SPINAL INJURY MODULE

The majority of spinal injuries are a result of MVA, falls or sports-related injuries.1
Alcohol intoxication is frequently a contributing factor.

Fortunately serious spinal injury is relatively uncommon. The incidence of C Spine

injury is approximately 1.5 - 4% in patients with major trauma.2,3 The incidence of
thoracolumbar spine injury is approximately 4 - 5% in patients with major trauma.4
Spinal cord injuries occur in 10-20% of patients with spinal fractures, and nearly 50%
of patients with cervical vertebral fractures.3

Patients with significant spinal injuries frequently sustain trauma to other parts of the
body, commonly the head (approx. 23% of patients with a spinal injury), extremities
(26%), chest (20%), abdomen (6%), pelvis (3%) and face (1.3%).1

Most spinal column injury in adult patients occurs between C3-C7 with 65% of all
fractures, most commonly between C5-6, and 75% of all dislocations, most
commonly between C6-7.5 If a fracture is found at one level it is imperative to go
looking for a fracture at another level as multiple fractures occur in 8-10% of patients
in whom a vertebral fracture is identified.

Spinal cord injury (SCI) can lead to substantial morbidity and disability.

Primary Injury focal cord compression

laceration
traction
transection
ischaemia

Secondary injury hypoxia

hypotension
inappropriate manual handling (uncommon as the
forces applied when handing the patient are much less
than those which caused the injury in the first place)

Distribution of spinal cord injury:

60% cervical (most commonly at C5-7)

30% thoracic
4% lumbar
2% sacral

ASSESSMENT OF SPINAL CORD INJURIES

Goals of assessment in patients with a possible spinal injury:

 Identify life threats

 Identify patients with spinal column and spinal cord injuries
 Identify patients who may have their spine cleared clinically without additional
imaging, and
 Determine the most appropriate imaging in situations where the spine is not able to
be cleared clinically

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

1. Rapidly identify life threatening complications

AIRWAY & BREATHING

 An injury above the innervation of the diaphragm (C3,4,5) has implications

for ventilation requirement
- 50% of patient with a C5 SCI require short term mechanical
ventilation
- most patients with a C4 SCI and all with a C3 SCI need mechanical
ventilation, with 50% of C3 quadriplegics being permanently ventilator
dependent

CIRCULATION

 Neurogenic shock can occur with SCI above T6

 Severe bradycardia & asystole can occur on tracheal suctioning and
turning due to unopposed vagal activity

2. Determine motor and sensory level bilaterally

 Use the ASIA assessment chart to assist6

 Assess sensory level using light touch and pin prick
 A motor score of 3 or more is deemed “normal”

 Neurological sensory level is the most caudal level with intact sensation.
The neurological motor level is the most caudal level with a motor score of
3 or more. The overall Neurological Level of Injury is the most caudal level
with intact sensation and a motor score of 3 or more bilaterally.

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

  Complete v incomplete
o Complete – absence of sensory and motor function at S4/5
o Incomplete – partial preservation of sensory and / or motor
function at S4/5

ASIA Impairment Scale (AIS):

AIS Score

A Complete No Sensory or motor function at S4/5

B Sensory Incomplete Sensation below the neurological level

including S4/5 but no motor function
more than 3 levels below the motor
level and at S4/5

C Motor Incomplete More than half of the key muscles

below the neurological level of injury
have a grade less than 3

D Motor Incomplete Half or more of the key muscles below

the neurological level of injury have a
grade greater than or equal to 3

E Normal All components of the exam are

normal

 Zone of Partial Preservation – can only be applied when there is a complete

injury and refers to those dermatomes / myotomes below the level of injury
that have some function (sensory score < 2, motor score < 3)

