Establishing a patent airway is of utmost importance in the patient with vertebral column injuries as these patients may suffer from inadequate respiratory function due to concomitant rib fractures, facial injuries, paralysis of the diaphragm, or other injuries. In patients requiring intubation, maintenance of spinal alignment is critical. This procedure is best performed by nasotracheal tube or by fiber-optic procedures in conjunction with inline cervical traction. Regardless of the adjuvant tools used to establish an airway, avoiding extreme cervical extension is critical as this position narrows the spinal canal more than positions of flexion [12].

Once an airway is secured, attention should turn to ensuring appropriate end organ perfusion and potentially avoid secondary ischemic injuries to the spinal cord. A spinal cord injury may cause vasospasm due to dysfunction of blood flow auto regulation. The hallmarks of neurogenic shock are hypotension, due to loss of sympathetic vascular tone; and bradycardia, due to loss of sympathetic innervations of the heart. If neurogenic shock is present, fluid resuscitation is a vital first intervention and follows the treatment principles used for brain injury. Central venous catheter and arterial lines are required for assessment of heart rate, blood pressure, and perfusion, while urinary catheters monitor urine output. The early use of blood products is recommended in the multiple injured patients with an associated spinal cord injury to maximize the oxygen-carrying capacity and to minimize the secondary ischemic injury to the spinal cord. Early use of vasopressors such as dopamine or atropine is recommended to maintain spinal cord perfusion. While the goal in many trauma centers is to maintain the MAP >85 – 90 mmHg, the overall objective is to avoid hypotension in order to protect the cord from further neurologic injury and potentially improve neurologic recovery [13–15].

Once airway and circulatory concerns are stabilized, the provider should devote attention to performing a complete physical and neurologic examination. Often during the course of examination, inspection and palpation can provide important clues to help identify both associated and concomitant levels of spinal injury. For example, a transverse band of ecchymosis across the abdomen can suggest a flexion-distraction type of injury caused by a seat belt and may help predict an associated intra-abdominal injury. Similarly, bruising along the rib cage may suggest a thoracic fracture. When the patient is log-rolled in ATLS® step “E,” any spontaneous pain from spine is noted as well as local hematomas. The spine must be palpated systematically for tenderness, step-off, or interspinous process gapping. During this portion of the examination it is also critical to perform a rectal exam. Elements of the rectal exam that should be noted include perianal sensation, rectal tone, voluntary contraction, and presence of the bulbocavernosus reflex. In awake and cooperative patients, the American Spinal Injury Association (ASIA) has provided a useful template for the essential elements of a complete neurologic examination (Fig. 14.2) [16]. In this system, the level of neurologic injury is determined by performing objective strength testing in ten myotomes and both light touch and pinprick sensation in 28 dermatomes. From this examination the motor, sensory, and neurologic levels of injury can be elucidated and an impairment classification can be assigned (Table 14.2). Throughout the course of the encounter, providers should remain mindful of associated injuries such as fractures, peripheral nerve injuries, and traumatic brain injuries due to their potential effects on the patient’s examination.

The unconscious patient can often be difficult to examine. In these situations, questioning first responders on observations in the field and in transport may help preliminarily detect neurologic deficits. In patients without radiographic injury, serial reexaminations should be performed until a complete assessment is possible. In patients with radiographic evidence of a vertebral column injury, providers may also consider obtaining a magnetic resonance imaging (MRI) to directly assess for injury to the neurologic elements in addition to serial examinations.

Upon identification of a neurologic deficit, providers should attempt to classify the level of injury in an accurate and reproducible manner. The ASIA classification is a commonly employed and widely accepted modification of the Frankel grading system (Table 14.2). Within this system, the distinction of complete and incomplete injuries hinges on the presence or absence of the motor and sensory function of the lowest sacral segment (sacral sparing). Sacral sparing represents at least partial structural continuity of the white matter long tracts. Clinically, it is demonstrated by perianal sensation, rectal motor function, and great toe flexor activity. This distinction has important prognostic implications as sacral sparing has been shown to predict neurologic improvement and improved chances of regaining the ability to ambulate [17, 18].

