Trauma Care and Cervical Spine Protection

Cervical Spine Injuries

• Localized edema can cause airway obstruction, and endotracheal intubation should be considered early in patients with injuries at the C5 level or above.
• Cervical spine protection equipment includes a rigid cervical collar, lateral head immobilizer, and full backboard with straps.

Circulation Management

• Patients may experience hypotension due to neurogenic or hypovolemic shock.
• Injuries at T6 or above can cause loss of sympathetic tone, leading to hypotension and bradycardia.

Pharmacologic Management

• Methylprednisolone (MP) may be administered within 8 hours of injury to reduce edema, ischemia, and prevent cellular death.

Cervical Tongs and Skeletal Fixation

• Unstable cervical fractures may be stabilized in the ED with application of cervical tongs or halo devices to provide consistent traction and minimize cord compression.

Spinal Cord Injuries

• Injuries of the vertebral column may occur with or without associated spinal cord injury.
• Spinal cord transections may be complete or incomplete, with complete transections leading to loss of all motor and sensory function below the level of the injury.
• Incomplete spinal cord transections result in partial preservation of some motor and/or sensory tracts.
• Patients with spinal cord injuries are at risk for deep venous thrombosis, decubitus ulcers, and pulmonary emboli.

Spinal and Neurogenic Shock

• Spinal shock is the loss of reflexes and motor and sensory function below the level of the injury.
• Neurogenic shock is characterized by hypotension and bradycardia, usually seen with injuries above the T6 level.

Anatomy and Physiology

• The vertebral column consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral vertebrae, and 1 coccygeal vertebrae.
• The cervical vertebrae are the most frequently injured due to their high mobility and delicate structure.
• The spinal cord consists of the posterior (dorsal) horn for sensory function, lateral horn for autonomic function, and anterior (ventral) horn for motor function.
• There are 31 pairs of spinal nerves, including 8 cervical nerves, 12 thoracic nerves, 5 lumbar nerves, 5 sacral nerves, and 1 coccygeal nerve.

Patient Assessment

• All patients with multisystem injuries or significant mechanisms of injury should be suspected of having a spinal injury and should be completely immobilized.
• Spinal protection involves manual immobilization with hands, cervical collar, lateral head support, and backboard with straps.
• The entire spine should be immobilized using a backboard with straps across the chest, abdomen, and knees.

Mechanism of Injury

• Common mechanisms of injury associated with cervical spine injuries include falls from a height greater than or equal to 3 feet or five stairs, axial loading, motor vehicle collisions at a high rate of speed with rollover or ejection, and bicycle collisions.
• Suspicion of spinal injury should be raised if the patient has a fall resulting in fractures of the heels or an unrestrained patient presents with facial injuries.

History and Inspection

• Pieces of history that may indicate a potential spinal cord injury include significant trauma, altered mental status, seizure activity, complaint of neck pain or altered sensation, neck tenderness, loss of consciousness, and incontinence.
• Obvious signs of spinal injury include deformity of the vertebral column, cervical edema, ballistic wounds, and abrasions or contusions at the level of the lap or shoulder belt.

Reflex Testing

• Biceps reflex tests C5-C6, and anal wink reflex tests S2-S4.

Radiographic Evaluation

• Cervical spine and all seven cervical vertebrae, including the C7-T1 junction, should be evaluated.
• Patients with a history of a fall or significant chest and abdominal trauma should have thoracic and lumbosacral spine films.
• Patients with an altered mental status require complete spinal radiographic evaluation.

Airway Management

• Patients with cervical spine trauma are at risk for hypoxia, respiratory arrest, and aspiration.

Incomplete Spinal Cord Injuries

• Types of incomplete spinal cord injuries include central cord syndrome, anterior cord syndrome, posterior cord syndrome, Brown-Séquard syndrome, and nerve root injuries.
• Characteristics include asymmetric reflexes, flaccid paralysis, and some preserved sensations below the level of the injury.
• Central cord syndrome causes greater loss of function in the upper extremities than in the lower extremities, and bowel and bladder function are typically maintained.
• Anterior cord syndrome results in loss of motor function and pain and temperature sensations below the level of the injury.
• Posterior cord syndrome is rare and results in impaired light touch and proprioception.
• Brown-Séquard syndrome results in ipsilateral paresis or hemiplegia and loss of motor function, touch, pressure, vibratory sense, and proprioception, and contralateral loss or decreased sensation of pain and temperature.
• Nerve root injuries include conus medullaris and cauda equina syndromes, resulting from nerve root compression.