Spinal cord trauma

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Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e >
Chapter 255. Spine and Spinal Cord Trauma
Bonny J. Baron; Kevin J. McSherry; James L. Larson Jr.; Thomas M. Scalea
Epidemiology
Trauma to the spinal column can injure the bony elements (vertebral fracture) or the neural elements (spinal
cord and nerve root injury), or both. The incidence of vertebral bone fractures is unknown, but there is better
accounting of traumatic spinal cord injury because of the creation of state and national registries.1 Data from
these organizations estimate the incidence of traumatic spinal cord injury in the U.S. to be 40 cases per million,
with a mean age of 40 years old and a male-to-female predominance of 4 to 1. Spinal injury occurs more
frequently on weekends and holidays and during summer months. The etiology of traumatic spinal cord injury
is estimated to be 42% due to motor vehicle collisions, 27% due to falls, 15% due to acts of violence
(primarily gunshot wounds), 8% from sports, and 8% from other mechanisms.
Functional Anatomy
The vertebral column is the central supporting structure for the head and trunk, and provides bony protection
for the spinal cord. This column consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused to
form the sacrum), and 4 coccygeal, which are usually fused.
Axial Vertebrae (C1 and C2)
The axial cervical vertebrae are anatomically and functionally unique. Along with the occiput, these two
vertebrae form complex articulations designed for rotary motion. The atlas (C1) consists of a ring formed by
anterior and posterior arches and two lateral masses that articulate with the occipital condyles and the vertebral
column. The axis (C2) consists of an anterior body—with a superior projection called the dens that articulates
with the inner surface of C1—and a posterior vertebral arch that encircles the spinal cord. The dens is
stabilized against the inner surface of the C1 ring by the transverse ligament.
Subaxial Vertebrae
In general, the vertebrae below C2 are fundamentally the same. In accordance with their weightbearing
function, the vertebrae become larger toward the lower end of the vertebral column. A typical vertebra is
composed of an anterior body and a posterior vertebral arch (Figure 255-1). The vertebral arch is comprised of
two pedicles, two laminae, and seven processes (one spinous, two transverse, and four articular). These
articulations enable the spine to engage in ﬂexion, extension, lateral ﬂexion, rotation, or circumduction

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(combination of all movements). The articular processes form synovial joints that act as pivots of the spinal
column. The orientation of these articular facet joints changes at different levels of the spine. Differences in
orientation of the facet joints account for variations in motion of specific regions of the vertebral column.
Figure 255-1.
Vertebral anatomy. Each vertebra consists of a vertebral body and posterior element. Vertebrae are stabilized
by an anterior longitudinal ligament, posterior ligament, and interspinous ligament.
A series of ligaments serve to maintain alignment of the spinal column. The anterior and posterior longitudinal
ligaments run along the vertebral bodies. Surrounding the vertebral arch are the ligamentum flavum and the
supraspinous, interspinous, intertransverse, and capsular ligaments. Between adjacent vertebral bodies are the
intervertebral disks, consisting of a peripheral annulus fibrosus and a central nucleus pulposus. The annulus
fibrosus is composed of fibrocartilage. The nucleus pulposus is a semifluid, gelatinous structure made up of

