Initial Evaluation and Management of Spinal Injuries

Overview

Each region of the spine must be evaluated carefully; coexisting injuries make this difficult, and errors can be devastating (Campbell). The estimated annual incidence of traumatic spinal cord injury in the United States is about 18,000 cases; spinal column injuries are about twice as common as cord injuries. Causes: motor vehicle accidents 38%, falls 32%, violence 15%, sports 8%. The most common neurologic category is incomplete tetraplegia (47%) (Campbell).

Prehospital Care and Immobilization (Campbell)

• Total spine immobilization for patients with evidence of spinal injury; not recommended for patients who meet the NEXUS criteria.

• If in doubt, full immobilization until the cervical spine is cleared: a hard collar with block supports (not sandbags) on an appropriately sized spine board.

• Adults: a 2- to 3-cm occipital pad to avoid relative extension. Children: a board with an occipital recess to avoid relative flexion.

• Prioritize imaging so the patient can be removed from the board as quickly as possible; immobilization carries risks of aspiration, increased work of breathing, pressure sores and raised intracranial pressure.

Initial Assessment

1. Complete ATLS primary survey (ABCs).

2. History: mechanism, preinjury function, weakness or sensory change, head trauma.

3. Examination: spinal tenderness, step-offs, interspinous widening; incontinence or priapism may indicate cord injury (Campbell).

4. Detailed neurologic examination on the ASIA/ISCoS form: light touch and pinprick in 28 dermatomes, 10 key myotomes per side, deep anal pressure and voluntary anal contraction (Campbell).

5. Repeat the examination every 4-6 hours for at least the first 24 hours in cord injuries or unstable column injuries (Campbell).

NEXUS low-risk criteria (Campbell, Rockwood)

A patient who meets all five needs no cervical imaging:

1. No posterior midline cervical tenderness.

2. No evidence of intoxication.

3. Normal level of alertness (e.g., GCS 15, oriented).

4. No focal neurologic deficit.

5. No painful distracting injury.

Canadian C-Spine Rule: applies to alert (GCS 15), stable patients. High-risk factors (age over 65, extremity paresthesias, dangerous mechanism: fall from more than 3 ft, axial load, MVC over 60 mph, rollover, ejection, unrestrained) mandate imaging. If none and a low-risk factor is present (rear-end MVC, sitting in ED, ambulatory, delayed neck pain, no posterior neck pain), active rotation of 45 degrees to each side means no imaging is needed (Campbell).

Key myotomes (Campbell)

Dermatomal landmarks: nipple line T4, xiphoid T7, umbilicus T10, inguinal region T12-L1, perianal S4-S5 (Campbell).

ASIA Impairment Scale (Campbell)

• The neurologic level is the most caudal myotome with at least 3/5 strength, with 5/5 strength and normal sensation above it (Campbell).

• A definitive determination requires the patient to be out of spinal shock, indicated by return of the bulbocavernosus reflex and anal wink, usually within 24-48 hours (Campbell).

Imaging (Campbell, Rockwood)

• Multidetector CT (MDCT) with sagittal and coronal reformats is the primary imaging modality; plain radiographs miss about 30% of cervical, 52% of thoracic and 14% of lumbar injuries and are not recommended for screening (Rockwood).

• MDCT with 1-mm collimation has about 98% sensitivity for cervical injury (Rockwood).

• Noncontiguous injuries occur in up to 15% of patients; image the whole spine once one injury is found (Campbell).

• MRI indications: unexplained neurologic deficit, identified osseous cervical injury, CT findings suggesting soft-tissue injury (prevertebral soft tissue more than 5 mm at C3, disc space widening, osteophyte avulsion, interspinous widening), and altered mental status after intoxicants are metabolized. Obtain within 48 hours for optimal sensitivity (Campbell).

• EAST (2015): in an obtunded patient without neurologic symptoms, a negative 64-slice or better MDCT read by an experienced radiologist does not require MRI (Campbell).

• Flexion-extension radiographs are not useful acutely and have caused neurologic injury in obtunded patients (Campbell).

Technique 48.1: Stretch test (White, Southwick and Panjabi) (Campbell)

Used when MRI is contraindicated and CT suggests soft-tissue injury; performed only under direct supervision of the attending surgeon, in an alert, hemodynamically stable patient.

1. Apply cranial skeletal traction; obtain a baseline lateral radiograph with the tube 72 inches from the film.

2. Start with 10 lb and increase in 3- to 5-lb increments, with a full neurologic examination and lateral radiograph after each increment, at least 5 minutes apart.

3. Stop if any neurologic change occurs or if there is an increase of 1.7 mm between adjacent vertebrae or 7.5 degrees of angulation at a disc level compared with the baseline image (always compare with the baseline, not the previous film).

