Spine injuries are most commonly caused by motor vehicle injuries followed by fall and gunshot injur . Most of the spine injuries occur in cervical spine followed by thoracic and lumbar.
The cervical spine injuries occur in more than half of all spine injuries in trauma patients.
Most isolated thoracic and lumbar spine injuries are related to osteoporosis. Thoracic and lumbar fractures account for 30% to 60% of all spine injuries.
Care of Spine Injuries
All trauma patients are at risk for spine injuries including spinal cord injury. Therefore proper extrication of the patient and immobilization of the cervical spine at the accident scene are critical to avoid further neurologic injury. The neck movements are to be avoided when taking out the person out of the car or shifting the person. For this, the head and neck need to be aligned with the long axis of the trunk and immobilized in this position.
The cervical spine needs to be immobilized to prevent further movements that can cause damage to the spinal cord. Immobilization with cervical collar, sandbags, tape, and spine board is superior to immobilization with a collar alone. Neutral flexion-extension head and neck alignment is optimal during prehospital transport. To maintain neutral head-neck alignment. in children, the relatively larger head of should be accommodated by elevating the trunk on padding or using a special pediatric spine board.Helmet and shoulder gear should be left in position until personnel trained in safe removal techniques are available.
In either case, initial evaluation of the patient must include spinal injury evaluation which might go concurrent with resuscitative measures.
- Gross neurological assessment with movement and sensation in all extremities
- Assessment of gross neurological function.
- Direct examination to get a a clinical idea of level of injuries
- Cervical spine x-ray, anteroposterior chest x-ray and xray of any other injured part
- Analysis of hemodynamic parameters
Any condition which needs immediate treatment should be part of the side by side ongoing resuscitation.
Hypotension, bradycardia, warm extremities in presence of normal urine output suggests neurogenic shock and should be differentiated from hemorrhagic shock as the treatment approach differs.
After the patient has been resuscitated, a detailed examination of the patient follows.
Detailed Examination After Resuscitation of Spine Injuries
After initial examination , complete spine examination and neurological assessment follows resuscitation.
If patient is responsive, a detailed history is obtained regarding acute symptoms and past history.
For unresponsive patients, a past history is obtained from family members or available previous medical records.
The patient must be rolled on his or her side using a log-rolling maneuver. For this, The patient’s head and neck are supported by one person and the trunk by two to three other assistants. The head and trunk are then rolled in unison to facilitate the examination of spine by physician.
Following things are noted
- Areas of hemorrhage
- Alignment of the spine
- Gross deformity
- Palpable gap in the spinous processes
Trunk and abdomen are also examined for injury.
After local examination of the spine neurological examination is performed.
The neurological examination would vary in awake-cooperative and unresponsive patients. Awake and cooperative patients require a complete neurological examination. There are many methods and gradings to assess the neurological deficit whose basic purposes are following
- Presence of spinal shock
- Localization of the lesion level
- To determine whether injury is complete or incomplete
- To determine if the injury fits into a particular pattern
This is achieved by detailed motor and sensory examination.
In case of unresponsive patient, radiographic studies are the primary modalities for identifying a spine injuries. Spine injury precautions must be observed until the spine is cleared. If a spinal column injury is identified, the neurological deficit should be assessed.
Imaging in Spine Injuries
After clinical evaluation, radioimaging is a very important part of spine assessment in spine injuries. Radiographs or xrays are the first imaging modality used however radiographs do not provide complete information due to their inherent limitations of two dimensional views.
Following xrays are essential in a patient who has multiple injuries
- Chest x-ray anteroposterior view
- Pelvis x-ray anteroposterior view
- Lateral cervical spine x-ray.
Rest of the imaging for spine is done after patient has been stabilized.
After patient is stabilized, a complete imaging of cervical spine views should be obtained. Following views are generally ordered.
- Open mouth
- Right and left oblique.
Lateral radiograph allows visualization of the spine from the occiput to C6 vertebra and C7 if shoulders are pulled during the xray. A swimmer’s lateral view or a CT scan may be needed if lower cervical spine cannot be visualized.
- Alignment of the cervical vertebrae- Assessed by examining longitudinal lines along vertebral bodies, lamina, and spinous processes.
- The prevertebral soft tissues are also examined for swelling related to acute hemorrhage. If increased, it suggests acute cervical spine injury.
Shows the C3 to T4 segments. A change in alignment of the uncovertebral joints (Small synovial joints between adjacent lateral lips of the bodies of the lower cervical vertebrae) and spinous processes can indicate an acute injury.
It is essential for excluding a C1 arch or odontoid process fracture.