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water and cartilage fibers. With advancing age, the proportion of water decreases and fibrocartilage increases.
The intervertebral disks act as shock absorbers to distribute axial load. When compressive forces exceed the
absorptive capacity of the disk, the annulus fibrosus ruptures, allowing the nucleus pulposus to protrude into
the vertebral canal. This may result in spinal nerve or spinal cord compression.
Spinal Cord
The spinal cord is a cylindrical structure that begins at the foramen magnum, where it is continuous with the
medulla oblongata of the brain. Inferiorly, it terminates in the tapered conus medullaris at the lower border of
the first lumbar vertebra. The conus medullaris continues at its apex by a prolongation of pia mater, the filum
terminale, which extends to the base of the coccyx. The spinal cord gives rise to 31 pairs of spinal nerves: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve emerges through the intervertebral
foramen corresponding to the appropriate spinal cord level. During childhood growth, the vertebral column
lengthens more than the spinal cord. As a result of this inequality, the length of the nerve roots within the
spinal canal increases progressively from above downward. The lower nerve roots, inferior to the conus
medullaris, form an array of nerves around the filum terminale, called the cauda equina.
Spinal Stability
The assessment of spinal stability is an important factor in the evaluation of the injured spine. Spinal stability
is defined as the ability of the spine to limit patterns of displacement under physiologic loads so as not to
damage or irritate the spinal cord or nerve roots. Spinal stability is mostly due to the strong ligaments that
connect the vertebral bodies and arches to each other. Although simple in principle, determining spinal
stability after an acute injury is particularly difficult. Three operational methods are generally used to
judge stability following an acute injury. The first is that an injury with separation of adjacent vertebral bodies
or arches obviously has enough ligamentous disruption to be unstable. The second method uses radiography to
associate patterns of injury with the potential for instability based on clinical experience. The third method
uses the Denis three-column principle to classify injuries as stable or not.2
The three columns in the Denis system are the anterior, middle, and posterior. The anterior column is formed
by the anterior part of the vertebral body, the anterior annulus fibrosus, and the anterior longitudinal ligament.
The middle column is formed by the posterior wall of the vertebral body, the posterior annulus fibrosus, and
the posterior longitudinal ligament. The posterior column includes the bony complex of the posterior vertebral
arch and the posterior ligamentous complex. The Denis principle is that for an injury to be unstable there must
be disruption of at least two columns. One important addition to the three-column principle is the degree of
vertebral body compression; vertebral body compressions of >25% for the third to seventh cervical
vertebrae or >50% in the thoracic or lumbar vertebrae from an acute injury are generally considered
unstable.
The ligaments providing stability to the spine can be damaged without associated radiographic abnormalities.
Determining stability in cases without associated fracture can be difficult and may require dynamic testing
(flexion-extension) or MRI. Determination of stability in such circumstances is better left to the spine
consultant.
Although these concepts are useful for managing the patient, the emergency physician may not have the
benefit of all the imaging necessary nor be able to perform a complete clinical examination due to the patient
having altered mental status or other serious injuries. Therefore, standard operational principle is that any

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patient with neurologic deficits or radiographic evidence of injury should be considered to have an
unstable injury.
Cervical Spine Fractures
The exposure and mobility of the cervical spine make it particularly vulnerable to injury. Injuries result from
one or a combination of mechanisms: flexion, extension, compression (axial loading), distraction, rotation, and
lateral bending. Differences in injury patterns between the upper cervical spine (occiput to C2) and the lower,
subaxial cervical spine (C3 to C7) are due to variations in bony anatomy and ligamentous support structures in
the two regions. Harris has created a classification system for describing cervical spine injuries based on the
biomechanical forces responsible for the injury (Table 255-1).3
Table 255-1 Cervical Spine Injuries
Flexion
Anterior subluxation (hyperflexion sprain) (stable)*
Bilateral interfacetal dislocation (unstable)
Simple wedge (compression) fracture (usually stable)
Spinous process avulsion (clay-shoveler’s) fracture (stable)
Flexion teardrop fracture (unstable)
Flexion-rotation
Unilateral interfacetal dislocation (stable)
Pillar fracture
Fracture of lateral mass (can be unstable)
Vertical compression
Jefferson burst fracture of atlas (potentially unstable)
Burst (bursting, dispersion, axial-loading) fracture (unstable)
Hyperextension
Hyperextension dislocation (unstable)
Avulsion fracture of anterior arch of atlas (stable)
Extension teardrop fracture (unstable)
Fracture of posterior arch of atlas (stable)
Laminar fracture (usually stable)
Traumatic spondylolisthesis (hangman’s fracture) (unstable)
Lateral flexion
Uncinate process fracture (usually stable)
Injuries caused by diverse or poorly understood mechanisms
Occipital condyle fractures (can be unstable)
Occipitoatlantal dissociation (highly unstable)
Dens fractures (type II and III are unstable)
*Usual occurrence. Overall stability is dependent on integrity of the other ligamentous structures.

