree of
back pain or tenderness, (2) are receiving chronic corticosteroid therapy, or (3) have a history of
vertebral disease should undergo radiography.
Classic patterns of thoracic and lumbar spine injuries are shown in Table 75.8.
Classification of Spinal Cord Injuries
Complete Injury
A spinal cord injury is classified as physiologically complete if the patient has no demonstrable
motor or sensory function below the level of injury. During the first few days following injury,
this diagnosis cannot be made with certainty because of the possibility of concurrent spinal
shock.
Incomplete Injury
A spinal cord injury is incomplete if motor function, sensation, or both are partially present
below the level of the injury. Signs of an incomplete injury may include (1) the presence of any
sensation or voluntary movement in the lower extremities or (2) evidence of sacral sparing. Signs
of sacral sparing include perianal sensation, voluntary anal sphincter contraction, and voluntary
great toe flexion.
Specific incomplete spinal cord injuries include central and anterior cord syndromes, Brown-
Squard syndrome, and conus medullaris syndrome. Patients with these syndromes have certain
characteristic patterns of neurologic injury with distinct findings on physical examination.
Central Cord Syndrome
Central cord syndrome is the most common spinal cord syndrome and is usually due to neck
hyperextension. Trauma to the central portion of the cord results in injury to the medially located
corticospinal motor tracts of the upper extremities. As a result, the upper extremities are
predictably and disproportionately weaker than the lower extremities. Many patients exhibit
bladder dysfunction (e.g., urinary retention) and varying degrees of sensory loss. Elderly patients
are more at risk for central cord syndrome because of underlying cervical spondylosis, a
thickened ligamentum flavum, or both.
Anterior Cord Syndrome
Anterior cord syndrome results from blunt or ischemic injury to the anterior spinal cord.
Affected patients have a complete and usually bilateral motor deficit below the level of the injury
along with loss of pain and temperature sensation a few levels below the lesion. Typically,
posterior column function is preserved.
Brown-Squard Syndrome
Brown-Squard syndrome is a rare hemicord injury that is usually associated with penetrating
trauma. Patients have crossed sensory and motor deficits: ipsilateral loss of motor function and
position sense below the level of the lesion and contralateral loss of pain and temperature
sensation one to two levels below the injury.
Conus Medullaris Syndrome
Conus medullaris syndrome results from injury to the spinal cord with occasional involvement of
the lumbar nerve roots. It results in areflexia of the bladder, bowel, and lower extremities.
Patients may exhibit perianal numbness. Motor and sensory deficits in the lower limbs vary.
Cauda Equina Syndrome
Although cauda equina syndrome is not a direct spinal cord injury because the cauda equina is
composed entirely of peripheral nerves (lumbar, sacral, and coccygeal nerve roots), it still
requires emergency neurosurgical intervention. Clinical findings include asymmetric sensory
loss, weakness of the lower extremities, urinary retention or incontinence, decreased rectal tone,
and saddle anesthesia.
Treatment
Prehospital and ED management should include protection of the spine and spinal cord until
injuries can be identified or excluded. A rigid backboard should typically be removed promptly
from beneath cooperative patients because a calm person can maintain spinal column neutrality.
Extended use of a rigid backboard is associated with complications such as back pain, respiratory
impairment, aspiration, and decubitus ulcers.
In-Line Immobilization of the Cervical Spine
During the initial resuscitation phase of trauma victims, patients with a potential cervical spine
injury may require endotracheal intubation before a definitive diagnosis can be made. By
preventing neck hyperextension during direct laryngoscopy, in-line cervical spine
immobilization during intubation maintains cervical spine neutrality ( Fig. 75.10 ).
Fig. 75.10
In-line cervical spine immobilization during endotracheal intubation.
Standing to the patient's side, the assistant uses both hands to stabilize the neck to prevent
hyperextension.