3. Determine if there is autonomic involvement

Autonomic effects of spinal cord injury

Cardiovascular system unopposed vagal activity if lesion above T6, generalised

vasodilation, sinus bradycardia and arterial hypotension

Gastrointestinal system paralytic ileus, passive aspiration of stomach contents,

faecal incontinence

Genitourinary priapism, urinary retention

Thermoregulatory poikilothermia

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

4. Determine if there is a cord syndrome

Complete cord transection: bilateral paralysis and anaesthesia

Central cord syndrome: disproportionate paralysis in arms

compared to legs

Hemi-cord syndrome : ipsilateral motor and proprioceptive

loss with contralateral pain and
temperature

Anterior cord syndrome: bilateral paralysis, loss of pain and

temperature, preservation of
proprioception and light touch

5. Identify co-morbid traumatic injuries

 Head injuries occur in 25% of patients with spinal injuries

 Multiple vertebral fractures are found in 8-10% of patients with a single vertebral
fracture

CLINICAL CLEARANCE OF THE CERVICAL SPINE

(See Appendix 1 for the PAH Cervical Spine Pathway)

Unrecognised cervical injury can produce serious morbidity and disability.

Among some clinicians, fear of failing to diagnose such injuries has led to a very
liberal use of imaging in blunt trauma. US figures from the past decade estimate that

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

800, 000 people undergo C-spine imaging at a cost of $180 million – with a 2% yield
for positive scans.1

With this in mind clinical decision rules were formulated in an attempt to reduce the
volume of radiological imaging.

Care needs to be taken in the application of decision rules however. They are not a
substitute for clinical judgment.

NEXUS7

NEXUS was a multicentre, prospective, observational study. All comers with

blunt trauma who received C-spine plain films were included. In total 34069
patients (including paediatric patients) were studied.

The decision instrument required patients to meet 5 criteria to be classified as

having low probability of injury.

 The absence of posterior midline cervical tenderness

 No evidence of intoxication
 No focal neurology
 Normal level of alertness
 No distracting injury

2.4% of the study population had radiographically documented C-spine injury.

The sensitivity of the decision rule was 99%, the conclusion being that those
people with a low probability of injury can forego imaging. In this study 13%
of participants were low probability of serious injury and would have avoided
imaging if NEXUS was applied.

Canadian C-Spine Rule8

This was a prospective cohort Canadian study published in 20012. 8924 adult
patients were enrolled with blunt trauma to the head or neck. They all had
normal vital signs and a GCS of 15.

In this population, clinically important C-spine injury (fracture, dislocation or

ligamentous injury) occurred in 1.7% patients. From this data a clinical
decision rule was derived with 100% sensitivity for clinically important C-
Spine injury.

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

The potential radiology ordering rate using the Canadian C-spine Rule in this study
was 58.2% of patients presenting with blunt trauma to head or neck.

There is an article published in the NEJM comparing the two algorithms which
9
suggests the Canadian approach is superior to its American counterpart . The paper

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

 quotes 99.4% v 90.7% sensitivity and lower radiology ordering rates with the
Canadian C-spine Rule. This paper however was written by the same people who
created the Canadian rule and the conclusions are less convincing if you look at the
paper critically. Both decision tools have similar ordering rates – roughly 60%. The
Canadian Rule has a significantly lower inter-rater reliability – in keeping with it being
a more complex algorithm. And somewhat surprisingly in 10% of cases physicians
rd
didn’t apply the Canadian C-spine Rules correctly – omitting the 3 step and testing
neck ROM.

All patients who cannot be clinically cleared must undergo radiographic evaluation.
Traditionally, and as supported by Nexus and CCR, radiologic evaluation has commenced
with plain films (i.e. AP, Lateral, PEG, Swimmer’s). There has been extensive discussion
10
over the past few years regarding the best approach to initial imaging of the C-spine . There
has been a strong push for the use of CT rather than plain films, particularly for patients at
high risk of c-spine injury given the high sensitivity and specificity of CT (approaching 100%)
for clinically significant injury. In the obtunded patient, a negative CT scan has been shown to
exclude clinically significant C-spine injury (< 1%) with MRI not contributing additional
10,11,12,13
information, especially when gross movement of all limbs has been observed. . The
Eastern Association for the Surgery of Trauma outline a worst case 9% cumulative literature
incidence of stable injuries after a negative high-quality CT c-spine with a negative predictive
14
value of finding an unstable c-spine fracture approaching 100%. Thus the risk-benefit ratio
does not appear to favour MRI in obtunded patients with a normal CT c-spine.