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Specific Cervical Spine Injuries
Occipital Condyle Fractures
Occipital condyle fractures are an unusual type of injury usually associated with high-velocity cervicocranial
injury. These fractures are categorized as type I (comminuted), type II (extension of a linear basilar skull
fracture), and type III (avulsion of a fragment). Occipital condyle fractures are rarely visible on plain
radiographs and usually require CT imaging for detection. Neurologic impairment is common; usually, lower
cranial nerve deficits and/or limb weakness. Patients who develop lower cranial nerve deficits or any patients
with type III occipital condyle fractures should be treated with internal fixation.
Occipitoatlantal Dissociation
In occipitoatlantal dissociation, the skull may be displaced anteriorly or posteriorly, or distracted from the
cervical spine. Occipitoatlantal dissociation frequently results in death. Severe occipitoatlantal dissociation is
easily detected on radiographs, but occipitoatlantal subluxation is more difficult to detect. A useful
measurement to detect occipitoatlantal subluxation is the basion-dental interval, the distance between the
basion and the superior cortex of the dens. This distance should normally be <8.5 mm on CT scan images, and
increases in this measurement suggest occipitoatlantal subluxation.1 Atlanto-occipital injuries are extremely
unstable.
C1 (Atlas) Fractures
Jefferson Fracture
The Jefferson fracture is usually produced when the cervical spine is subjected to an axial load, as would occur
from a direct blow to the top of the head. The occipital condyles are forced downward and produce a burst
fracture by driving the lateral masses of C1 apart (Figure 255-2). The Jefferson fracture produces outward
displacement of the lateral masses on the open-mouth odontoid radiograph. A fracture through one lateral mass
will cause unilateral displacement on the open-mouth view (Figure 255-3). Spinal instability from the
Jefferson fracture results from disruption of the transverse ligament and is likely if the lateral masses are
significantly displaced. If displacement of both lateral masses (measured as offset from the superior
corner of the C2 vertebral body on each side) is >7 mm when added together, rupture of the transverse
ligament is likely, and the spine is unstable.
Figure 255-2.

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Jefferson fracture.
Figure 255-3.

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Jefferson fracture CT and radiographs show a Jefferson burst fracture in a 46-year-old man, who sustained
injuries while body surﬁng. A. Axial CT images viewed on bone windows show bilateral fractures of both the
anterior and posterior arches of C1. B. Lateral radiograph of the cervical spine shows the fracture of the
posterior arch of C1, with slight distraction of the posterior fracture fragment. C. Open-mouth view shows
slight asymmetry of the dens in relation to the lateral masses of C1, with slight widening of the interval
between C1 and the dens. The right lateral mass of C1 is slightly subluxed laterally at the right atlantoaxial
joint.
Transverse Ligament Disruption
The transverse ligament is located anteriorly on the inside of the ring of C1 and runs along the posterior
surface of the dens. The transverse ligament is crucial to maintaining the stability of the ﬁrst and second
vertebrae. Pure ligamentous rupture without an associated fracture can occur in older patients from a direct
blow to the occiput, as would occur in a fall. Without a fracture present, radiographic diagnosis relies on
identifying the atlantodens interval, also known as the predental space, which is the space between the
posterior aspect of the anterior arch of C1 and the anterior border of the odontoid. The predental space should
be 3 mm or less in adults when measured on a lateral radiograph or 2 mm or less on CT images.2 A predental
space of >3 mm on a lateral radiograph (2 mm for CT images) implies damage to the transverse
ligament; >5 mm implies rupture of the transverse ligament.

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Avulsion Fracture of the Anterior Arch of the Atlas
A hyperextension injury may avulse the inferior pole of the anterior tubercle of C1. This is most readily
detected on the lateral view (Figure 255-4). The presence of perivertebral soft tissue swelling and absence of
cortication distinguish an avulsion fracture from the ununited secondary ossiﬁcation center of the inferior pole
of the tubercle. An isolated avulsion of the anterior tubercle is considered a stable fracture.
Figure 255-4.
Avulsion fracture of the anterior arch of the atlas.
Fracture of the Posterior Arch of the Atlas
Fracture of the posterior arch of the atlas usually results from hyperextension, with the breakage occurring
from wedging of the posterior arch between the occipital bone and the C2 vertebra. Axial compression may
also cause such compressive forces, and marked ﬂexion may produce an avulsion-type of injury to the
posterior arch. An isolated fracture of the posterior arch of the atlas is considered a stable fracture.
C2 (Axis) Fractures