4. The test is negative if one-third of body weight or 65 lb is reached without change.

Spinal Cord Injury Management

• Neurogenic shock: loss of sympathetic tone causing hypotension, bradycardia and hypothermia; distinguish from hemorrhagic shock, which may coexist (Campbell).

• Spinal shock: temporary loss of reflexes and sensorimotor function below the injury, usually resolving within 24-48 hours (Campbell).

• Treat hypotension initially as hemorrhagic with balanced crystalloid, then blood; if persistent with normal central venous pressure, use pressors with alpha and beta activity (dopamine, dobutamine, norepinephrine) rather than pure alpha agonists (phenylephrine, reflex bradycardia) (Campbell).

• Maintain MAP 75-95 mm Hg (MAP 85-90 mm Hg correlates with better outcomes) for 3-7 days, and keep oxygen saturation near 100% (Campbell).

• Methylprednisolone: benefits are unclear and risks are significant (Campbell). AO Spine guidance cited by Rockwood: a high-dose 24-hour infusion is not recommended for patients presenting more than 8 hours after injury but may be offered within 8 hours; a 48-hour infusion has no role.

• Timing of surgery: decompression and stabilization within 24 hours of injury when possible (Campbell). In STASCIS, early surgery (under 24 hours) for cervical cord injury improved neurologic recovery at 6 months (Rockwood).

Closed Reduction of Cervical Fractures and Dislocations

• Rapid realignment with skeletal traction can relieve cord compression faster than surgery, often within 1-2 hours of arrival (Campbell).

• In awake, alert patients with significant deficits (AIS A, B or C), the authors proceed with expeditious reduction without prereduction MRI; only 11 of 1200 awake patients (under 1%) had permanent worsening after closed reduction. Obtain MRI before reduction in patients with less severe deficits (more than half of key myotomes 3/5 or better) (Campbell).

• Do not attempt closed reduction in obtunded patients, with distraction injuries at other levels, certain skull fractures or hemodynamic instability (Campbell).

• Closed reduction succeeds in about 80% of patients (Campbell).

Technique 48.2: Gardner-Wells tongs (Campbell)

1. Stabilize the neck in a rigid collar; use a bolster under the occiput or shoulders for neutral alignment.

2. Mark a point 1 cm above the top of the ear, directly above the external auditory canal, on each side.

3. For neutral alignment place pins in line with the canal but no farther forward (temporal artery); more posterior pins produce slight flexion.

4. Clean with antiseptic and infiltrate 1 mL of 2% lidocaine to the periosteum.

5. Check that the central pin is recessed, pin points are intact, locking nuts and S hook are in place.

6. Position the tongs symmetrically (nose centered) and advance the pins until the central indicator pin protrudes 1 mm on one side; tighten the locking nuts.

7. Remove the collar and set the pulley for in-line traction.

Technique 48.3: Closed reduction (Campbell)

1. Elevate the head of the bed 30-40 degrees and obtain a baseline radiograph.

2. Apply an initial weight of 8-10 lb for the head plus 3-5 lb per cervical level above the injury.

3. Document a neurologic examination; give analgesia and muscle relaxation without reducing consciousness.

4. Add weight incrementally, repeating the neurologic examination and lateral radiograph, at least 5 minutes apart.

5. Stop if maximal weight is reached, the neurologic examination deteriorates, or the injury level distracts more than 2 mm relative to the normal adjacent disc (compare with the initial film).

6. After reduction (or termination), decrease traction to 10-15 lb, repeat radiographs and examination, and maintain traction until definitive stabilization.

Spine Precautions (Campbell's Concepts)

• Remove the patient from the backboard once hemodynamically stable and CT is complete; maintain the collar.

• Fix the traction pulley crossmember to the bed frame so traction stays neutral if the bed moves; reverse Trendelenburg then allows head elevation.

• Unstable thoracolumbar injuries awaiting fixation: flat in bed (reverse Trendelenburg allowed), log-rolled every 2 hours; a rotating bed if stabilization is delayed more than 24-48 hours.

• Patients treated in a thoracolumbar orthosis may have the head of the bed at 0-30 degrees without it; the orthosis is required above 30 degrees.

• Patients with ankylosing spondylitis may need several pillows to accommodate fixed cervicothoracic kyphosis.

Incomplete Cord Syndromes (Campbell)

General prognostic rules: greater sparing below the injury, earlier and faster recovery, and age under 50 predict better recovery; recovery may continue 12-15 months (Campbell).

References

1. Williams KD. Fractures, dislocations, and fracture-dislocations of the spine. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 48, Techniques 48.1-48.3.

2. Lightsey HM, Harris MB, Tobert DG. Principles of spine trauma care. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 47. (Turkish edition: Erişkin Kırıkları.)