When to proceed to advanced imaging of the C-spine:

CT:

 Bony injury is best visualised by CT imaging

 The obtunded / intubated multi-trauma patient
 When C-spine plain films are abnormal or inadequate
 When the patient has significant pain or limited ROM even with normal plain imaging
 When the patient with concerns for a C-spine injury is having a CT of another body
region, most commonly the head

When do you proceed to MRI in the ED?

 All patients with suspected cord injury in the setting of trauma – without adequate
delineation on CT - should have MRI imaging of their spine
 Consideration should be given to MRI for suspected ligamentous or disc injury – i.e.
ongoing significant midline or radicular pain / neurology with a normal CT

THORACO-LUMBAR SPINE

(See Appendix 2 for the PAH Thoraco-lumbar Spine Pathway)

The incidence rate of TL spine fractures in blunt trauma is approximately 5%.15

Approximately 50% of all spinal fractures occur in the TL region and 19-50% of these
fractures are associated with neurology.15 A delay in diagnosis of these patients may
result in up to an eightfold increase in neurology.15

While TL fractures may be asymptomatic, the literature supports the notion that a
patient who has a reliable examination (is neurologically intact with a normal GCS, is
not intoxicated, has no midline tenderness and no major distracting injury) can be
clinically cleared15. Judgment needs to be used when considering whether patients
should be screened based on mechanism alone and what constitutes a distracting
injury16.

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

In light of the above, screening for TL injuries is considered when:

 There is a high risk mechanism

o MVA > 60 km/hr
o MBA / cyclist > 30 km/hr
o Paedestrian impact > 30km/hr
o Fall > 3m
o Vehicle rollover
o Fatality in the same vehicle
o Ejection from vehicle
o Explosion

 Low risk clinical identifiers:

o Midline tenderness
o Altered GCS
o Intoxication
o Major distracting injuries

 A c-spine fracture has been identified due to the high risk of multi-level fractures

What imaging is best for thoracolumbar spine fractures?

Plain films may be used when patients meet the criteria for screening as per above.

CT scanning is more sensitive and specific (approaching 100% for reformatted images with
3mm slices) compared to plain films(sens for diagnosing unstable fractures ranging from 33-
15
77%). Indications for CT include
 The obtunded / intubated multi-trauma patient
 Abnormal neurological exam suggestive a TL spine injury
 Haematoma or midline step
 Abnormal plain films
 When the chest, abdomen and pelvis are being imaged allowing reformatting of TL
spine views

MRI of the TL spine is indicated when there is a suspected spinal cord injury, ligamentous
15
injury, cord or epidural haematoma, disc injury or facet joint involvement.

MANAGEMENT OF SPINAL INJURIES

The priority in managing the patient with spinal injuries is to prevent secondary spinal cord
injury while facilitating early intervention of the primary insult.

 Triage to resuscitation area

 Full spinal immobilisation
 Comprehensive non-invasive monitoring
 Urgent orthospinal/neurosurgical referral for intervention if indicated

AIRWAY & BREATHING

 Ensure adequate ventilation – high cervical injuries affecting diaphragmatic

innervation will likely require mechanical ventilation in the short term

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

 RSI likely indicated if:

GCS < 9 or combativeness preventing imaging

Ventilatory failure with high cervical cord injury
Multi-system injuries requiring intubation for overall stabilisation

Ventilator settings
FiO2 initially set at 100%
VT of 8mL/kg
Rate to achieve pCO2 35-40mmHg
PEEP ≥ 5cm H2O

CIRCULATION

 Correct hypovolaemia
 Volume load to maintain MAP 70 mmHg
 Inotropic support may be necessary in the setting of neurogenic shock after
haemorrhage has been excluded – noradrenaline is first line
 Place an arterial line and central venous line if inotropic support required

SPECIFIC

 Full spinal immobilisation

o Manage cervical spine injuries in soft collar
o Log roll and pat slide in the department
o Engrit bed

 Steroids in acute cord injury

17
o Controversial practice with inconclusive evidence base
o Guided by treating spinal team – however the practice is not supported by the
PAH