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Odontoid Fractures
Fractures of the odontoid usually result from significant external forces that frequently involve other injuries to
the cervical spine and multisystem trauma. Conscious patients will usually describe immediate and severe high
cervical pain with muscle spasm aggravated by movement. The pain may radiate to the occiput. Neurologic
injury is present in 18% to 25% of cases with odontoid fractures, ranging from minimal sensory or motor loss
to quadriplegia. Odontoid fractures are classified according to the level of injury (Figure 255-5). Type I
fractures are avulsions of the tip. The transverse ligament remains attached to the dens, the fracture is stable,
and the injury carries a good prognosis. Type II fractures occur at the junction of the odontoid with the body of
C2 and are the most common type of odontoid fracture (Figure 255-6). Type III odontoid fractures occur
through the superior portion of C2 at the base of the dens. Both type II and III odontoid fractures are
considered unstable.
Figure 255-5.
Classification of odontoid fractures.
Figure 255-6.
Type II odontoid fracture. CT scans demonstrate a type II odontoid fracture with posterior ligament complex
injury in a 34-year-old woman involved in a motor vehicle crash. A. Axial CT shows oblique fracture of the
dens. B. CT sagittal reformatted image shows the dens fracture with slight anterior angulation.
Traumatic Spondylolisthesis of the Axis (Hangman’s Fracture)
The hangman’s fracture describes a fracture of both pedicles of C2. The resulting instability allows the body of
C2 to displace anteriorly on C3 (Figure 255-7). This fracture is caused by an extension mechanism and has
acquired its colloquial name from its association with judicial hangings, where the noose knot is placed under
the subject’s chin and snaps the head backward as the rope becomes taut at the end of a fall. Suicidal hangings
do not usually cause the extreme hyperextension seen in judicial hangings and are not associated with the
hangman’s fracture. The same fracture is seen in motor vehicle crashes and diving accidents, where sudden
hyperextension forces are applied in deceleration. Owing to the large diameter of the spinal canal at the level
of C2, even displacement of C2 on C3 may not cause neurologic injury, and patients may be neurologically
intact.
Figure 255-7.
Hangman’s fracture.
Lower Cervical Spine (C3 to C7) Fractures
The Denis three-column model of the spine is useful when assessing stability of fractures involving the third to
seventh cervical vertebrae. Instability of the anterior column can occur when the anterior 20% of the vertebral

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body is damaged by compression, such as that seen with a teardrop fracture. Loss of 25% or more of the
vertebral body height also is a marker of anterior column instability. Loss of integrity of the posterior wall of a
vertebral body is a marker for instability in the middle column and is visualized by detecting sagittal plane
fracture lines through the posterior vertebral body cortex or loss of >25% of posterior vertebral body height.
Instability of the posterior column can result from damage to the facet complex, and associated radiographic
findings include fractures through the facet and widening of the pedicles.4
Anterior Subluxation
Anterior subluxation, also known as hyperflexion sprain, produces ligamentous failure in the interspinous
and/or posterior longitudinal ligament. An isolated subluxation injury has no associated fractures.
Radiographic findings may be absent. Significant ligamentous injury can display anterior soft tissue swelling, a
“fanning” or widening of the spinous processes at the level of injury, and posterior widening of the
intervertebral space. The cervical disk spaces should have a variation in alignment of <11 degrees between
adjacent spaces; a variation of more than this may also signal a ligamentous injury. Anterior subluxation
injuries are usually stable, depending on the integrity of the posterior ligaments.
Simple Wedge Fracture
A vertebral wedge fracture is caused by compression between two other vertebral bodies. Normally the
superior end plate of the vertebral body fractures while the inferior end plate remains intact. The posterior
ligaments may be disrupted and increase the distance between the spinous processes. An isolated simple
wedge fracture is stable, but the presence of significant posterior ligamentous disruption can make the injury
unstable. A simple wedge fracture is differentiated from a burst fracture by the absence of a vertical fracture of
the vertebral body.
Flexion Teardrop Fracture
Extreme flexion can produce the flexion teardrop fracture complex. The “teardrop” is the anteroinferior portion
of the vertebral body that is separated and displaced from the remaining portion of the vertebral body. There is
also complete disruption of the ligamentous structures at the level of injury. The anterior spinal cord syndrome
is associated with this injury presumably because of impingement of the spinal cord on the fracture-induced
hyperkyphosis. This injury is highly unstable.
Spinous Process Avulsion (Clay-Shoveler’s) Fracture
Avulsion off the end of one of the lower cervical spinous processes, classically C7, is known as a clay-
shoveler’s fracture. This injury is caused by intense flexion against a contracted posterior erector spinal muscle
that fractures the tip of the spinous process. An isolated spinous process avulsion fracture is mechanically
stable.
Unilateral Interfacetal Dislocation
Simultaneous forces of flexion and rotation can produce unilateral facet dislocation, where the articular mass
and inferior facet on one side of the vertebra is anteriorly dislocated. On a lateral view, the involved vertebral
body will be displaced <50% of its width. On anterior view, there is rotation of the involved vertebra, with the

