Immediate Management of the Patient with Suspected Spinal Injury
Patients with blunt trauma, particularly those with head injury, severe mechanism, or neurologic complaints should be assumed to have spine injuries until proven otherwise. Such injuries are major causes of morbidity and mortality in the trauma patient, so thorough assessment beginning in the prehospital setting is essential. The potential instability of such injuries necessitates that the utmost care be taken not to render additional harm to these patients.
Immobilization of the spine is essential to prevent further injury to the spinal cord. From the field, or when transferred, the patient should be on a long spine board, in a rigid cervical collar (Philadelphia) with lateral rolls and tape across the forehead. Upon arrival, logroll the patient off this board and onto the examination bed, maintaining in-line stabilization (see below). Careful immobilization should be maintained throughout resuscitation procedures, physical examination, and diagnostic evaluation.
The optimal position for examination and in-line immobilization is supine. Once in the emergency department, the patient’s rigid collar should be changed to a semirigid collar (Miami-J). Remember to limit the amount of time the patient is kept on any hard surface to minimize discomfort and avoid pressure injury.
If the patient cannot lie supine for any reason (eg, vomiting), the lateral position with careful in-line cervical stabilization is acceptable.
If the patient must be moved, in-line spinal stabilization should be maintained and the head and trunk rolled as one unit (logroll). Proper technique requires three individuals. The first individual stands at the head of the bed and is responsible for maintaining cervical spine immobilization and controlling the turn. The two remaining individuals stand to one side of the patient and are in charge of maintaining thoracic and lumbar spine immobilization.
As with all patients in the emergency department, initial assessment should focus on airway and breathing. However, when vertebral or spinal injury is suspected, neck alignment and immobility must be maintained during all attempts to establish adequate ventilation.
In the patient with apnea or overt respiratory failure, a definitive airway should be established immediately. Whenever possible, rapid sequence intubation is the preferred as the least traumatic and most efficient method of achieving intubation (see Chapter 10). Designate an assistant to maintain cervical spine immobilization during intubation, and minimize neck extension induced by direct laryngoscopy. Airway adjuncts such as a fiberoptic bronchoscope or videolaryngoscope, in the hands of an experienced user may further minimize neck movement. Nasotracheal intubation is an option only in the spontaneously breathing patient.
Spontaneously breathing patients with cervical spinal cord injuries can have loss of diaphragmatic and/or intercostal muscle innervation, which may cause them to tire easily, causing ineffective ventilation and progressively worsening hypoxemia and hypercapnia. In such cases, continuous pulse oximetry, close clinical observation, and serial capnography are useful adjuncts to monitor changes in ventilatory status.
Although hypotension may be caused directly by spinal injury, hypovolemia remains more common in the setting of blunt or penetrating trauma. Therefore, shock must be presumed hypovolemic (ie, hemorrhagic) until proven otherwise (see Chapter 11). If open wounds are present, significant external hemorrhage may have occurred at the scene of the injury. Hypovolemia may also occur as a result of hemorrhage into internal compartments such as the chest or pelvis. Initial treatment of hypotension should be aimed at volume replacement using crystalloid and/or blood products.
Neurogenic shock causes hypotension as a result of loss of sympathetic tone below the level of a spinal cord injury. This can occur when there is injury at or above T6. Although this diagnosis can only be made once hypovolemia has been ruled out through appropriate examination, imaging, and laboratory studies, appropriate treatment should not be withheld during the workup. The therapeutic goal for neurogenic shock is maintenance of adequate perfusion, which is commonly refractory to volume replacement. Following fluid resuscitation of at least 2 L warmed crystalloid, start a vasopressor such as dopamine to keep the mean arterial pressure above 85–90 mm Hg. Place a Foley catheter and carefully monitor urine output, which should be equal to or greater than 30 mL/h.
Head injuries are associated with approximately 25% of all patients with spinal cord injury. Patients with altered mental status, seizures, or cranial nerve or other focal neurologic deficits require emergency imaging of the brain after the initial assessment and stabilization of the ABCs. A noncontrast CT scan of the head is the study of choice to identify intracranial injuries. If the patient has only a history of loss of consciousness and is alert and oriented in the emergency department, head CT scan can be delayed and accomplished in conjunction with other CT scans that may be required to evaluate the patient with possible spinal injury.
There has been heavy debate over the clinical significance of the use of corticosteroids in the treatment of spinal injury based on the NASCIS II AND NASCIS III studies. The 8th edition of the Advanced Trauma Life Support Guidelines no longer recommends methylprednisolone administration, stating “at present, there is insufficient evidence to support the routine use of steroids in spinal cord injury.” In addition, the Canadian Association of Emergency Physicians no longer supports the use of steroids in the acute care of spinal cord injuries. It is important to note that, despite these conclusions, high-dose methylprednisolone remains a treatment option in acute blunt spinal cord injuries and remains widely utilized. If chosen as a treatment, give methylprednisolone, 30 mg/kg as an intravenous bolus over 15 minutes; after a 45-minute delay, begin a maintenance infusion of 5.4 mg/kg/h for 24 hours in patients receiving treatment within the first 3 hours after injury. Patients receiving treatment 3–8 hours after injury should be maintained on steroid therapy for 48 hours. Initiation of steroid treatment more than 8 hours after injury is not indicated. It is important to remember that there is risk associated with steroid therapy in both increased incidence of infection and avascular necrosis. Because of the often-limited information regarding time of injury in the initial emergency department evaluation, therapy may be instituted until injury time has been confirmed. Obtain specialty consultation as soon as possible.