 ADT prophylaxis and cephazolin 1g for penetrating wounds

SUPPORTIVE

 Keep warm
 Place NGT
 Place IDC
 Ensure adequate analgesia
 Chart prophylactic antiemetics
 Ensure Pressure ulcer prevention
 Maintenance fluids of normal saline 0.9% 100mL/hr
 Update family where possible and document contact details in chart

DISPOSITION

 All ventilated patients, or those on inotropic therapy are managed in the ICU

 Other suitable spinal injured patients are managed in the trauma HDU or orthospinal
ward

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

PAEDIATRIC SPINAL INJURY AND SCIWORA

INTRODUCTION

Paediatric spinal injuries are uncommon. They are usually secondary to motor
vehicle accidents and to a lesser extent falls and sporting injuries. As in adults they
are commonly associated with concurrent head injuries. Spinal cord injury is very
uncommon with the incidence of spinal cord injury in spine-injured children is 1%.18

ANATOMICAL CONSIDERATIONS OF THE PAEDIATRIC SPINE19

 Relative ligamentous laxity

 Shallow (relatively vertical) angulation of facet joints
 Immature development of neck musculature
 Incomplete ossification of vertebrae
 Disproportionately large head

Subsequently 60-80% of all paediatric spinal injuries are in the cervical region,
particularly the upper cervical spine – with 80% occurring at C1-3 in children <8 yo.

The fulcrum of neck movement is at C2-3 in the infant, C3-4 at 6 yo and C5-6 at 8yo.

After 8 yo the injury pattern is similar to adults.

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality)

SCIWORA refers to objective signs of spinal cord injury following trauma without any
evidence of fracture or ligamentous injury on radiological imaging.

The phenomena was first reported in 1982 by Pang & Wilberger20 who also noted
that delayed presentations with paralysis were occurring up to 4 days following injury.
Its incidence has been reported between 1-10% of all spinal cord injuries in children.
It is more common in children < 8yo with cervical spine injuries. The hypothesis
behind the aetiology of SCIWORA is that of ligamentous laxity and bony immaturity
allowing the transfer of forces through to the spinal cord resulting in myopathy
without bony injury.

In modern times, SCIWORA has become a misnomer as most of these patients

actually have a radiological abnormality on MRI. True SCIWORA is now exceedingly
rare.19

SPINAL IMMOBILISATION

Spinal immobilisation can be particularly difficult in smaller children and infants.

Traditionally immobilisation has been performed with a rigid cervical collar and
fixation to a spinal board with a head immobiliser and strapping. However this can
lead to discomfort, distress, pressure areas and in some cases can worsen the initial
injury with elevated ICP, the potential for airway obstruction and ventilatory
compromise.18 Spinal boards need to be modified in children under 8 yo to prevent
neck flexion with either an occipital recess or mattress padding.

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

A balance must be made between diminishing any secondary spinal injury and
interfering with assessment and comfort of the child. Parents and carers should be
encouraged to help in the process where feasible. Time kept on the spinal board
must be limited to the shortest time possible.

Assessment of Possible C-Spine Injury in Children Suffering Blunt Trauma

The Queensland Paediatric Trauma Service has developed an evidence based

pathway for assessing the c-spine of children involved in blunt trauma21, based on
the fact that serious cervical spine injury in blunt trauma is uncommon in the
paediatric population (1% of all paediatric blunt trauma cases, incidence ranging from
0.4% in pre-school age to 2.5% in adolescents). The majority of these injuries are
stable with only 1-5% requiring operative fixation. Imaging plays an important role in
identifying injuries, but has an associated increased life-time risk of malignancy,
albeit poorly defined. The PECARN group has identified 8 factors which associated
with C-spine injury that form the basis for the clinical algorithm put forward by the
Queensland Paediatric Trauma Service:

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

If a patient is having a CT for other injuries, then serious consideration should be
given to concurrent CT of the spine.