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affected spinous process pointing toward the side that is dislocated. This dislocation is mechanically stable
unless there is a concomitant fracture either at the base of the inferior articular mass of the dislocated vertebra
or at the base of the superior articular mass of the vertebra below.
Bilateral Interfacetal Dislocation
Bilateral interfacetal dislocation occurs when disruption of all ligamentous structures due to hyperflexion
allows the articular masses of one vertebra to dislocate superior and anteriorly into the intervertebral foramen
of the vertebra below. On radiographs, the vertebral body is dislocated anteriorly at least 50% of its width
(Figure 255-8). These injuries are unstable and usually present with neurologic deficits. In partial bilateral
interfacetal dislocation, the inferior articular masses of the dislocated vertebra are “perched” on the superior
articular processes of the vertebra below. These patients may not have neurologic deficits. The term locked
facets or perched facets—both of which imply a degree of stability—to describe bilateral interfacetal
dislocation is misleading because this injury is unstable regardless of the radiographic appearance.
Figure 255-8.
Bilateral interfacetal dislocation injuries incurred by a 32-year-old man following a head-on collision while
playing football. A. Lateral radiograph and CT with (B) axial, (C) sagittal, and (D) three-dimensional
reconstruction, show a C3-C4 subluxation with bilateral locked facet joints.
Pillar or Pedicolaminar Fracture
A pillar fracture is an isolated vertical or oblique fracture through the lateral mass composed of the superior
and inferior articular processes. The adjacent lamina and pedicle remains intact. The mechanism that produces
a pillar fracture is extension and rotation with impaction of a superior vertebra on the articular surface of its
inferior neighbor. The fractured articular mass is displaced posteriorly and may be visible as a double outline
on the lateral radiograph. Normally, the right and left articular masses are superimposed on one another, and
one radiographic outline is seen in the lateral view. When one is displaced, the two outlines are no longer
superimposed and display as a double image. Pillar fractures may or may not be stable, depending on the
degree of ligamentous damage.
Burst Fracture
A direct axial load may cause a burst fracture of the lower cervical vertebra, with fragments displacing in all
directions (Figure 255-9). The spinal cord may be injured if a fragment enters the spinal canal. The lateral
radiograph may show fracture of the superior and inferior end plates, and retropulsion of the posterior portion
of the vertebral body into the spinal canal. The anterior radiographic view will show a vertical fracture through
the vertebral body and widening of the interpedicular distance. This injury is unstable.
Figure 255-9.
Burst fracture. A. CT and (B) MRI demonstrate a C7 burst fracture with cord compression in a 19-year-old
man involved in a motorcycle crash.

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Hyperextension Dislocation
An extreme hyperextension injury involves a complete tear of the anterior longitudinal ligament and
intervertebral disk, with disruption of the posterior ligamentous complex. Patients usually present with facial
trauma and a central cord syndrome. On the lateral radiographic view, the vertebrae may be normally aligned
because the dislocation is reduced by the routine use of cervical immobilization collars, but diffuse
prevertebral soft tissue swelling is usually present. Other radiographic signs include anterior disk space
widening or fracture of the anteroinferior end plate of the vertebral body. These fractures are unstable.
Extension Teardrop Fracture
Hyperextension may cause the anterior longitudinal ligament to avulse a fragment off the anteroinferior corner
of the vertebral body. The height of the avulsed fragment usually exceeds its width. This fracture is more
common in older patients with osteoporosis. The extension teardrop fracture is unstable in extension.
Laminar Fracture
Isolated laminar fractures are caused by hyperextension and may be associated with spinous process fractures.
Laminar fractures are difficult to visualize on plain radiographs and usually require CT for diagnosis.
Uncinate Process Fracture
The lateral superior edges of the vertebral body form bilateral ridges, called the uncinate processes. These
processes are found on the C3 to T1 vertebrae. Extreme lateral flexion may cause a transverse fracture at the
base of the uncinate process. Uncinate process fractures usually present with ipsilateral neurologic deficits, and
other cervical spine fractures are common. Isolated uncinate process fractures are usually stable.
Thoracic and Lumbar Spine Fractures
Thoracic Spine (T1 to T10)
The thoracic spine is a rigid segment, with its stiffness enhanced 2.5 times by articulation with the rib cage.
Relative to other regions of the vertebral column, a large force is necessary to overcome the intrinsic stability
of the thoracic spine. Although injury to the thoracic spine is less common than in other regions, the presence
of a thoracic vertebral injury indicates that severe forces were present. The spinal canal in the thoracic region
is narrower than that found in either the cervical or lumbar spine. This narrowing relative to the spinal cord
diameter increases the risk of cord injury. When spinal cord injuries occur in the thoracic region, most are
neurologically complete. There is an important association between fractures of the thoracic spine and
intrathoracic injuries. Patients with blunt chest trauma and mediastinal widening should be evaluated for
both aortic and thoracic spine injuries.
Thoracolumbar Junction (T11 to L2)
The thoracolumbar junction (T11 to L2) is considered a transitional zone between the highly fixed thoracic and
relatively mobile lumbar regions. This distinction is important because the transitional zones sustain the