To identify injuries of the facet joints, pedicles, and lateral masses.
Thoracic, Lumbar and Sacral Spine Injuries
Anteroposterior and lateral thoracic and lumbar radiographs and a pelvis AP view are standard xrays.Alignment, destruction of vertebrae or reduction in height of vertebra, vertebral fractures are signs of injury.
Computed Tomography in Spine Injuries
CT scans are done for
- Patients with suspected spinal fracture and/or dislocation
- Difficult visualization of their spinal column on radiographs.
- Preoperative planning
- Substitute for the open mouth view in unresponsive person
- Junctional injuries – Cervothoracic area, Thoracolumbar junction
CT is superior to MRI in demonstrating bony injury.
Magnetic Resonance Imaging
It is done in patients with cervical level spinal cord injury, incomplete spinal cord injury, and for assessment of disk or ligament injuries. The purpose of MRI is to look for integrity of the cord and severity of injury to the cord.
Treatment of Patient With Spine Injuries
All trauma patient must be provided protection and immobilization of the spine until spinal injuries has been ruled out or treated definitively.
This general principle and implications are commonly referred to as spine precautions. These precautions include
- All trauma patients should be maintained in the supine position at strict bed rest with the bed flat
- Transfers should be done with a spine board
- Patients with cervical injury must be stabilized with hard cervical collar
- Log-rolling should be don to turn the patients
Further course of events depend upon the clinical and radiological assessment of the injury.
Patients under intoxication and normal total spine radiographs/computerized tomography shouold remain in bed until a clinical exam can be performed to reliably.
After initial care of the patient with spinel injuries, decision is made about the definitive care.
A definitive care aims at making the injured spine stable and removing any decompression on the spinal cord.
Because not all patients would have neural injury and not all patients would have instability of the spine, the definitive treatment has a spectrum from immobilization with a collar to surgery. There are indications for each method and one treatment cannot treat all kind of injuries.
Following are the ways of treating a spinal injury
- Non operative Treatment
- Operative treatment
- Closed reduction with or without surgery (in cervical spine only)
Non Operative Treatment of Spine Injuries
Non operative treatment remains the standard of care for spine injuries. Most of injuries can be treated with these methods.
Closed treatment options are
- Traction – In case of cervical spine injuries
- Bed rest with regular periodic turning to avoid bed sores.
- Halo apparatus, external orthosis, or cast.
Bed rest is advised for the initial few weeks and is followed by bracing. This option can be used in unstable injuries too. External orthosis is chosen as per level of the injury.
Bracing is continued for 8–12 weeks in cervical injuries and 12–24 weeks in thoracolumbar injuries. This is the time taken for the frcture to heal sufficiently to bear the load.
Prolonged bed rest as definitive treatment may be advised in rare cases of patients unwilling to undergo bracing or surgery or are unsuitable for that treatment because of severe preexisting deformity, morbid obesity, or medical problems etc.
In some patients, non operative treatment of may lead to chronic pain at a later date.
Operative Treatment of Spine Injuries
Surgical stabilization of the spinal column aims at
- Prevention of further mechanical injury
- Decompress spinal cord by removing the structures causing compression e.g. bone fragments pressing on the spinal cord
Following patients should be considered for surgery
- Skeletal instability with a neurologic deficit.
- Unstable ligamentous injury in adult patient where non operative treatment does not restore sufficient strength for stability
- Patients with multiple injuries
- Multiply injured patients
The surgery of injured spine varies as per level of the injury but the principle followed are
- Fixation of the injured segment with implant
- Fusion of the segment with bone graft
The purpose of the implant is to hold the segment in the position till the time fusion occurs. If not fused, implant would fail some day and spine would again become unstable.
There are various gadgets available for spine surgery and each has its own advantages and disadvantages.
This method is used in cervical spine dislocations. The principle behind this is to use heavy weights to distract the injured area so that a slow maneuver can be performed to reduce the spine. It is quite safe method. Neurologic deterioration during reduction is a risk but is quite rare if done meticulously.
This needs insertion of Crutchfield tongs or Gardner-Wells tongs.
- In alert cooperative patients, imaging is not necessary prior to reduction
- An unconscious patient should be undergo an MRI scan before reduction.
- Injuries such as craniocervical dissociation or a cervical injury that shows distraction should not be put on traction.
Benefits of closed reduction
- Decreases the need for complicated surgical procedures
- Improves stability, prevent neurologic deterioration or can improve neurologic status
- Reduction within the first few hours of injury may lead to dramatic improvement in neurologic status.
There is no effective closed reduction technique for thoracolumbar spine.
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