Neurogenic Shock
Neurogenic shock results from a sympathectomy-induced reduction in blood pressure, heart rate,
cardiac contractility, and cardiac output. Overly vigorous fluid resuscitation can be hazardous
because of compromised cardiac output. Judicious use of vasopressors such as phenylephrine
hydrochloride, dopamine, and norepinephrine is often indicated. Significant bradycardia should
be treated hemodynamically with atropine.
Systolic blood pressure lower than 80 mm Hg is rarely due to neurogenic shock alone, and other
causes of shock, primarily from hemorrhage, must be excluded. It should never be assumed that
hypotension is due to spinal shock until hemorrhage is excluded.
Corticosteroid Therapy for Spinal Cord Injury
Though controversial, treatment of blunt spinal cord injury with high-dose methylprednisolone is
common. This therapeutic recommendation is based on the findings of the National Acute Spinal
Cord Injury Study (NASCIS), which demonstrated improved neurologic function in patients
receiving high-dose corticosteroids within 8 hours of injury. Improved neurologic function,
however, was defined as a modest gain in motor scores but not functional improvement. In
NASCIS, a loading dose of 30 mg/kg of methylprednisolone administered over a 15-minute
period was followed by an infusion of 5.4 mg/kg/hr and continued for 24 hours (in patients
treated within 3 hours of injury) or 48 hours (in patients treated 3 to 8 hours after injury).
20 21
No
benefit was found when steroids were administered more than 8 hours after injury.
Steroid therapy is not indicated for penetrating injuries and has not been adequately studied in
children younger than 13 years or in patients with cauda equina or spinal root injury.
Finally, systemic corticosteroid therapy is not benign. Complications of steroid therapy include
gastrointestinal hemorrhage and wound infection in patients treated with corticosteroid infusions
for 24 hours and higher rates of severe sepsis and severe pneumonia in those treated for 48 hours.
The use of steroids for blunt traumatic spinal cord injury is far from the standard of care.
22
More
research is needed to verify or refute this controversial therapy.
Surgical Management of Spinal Cord Injury
Timely reduction of the displaced spinal column plus decompression of the spinal cord has been
associated with recovery from otherwise devastating spinal cord injuries.
23
The optimal timing
of surgery following a spinal injury remains controversial. Some argue for immediate surgery,
whereas others advocate delayed surgery because of the initial posttraumatic swelling. The sole
absolute indication for immediate surgery is progressively worsening neurologic status in
patients with spinal fracture-dislocations who initially have incomplete or absent neurologic
deficits.
24

In a series of patients with traumatic central cord syndrome, those who underwent early surgery
(<24 hours after injury) and had an underlying disk herniation or fracture-dislocation exhibited
significantly greater overall motor improvement than did those who underwent late surgery (>24
hours after injury).
25
Unfortunately, early decompressive surgery does not uniformly improve
outcome following spinal cord injury.
Priority Actions
Provide pain control.
Maintain full spinal precautions until the spine can be cleared radiographically or
clinically.
If intubating a trauma patient, an assistant should provide in-line cervical spine
immobilization until the cervical spine can be assessed more definitively at a later time.
Perform a careful initial neurologic examination, especially in patients who are about to
undergo sedation or neuromuscular blockade.
If a spinal fracture is suspected or detected, evaluate for associated injuries:
o
For the cervical spine, examine for associated head and facial injuries.
o
For the thoracic spine, examine for rib fractures and pulmonary, cardiac,
diaphragmatic, and mediastinal injuries.
o
For the lumbar spine, examine for intraabdominal injuries, pelvic fractures, and
calcaneal fractures.
o
For all spinal levels, examine for spinal cord injury.
Obtain urgent spine imaging if a fracture or spinal cord injury is suspected.
Obtain emergency magnetic resonance imaging of the spine if a spinal cord injury is
suspected.
Consider administering corticosteroids if an adult patient has sustained blunt spinal
trauma and exhibits neurologic deficits within 8 hours of injury.