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greatest amount of stress during motion and are most vulnerable to injury. In addition to this change in bone
anatomy, the thoracolumbar junction serves as the level of transition from the end of the spinal cord (about L1)
to the nerve roots of the cauda equina. Relative to the thoracic spine, the width of the spinal canal in the
thoracolumbar region is greater. Therefore, despite a large number of vertebral injuries at the thoracolumbar
junction, most do not have neurologic deficits, or, if present, they are partial or incomplete.
Lumbar Spine (L3 to L5)
Relative to the thoracic and thoracolumbar regions, the lower lumbar spine is more mobile. Because of the
width of the spinal canal in the lumbar region and the ending of the spinal cord at the L1 level, isolated
fractures of the lower lumbar spine rarely injure the spinal cord or result in neurologic injury. When neurologic
injuries occur, they are usually complete cauda equina lesions or isolated nerve root deficits.
Specific Thoracic and Lumbar Spine Fractures
Fractures of the thoracolumbar spine can be divided into minor and major injuries (Table 255-2). Minor
injuries are those that are localized to part of a column and do not cause instability. These fractures often result
from direct blunt trauma to the posterior elements of the spine. Often, these injuries are found when CT is used
to evaluate for potential intra-abdominal injury.
Table 255-2 Thoracic and Lumbar Spine Fractures
Minor Injuries Major Injuries
Transverse process fracture Compression (wedge) fractures
Spinous process fracture Burst fractures
Pars interarticularis fractures Flexion-distraction (“seat-belt”) injuries
Fracture-dislocation (translation) injuries
Compression fractures result from axial loading and flexion, with subsequent failure of the anterior column
(Figure 255-10). The middle column remains intact. These injuries are usually stable unless they produce
>50% decrease in vertebral body height. Compression fractures are unlikely to be directly responsible for
neurologic damage.
Figure 255-10.
Wedge compression fracture. Wedge compression fractures are often caused by axial unloading with failure of
the anterior column. A. Schematic of a compression fracture. B. Lateral reconstruction CT scan demonstrates
the anterior wedging. C. Axial CT scan demonstrates the anterior wedging and vertebral body fracture. Note
the lack of retropulsion of elements into the spinal canal.
Burst fractures occur following failure of the vertebral body under axial load (Figure 255-11). In contrast to
compression fractures, both the anterior and middle columns fail. There is retropulsion of bone and disk
fragments into the canal that may cause spinal cord compression. Burst fractures are considered unstable.
Figure 255-11.

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Burst fracture. Burst fractures are also caused by axial loading. Both anterior and middle columns have failed.
A. Schematic of the forces transmitted. B. Lateral reconstruction CT scan demonstrates failure of both the
anterior and middle columns. C. Axial CT scan demonstrates the burst vertebral body. Note the retropulsion of
elements into the spinal canal.
Flexion-distraction injuries are commonly seen following seat belt–type injuries, particularly those in which
lap belts alone are used (Figure 255-12). The seat belt serves as the axis of rotation during distraction, and
there is failure of both the posterior and middle columns. The intact anterior column prevents subluxation.
Typical radiographic findings reveal increased height of the posterior vertebral body, fracture of the posterior
wall of the vertebral body, and posterior opening of the disk space. Flexion-distraction injuries are considered
unstable. A variant of flexion-distraction injuries is the Chance fracture, a fracture complex that presents with
minor anterior vertebral compression and significant distraction of the middle and posterior ligamentous
structures; usually including the interspinous ligament, ligamentum flavum, facet capsule, posterior annulus,
and thoracodorsal fascia. These injuries are often misdiagnosed as an anterior compression fracture, but
whether or not a fracture is present, all three supporting columns are distracted, and this injury is unstable. The
presence of an anterior compression fracture in the thoracolumbar transition zone (T11 to L2) in a restrained
young patient following a motor vehicle collision should suggest the possibility of a Chance fracture.
Figure 255-12.
Flexion-distraction injuries. Flexion-distraction injuries involve rotation of forces. This results in failure of
both the posterior and middle columns. A. Schematic of the forces transmitted. B. Lateral view of plain film
demonstrating a flexion distraction injury. C. Lateral CT reconstruction confirming the pattern, also
demonstrating posterior opening of the disk space. D. Axial CT scan shows loss of the middle column with
fracture through the lateral elements.
Fracture-dislocations are the most damaging of injuries (Figure 255-13). Compression, flexion, distraction,
rotation, or shearing forces lead to failure of all three columns. The end result is subluxation or dislocation
with a grossly unstable spine (Figure 255-14).
Figure 255-13.
Fracture-dislocation injuries. Fracture dislocations are the most damaging of injuries leading to failure of all
three columns. A. Schematic demonstration of these injuries. B. Lateral CT reconstruction demonstrates loss
of all three columns. C. Axial CT scan demonstrates the dislocation and displacement of the vertebral body.
Figure 255-14.
Fracture-dislocation injury CT with (A) axial, (B) sagittal, and (C) three-dimensional reconstructions shows a
T10-T11 fracture-dislocation in a 37-year-old man who sustained a 20-ft fall.
Sacrum and Coccyx Fractures