FURTHER READING:

Raniga S, Menon V, Muzahma KS et al. MDCT of acute subaxial cervical spine trauma: A
mechanism-based approach. Insights Imaging. 2014; 5: 321-338

Kanwar R, Delasobera BE, Hudson K et al. Emergency department evaluation and treatment
of cervical spine injuries. Emerg Med Clin N Am. 2015; 2: 241-282

REFERENCES

1. Hasler RM, Exadaktylos AK, Bouamra O et al. Epidemiology and predictors of

cervical spine in adult major trauma patients: A multicentre cohort study. J Trauma.
2011; 72(4): 975-981

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

2. Holmes JF and Akkinepalli R. Computed tomography versus plain radiography to
screen for cervical spine injury: A meta-analysis. J Trauma. 2005; 58: 902-905
3. Kanwar R, Delasobera BE, Hudson K et al. Emergency department evaluation and
treatment of cervical spine injuries. Emerg Med Clin N Am. 2015; 33: 241-282
4. Sixta S, Moore FO, Ditillo MF et al. Screening for thoracolumbar spinal injuries in
blunt trauma: An eastern association for the surgery of trauma practice management
guideline. J Trauma. 2012; 73(5S4): S326- S332
5. Raniga SB, Menon V, Al Muzahmi et al. MDCT of acute subaxial cervical spine
trauma: A mechanism-based approach. Insights Imaging. 2014; 5: 321-328
6. The American Spinal Injury Association – website and education module
7. Hoffman J, et al. “Selective Cervical Spine Radiology in Blunt Trauma: Methodology
of the National Emergency X-Radiography Utilisation Study (NEXUS)” Annals of
Emergency Medicine. 1998; 32 (4): 461-9
8. Stiell I, et al. “The Canadian C-spine Rule for Radiography in Alert and Stable
Trauma Patients” JAMA. 2001; 286: 1841-8
9. Stiell I, et al. “The Canadian C-spine Rule versus the NEXUS Low-Risk Criteria in
Patients with Trauma” NEJM. 2003; 349(26): 2510-8
10. Como J, Diaz JJ, Dunham M et al. Practice management guidelines for identification
of cervical spine injuries following trauma: Update from the Eastern Association for
the surgery of trauma practice management guidelines committee. J Trauma. 2009;
67(3): 651-659
11. Vanguri P, Young AJ, Weber WF et al. Computed tomographic scan: It’s not just
about the fracture. J Trauma. 2014; 77(4): 604-607
12. Como JJ, Leukhardt WH, Anderson JS et al. Computed tomography alone may clear
the cervical spine in obtunded blunt trauma patients: A prospective evaluation of a
revised protocol. J Trauma. 2011; 70(2): 345-351
13. Khanna P, Chau C, Dublin et al. The value of cervical magnetic resonance imaging in
the evaluation of the obtunded or comatose patient with cervical trauma, no other
abnormal neurological findings, and a normal cervical computed tomography. J
trauma. 2011; 72(3):699-702
14. Patel MB, Humble SS, Cullinane DC et al. Cervical spine collar clearance in the
obtunded adult blunt trauma patient: A systematic review and practice management
guideline from the eastern association for the surgery of trauma. J Trauma. 2014; 78
(2):430-441
15. Sixta S, Moore FO, Ditillo MF et al. Screening for thoracolumbar spinal injuries in
blunt trauma: An Eastern Association for the surgery of trauma practice management
guideline. J Trauma. 2012; 73(5S4): S326-332
16. Cason B, Rostas J, Simmons J et al. Thoracolumbar spine clearance: Clinical
examination for patients with distracting injuries. J Trauma. 2015; 80(1):125-130
17. Shanker N. “Steroids and Spinal Cord Injury: Revisiting the NASCIS 2 and NASCIS 3
Trials.” J Trauma: Injury, Infection and Critical Care 45(6): 1088-93
18. Cameron P et al. “Textbook of Paediatric Emergency Medicine.” 2006;
Churchill Livingstone, Sydney.
19. Cirak, B. et al. “Spinal Injuries in Children.” J Pediatr Surg. 2004; 39(4): 607-
12
20. Pang D & Wilberger JE. “Spinal Cord Injuries without radiographic
abnormalities in children.” J Neurosurg. 1982; 57(1):114-29
21. Brady et al. Queensland Children’s Hospital, Queensland Paediatric Trauma
Service, Assessment of Possible Cervical Spine Injury in Children Suffering
Blunt Trauma. Clinical Guideline 2013.

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

Appendix 1

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016

Appendix 2

PAH Department of Emergency Medicine Spinal Injury Module Revised 2016