Tips and Tricks
Prolonged immobilization on a rigid backboard is uncomfortable for the patient and
places the patient at risk for aspiration and early pressure sores. Aim to remove the
backboard as soon as possible and ideally within 2 hours of patient arrival. A standard
hospital gurney provides adequate thoracic and lumbar stability.
Perform serial neurologic examinations on patients with suspected or known spinal
injuries to document neurologic improvement or deterioration. Neurologic deterioration
involving the cervical and upper thoracic levels may require empiric endotracheal
intubation for impending respiratory failure.
Once a spinal injury is detected, carefully reexamine the entire cervical, thoracic, and
lumbar spine. Obtain plain films or computed tomography scans of any levels with pain
or tenderness because of the high risk for a second spinal injury.
When performing clinical clearance of a patient's cervical spine or obtaining flexion-
extension cervical spine plain films, do not passively range the neck for the patient. This
may cause an iatrogenic spinal injury. Pain with active movement will prevent the patient
from overranging the neck.
Red Flags (Pitfalls)
Failure to identify occult injuries in hypoesthetic areas. For example, in a patient with a
midthoracic sensory level deficit, occult intraabdominal injuries may be hidden because
the abdomen may be insensate.
Failure to consider a spinal cord injury in a patient with normal radiographic and
computed tomographic (CT) findings.
Failure to repeat plain films or obtain CT imaging when plain film radiographs of the
cervical, thoracic, or lumbar spine are inadequate.
Failure to exclude other causes of hypotension in a trauma patient before assuming that it
is neurogenic shock. A search for occult blood loss should first be done.
Failure to consider a distracting injury, particularly fractures, as a reason for a patient's
ability to localize neck and back pain.
Follow-up, Next Steps in Care, and Patient Education
Most patients with traumatic spinal fractures are admitted to the hospital because they fulfill at
least one of four admission criteria: (1) intractable pain, (2) fracture involvement of more than
one column, (3) a functionally unstable fracture pattern, and (4) the presence or potential for
development of a spinal cord injury.
Patients who can be discharged home include those with normal neurologic function and (1) an
isolated, stable posterior column fracture (spinous process, transverse process) in the cervical,
thoracic, or lumbar spine or (2) a stable wedge fracture in the thoracic or lumbar spine.
Patients with confirmed or suspected spinal cord injury should be scheduled for early
consultation with a neurosurgeon or orthopedist. This may require transfer of the patient to a
spine specialty center.
The level of the spinal cord injury, associated neurologic deficits, and other traumatic injuries
will determine whether the patient should be admitted to the intensive care unit, neurosurgical
observation unit, or general ward. Circular beds, rotating frames, and serial inflation devices are
used to protect the patient from pressure sores.
Discharged patients without a fracture or spinal cord injury require only conservative
management. Discharged patients with a stable spinal fracture require only conservative
management with or without an immobilization device, such as a cervical collar or
thoracolumbar sacral orthosis back brace. Soft collars and back braces are not recommended
because they predispose patients to stiffness of the neck and back, respectively.
Discharged patients with persistent neck pain who are still at risk for an unstable ligamentous
injury should wear a semirigid cervical collar (e.g., Philadelphia or Miami J collar) for 7 to 10
days until adequate flexion-extension plain films can be obtained. Discharge instructions should
include information about the warning signs of spinal cord injury.
Documentation
Document neck and back tenderness, along with the neurologic examination, in all
trauma patients.
In spinal cord injury patients, mark the initial level of sensory deficit to monitor
progression of the patient's neurologic status.
For patients with neurologic deficits, perform and document the bulbocavernosus reflex
and sacral-sparing examination to assess for spinal shock.
Suggested Readings
1Bracken MB, Shepard MJ, Holford TR,
et al
: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in
the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury
Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997; 277: 1597-
1604
2Hoffman JR, Mower WR, Wolfson AB,
et al
: Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt
trauma. N Engl J Med 2000; 343: 94-99
3Stiell IG, Clement CM, McKnight RD,
et al
: The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J
Med 2003; 349: 2510-2518