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The sacrum supports the lumbar vertebral column and transmits loads from the trunk to the pelvic girdle and
into the lower limbs. The upper border articulates with the fifth lumbar vertebra, and the inferior border
articulates with the coccyx. Laterally, the sacrum articulates with the iliac bones to form the sacroiliac joints.
The vertebral foramina together form the sacral canal that contains the nerve roots of the lumbar, sacral, and
coccygeal spinal nerves and the filum terminale. The coccyx, which articulates with the sacrum, consists of
four vertebrae fused together. Except for the first vertebra, the remaining coccygeal vertebrae consist of bodies
only.
Injuries of the sacral spine and nerve roots are very unusual. When they occur, they are frequently associated
with fractures of the pelvis. There are multiple different classification schemes of sacral fractures that help to
predict neurologic deficits and establish treatment protocols. In general, transverse fractures through the body
are most significant in that they cause injury to part or all of the cauda equina. Longitudinal fractures may
cause radiculopathy. Sacral fractures that involve the central sacral canal can produce bowel or bladder
dysfunction.5
Coccygeal injuries are usually associated with a direct fall onto the buttocks. Patients typically describe intense
pain with sitting and straining. Diagnosis of a coccyx fracture is made on rectal examination by eliciting pain
with motion of the coccyx. Imaging is not needed to diagnose coccygeal fractures. Treatment is symptomatic
with analgesics and use of a rubber doughnut pillow.
Mechanism of Injury
Motor vehicle crashes are the principal cause of injury to the spinal cord in developed countries. Other
etiologies, in descending order of frequency, include falls, gunshot wounds, and injuries secondary to sports or
recreational activities. Obvious neurologic deficits identify an unstable injury and the need for emergent
treatment. In the absence of deficits, the mechanism of injury with an understanding of the forces involved can
guide management.
Blunt Injury
Motor Vehicle-Related Injuries
Motor vehicle crashes usually produce acceleration-deceleration injuries. The cervical spine is the most
susceptible to injury by this mechanism, but the thoracic and lumbar regions are also at risk. The majority of
patients seen in the ED for spine trauma following a motor vehicle crash are involved in low-impact crashes
with primarily soft tissue injuries. Patients usually describe pain in the posterior neck and back. High-speed,
high-energy crashes are more likely to result in structural damage to the spine. Lap-only seat belts are
associated with thoracolumbar injuries.
Pedestrians struck by vehicles and motorcyclists are at considerable risk for multiple skeletal injuries,
including spinal injuries.
Falls
Falls from a height produce axial loading forces and are associated with fractures of the lower extremities,
pelvis, and spine. The most common site of spinal injury from a fall is the thoracolumbar junction. These