Plain radiographs have long been mainstays in the radiographic evaluation of trauma patients due in part to their cost, wide availability, and portability. In modern trauma centers, these studies can often be obtained rapidly in the trauma bay without the need to transport a critically injured patient. Though these benefits are obvious, plain radiographs are often limited by the poor specificity and potential difficulty evaluating transitional areas of the spine such as the craniocervical and cervicothoracic junctions. In the cervical spine, the percentage of plain radiographs that provide adequate visualization ranges from 27.8 to 48 % [23, 24]. In regards to specificity, a meta-analysis comparing plain radiographs to computed tomography (CT) in the detection of cervical spine fractures demonstrated that plain radiographs were only able to identify only 52 % of injuries while 98 % were seen on CT [25]. This low specificity and difficulty obtaining adequate films coupled with increased availability of CT has limited the current use of x-ray in many modern trauma centers.

In most trauma centers, CT has replaced plain radiographs as the primary tool for evaluation of the polytrauma patient with spinal injuries because of its established role in screening for concomitant brain, visceral, or bony injuries and improved accuracy. In a prospective study comparing orthogonal radiographs of the thoracolumbar spine to helical truncal CTs, Hauser and associates demonstrated superior sensitivity and specificity as well as superior positive and negative predictive values using CT in a traumatized population [26]. CT has also been shown to require less time with similar cost compared to using plain radiographs alone in an emergency room setting when comparing patients that have inadequate x-rays performed initially or require CT secondary to neck pain [24, 27].

The use of CT as an imaging modality also helps surgeons assess the stability of various spine fractures by demonstrating better bony detail while minimizing radiographic overlap. In a cervical sagittal CT scan, a displacement of more than 3.5 mm as well as segmental kyphosis of more than 11°may account for instability [28]. A widened intervertebral space and facet joint distraction of more than 50 % represent unstable discoligamentous injury [29]. Bony avulsion injuries of the anterior or posterior portions of both upper and lower vertebral endplate might indicate a rupture of the anterior or posterior longitudinal ligaments. At C1, this accounts for bony avulsion injuries of the transverse ligament. The frontal and axial CT reconstructions should rule out rotational offset of the vertebral segment, which indicates rotational instability with special attention to the C1-2 area. In the thoracolumbar region, a loss of more than 50 % of vertebral height, sagittal angulations of more than 25°, spinal canal encroachment more than 50 %, and increased interspinous distances are associated with unstable spine injuries [30, 31]. This enhanced ability to visualize specific injury patterns helps surgeons determine and predict the success of their treatment plans.

Blunt cerebral vascular injuries (BCVI), primarily arterial dissection, may occur in association with cervical spine trauma [32]. Early diagnosis and treatment reduces morbidity (stroke) and mortality in patients with vertebral artery injuries [33, 34]. While catheter angiography has been the historic gold standard, it is invasive. Currently, routine screening with MR angiography and 16-slice CT angiography can be performed in the initial radiologic workup [35]. Trauma victims with any of the following signs or symptoms should be considered to have BCVI until proven otherwise: coma unexplained by CT; neurologic deficit, including hemiparesis, transient ischemic attack, Horner’s syndrome, oculosympathetic paresis or vertebrobasilar insufficiency, and evidence of cerebral infarction on CT; arterial hemorrhage from neck, mouth, nose, ears, large or expanding cervical hematoma, and cervical bruit in a patient younger than 50 years; fracture subluxation in cervical spine at any level, fractures from C1 to C3, and fractures into the transverse foramen at any level; and displaced mid-face fracture (LeFort II or III), basilar skull fracture with carotid canal involvement, closed head injury with consistent diffuse axonal injury, neck belt sign or significant swelling, and near hanging with anoxia [36, 37]. The timely recognition and treatment of these associated vertebral artery injuries can help prevent stroke and associated neurologic injuries.

The role of magnetic imaging in the evaluation of patients with vertebral column injuries is currently being defined. This imaging modality provides superior visualization of the disc complexes, ligaments, and the spinal cord. While the routine use of MRI may improve provider’s ability to detect purely ligamentous injuries, the clinical significance of this increased sensitivity remains in question. Stassen and associates detected 13 ligamentous injuries in 44 obtunded patients (30 %) with no evidence of injury on helical CTs. None of the injuries detected on MRI alone required more than a rigid collar for treatment [38]. In a larger study examining 1577 patients with plain films and CTs, Diaz et al. obtained MRIs in 85 patients without fracture who could not be cleared and found 14 purely ligamentous injuries that were not detected by CT. However, none of these injuries required surgical treatment [39]. While the routine use of MRI in awake, neurologically, radiographically normal patients may not prove cost effective, it should be considered in cases of neurologic injury, cervical spine clearance in the obtunded patient population and evaluation of patients with persistent midline pain, and normal CTs.