Note: Steroids play no role in the treatment of penetrating spinal cord injuries.
Patients with penetrating spinal cord injury (eg, gunshot wound) should receive prophylactic antimicrobials. Nafcillin, 200 mg/kg/d intravenously in 4–6 divided doses, is widely recommended.
Patients may not note bladder dysfunction after spinal trauma because of loss of sensation below the lesion. Insert an indwelling catheter whenever spinal trauma is suspected to prevent urinary retention and to aid in monitoring urine output.
Paralytic ileus and gastric atony are common after spinal trauma. Give the patient nothing by mouth until spinal injury is excluded. If spinal cord injury is confirmed, a nasogastric tube connected to intermittent low-pressure suction should be placed to prevent vomiting in the acute post-injury period.
Diligent suctioning of secretions and antiemetics are essential in management of spinal trauma. Aspiration pneumonitis is a serious complication in patients with decreased respiratory function and inability to adequately protect their airway.
Denervated skin is prone to the development of pressure necrosis. Remove the spine board promptly during the evaluation while continuing to maintain logroll precautions. Completely undressing the patient will not only allow for a complete examination but it will also ensure that no foreign objects such as car keys, a belt, or wallet are pushing into the skin thereby increasing the likelihood of pressure ulcer formation.
Patients with spinal cord injury are particularly susceptible to exposure and, while exposure is essential, the patient should be covered with warm blankets in the emergency department to prevent hypothermia.
A patient with spinal cord injury requires the same resuscitative measures customarily employed in major trauma. Evaluate and treat all life-threatening conditions (eg, tension pneumothorax, cardiac tamponade, hemorrhagic shock) that take precedence over definitive treatment of vertebral and spinal cord trauma (Chapter 11). In other words, follow the ABCs of trauma evaluation. Always maintain in-line spinal immobilization during resuscitation and treatment.
Further Evaluation of the Patient with Spinal Injury
Mechanism is an essential part of the history to be obtained by the patient, EMS, or any person who witnessed the event. For instance, a restrained individual in a motor vehicle collision would be more prone to a flexion/extension injury, whereas an individual who fell and landed on his or her feet would be susceptible to compression force and subsequent vertebral damage.
Complaints of back or neck pain should arouse a suspicion of spine injury and is more sensitive than pain with palpation of the spine. However, the absence of spinal pain does not eliminate the possibility of spinal injury, especially if the patient is under the influence of alcohol or other mind-altering drugs. Consider spinal injury in any patient with blunt head injury, a neurologic deficit anatomically consistent with injury at a particular spinal level, or a penetrating injury to the neck, chest, or abdomen.
A brief general physical examination should precede specific assessment of neurologic function. Obtain complete vital signs, including core temperature.
Carefully examine the head, chest, heart, abdomen, and extremities for other abnormalities. Remember that patients with spinal cord injuries may show few, if any, signs or symptoms of coexisting major injury because of anesthesia below the level of the lesion. Pain, guarding, rebound tenderness, and other signs may be absent despite the presence of fractured ribs, hemothorax, hemoperitoneum, peritonitis, and other major injuries. Examination of the genitals, rectum, and perineum may reveal priapism, decreased or absent rectal sphincter tone, or diminished perineal sensation, which are all suggestive of spinal cord injury. Diligent, repeated examinations, laboratory tests, and appropriate radiologic imaging are necessary to detect unsuspected injury.
Gently but thoroughly examine the neck and spine for deformity, edema, ecchymosis, muscle spasm, or tenderness indicating possible vertebral fracture. A palpable defect in the posterior neck ligaments may be the only clue to major spinal injury.
Neurologic examination assesses the following functions: mentation, motor function, sensation, and brainstem and spinal reflexes.
The spectrum of mentation includes all levels of consciousness ranging from alert to comatose. The patient’s ability for mentation is best assessed by their Glascow Coma Score (Chapter 12). This systematic evaluation is easily reproduced to monitor changes, is widely used, and easily conveyed to the neurosurgical or orthopedic consultant.
(See Table 27–1.) The American Spinal Injury Association recommends the following scale for gradation of motor strength:
- 0—No contraction or movement
- 1—Minimal movement
- 2—Active movement, but not against gravity
- 3—Active movement against gravity
- 4—Active movement against light resistance
- 5—Active movement against full resistance
Normal movement means that the patient moves all extremities spontaneously, purposefully (ie, in response to specific commands), and with full strength and range of motion. This would be a 5/5 on the above scale.
Paralysis denotes no movement of the extremity or muscle group, either spontaneously or in response to painful stimuli. Complete paralysis would be a grade of 0/5 on the above scale. (Stimuli should be applied both directly to the extremity and to the trunk, because failure to move may be secondary to hypoesthesia of the extremity.) Failure to move at all, either spontaneously or in response to an unpleasant stimulus, may indicate paralysis due to a structural lesion (eg, fracture) or metabolic causes (eg, drug overdose). Often, failure to respond is simply due to an inadequately painful stimulus.
Gradation between these extremes (grade 0–5) should be described precisely, for example, “Patient extends right arm and leg, flexes left arm, and extends left leg in response to supraorbital pressure.” Avoid broad descriptive terms such as “paraparesis” or “decerebrate posturing.”