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fractures can he highly unstable with significant distraction (Figure 255-13).
Sports Injuries
The specific spinal injury from a sport is more related to the mechanism, the force involved, and the point of
application of the force, rather than to the specific sport. The majority of injuries are self-limiting soft tissue
injuries. Sports-related injuries can also damage the intervertebral disk and produce disk herniation or
degeneration. Injuries to bone can range from minimal avulsion-type fractures to compressions or fracture
dislocations. Most bone injuries are not associated with neurologic sequelae. When neurologic impairment
occurs, it is usually secondary to direct axial forces. Catastrophic spinal injuries have been associated with
contact sports (e.g., football, rugby, lacrosse, and ice hockey) and sports with the potential for falls and
collision with solid objects (e.g., gymnastics and diving) (Figure 255-14).6
Penetrating Injury
Most penetrating spinal cord lesions are caused by gunshot wounds. These wounds may be localized to the
spine or may involve transperitoneal trajectories. The spinal cord may be injured by direct contact with the
bullet, by bone fragments, or from concussive forces.7 Most gunshot wounds result in stable vertebral injuries,
although associated spinal cord lesions are often complete. Stabbing injuries to the spinal cord are much less
common. These may be inflicted by a variety of implements, including knives, axes, ice picks, screwdrivers,
and glass fragments. The majority of stab wounds that injure the spinal cord produce incomplete Brown-
Séquard lesions in the thoracic section. Among incomplete spinal cord injuries, the prognosis for patients with
stab injuries to the spine and incomplete paralysis is significantly better than for patients with gunshot wounds
to the spine and a similar extent of paralysis.
Spinal Cord Injuries
Damage to the spinal cord is the result of two types of injury. First is the direct mechanical injury from
traumatic impact. This insult sets into motion a series of vascular and chemical processes that lead to
secondary injury. The initial phase is characterized by hemorrhage into the cord and formation of edema at the
injured site and surrounding region. Local spinal cord blood flow is diminished owing to vasospasm and
thrombosis of the small arterioles within the grey and white matter. Extension of edema may further
compromise blood flow and increase ischemia. A secondary tissue degeneration phase begins within hours of
injury. This is associated with the release of membrane-destabilizing enzymes, mediators of inflammation, and
disturbance of electrophysiologic coupling by disruption of calcium channel pathways. Lipid peroxidation and
hydrolysis appear to play a major role in this secondary phase of spinal cord injury.
Spinal Cord Lesions
The severity of spinal cord injury determines the prognosis for recovery of function, so it is important to
distinguish between complete and incomplete spinal cord injuries. Complete lesions have a minimal chance of
functional motor recovery. Patients with incomplete lesions are expected to have at least some degree of
recovery. The American Spinal Injury Association defines a complete neurologic lesion as the absence of
sensory and motor function below the level of injury. This includes loss of function to the level of the
lowest sacral segment. In contrast, a lesion is incomplete if sensory, motor, or both functions are partially

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present below the neurologic level of injury. This may consist only of sacral sensation at the anal
mucocutaneous junction or voluntary contraction of the external anal sphincter upon digital examination. The
differentiation between complete and incomplete spinal cord damage may be complicated by the presence of
spinal shock. Patients in spinal shock lose all reflex activities below the area of injury, and lesions cannot
be deemed complete until spinal shock has resolved.
There are four distinct incomplete spinal cord syndromes identified by predictable physical examination
findings (Table 255-3).
Table 255-3 Incomplete Spinal Cord Syndromes
Syndrome Etiology Symptoms Prognosis*
Anterior
cord
Direct anterior
cord compression
Complete paralysis below the lesion with loss of pain and
temperature sensation
Poor
Flexion of cervical
spine
Preservation of proprioception and vibratory functionThrombosis of
anterior spinal
artery
Central
cord
Hyperextension
injuries
Quadriparesis—greater in the upper extremities than the lower
extremities. Some loss of pain and temperature sensation, also
greater in the upper extremities
Good
Disruption of
blood flow to the
spinal cord
Cervical spinal
stenosis
Brown-
Séquard
Transverse
hemisection of the
spinal cord Ipsilateral spastic paresis, loss of proprioception and vibratory
sensation, and contralateral loss of pain and temperature sensation
Good
Unilateral cord
compression
Cauda
equina
Peripheral nerve
injury
Variable motor and sensory loss in the lower extremities, sciatica,
bowel/bladder dysfunction, and “saddle anesthesia”
Good
*Outcome improves when the effects of secondary injury are prevented or reversed.
A large number of descending and ascending tracts have been identified in the spinal cord. The three most
important of these in terms of neuroanatomic localization of cord lesions are the corticospinal tracts,
spinothalamic tracts, and dorsal (posterior) columns.
The corticospinal tract is a descending motor pathway. Its fibers originate from the cerebral cortex through
the internal capsule and the middle of the crus cerebri. The tract then breaks up into bundles in the pons and
finally collects into a discrete bundle, forming the pyramid of the medulla. In the lower medulla,
approximately 90% of the fibers cross (decussate) to the side opposite that of their origin and descend through
the spinal cord as the lateral corticospinal tract. These fibers synapse on lower motor neurons in the spinal
cord. The 10% of corticospinal fibers that do not decussate in the medulla descend in the anterior funiculus of
the cervical and upper thoracic cord levels as the ventral corticospinal tract. Damage to the corticospinal tract

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neurons (upper motor neurons) in the spinal cord results in ipsilateral clinical findings such as muscle
weakness, spasticity, increased deep tendon reflexes, and a Babinski’s sign.
The two major ascending pathways that transmit sensory information are the spinothalamic tracts and the
dorsal columns. The first neurons of both of these afferent systems begin as sensory receptors situated in the
skin and stretch receptors of muscles. Their cell bodies are located in the dorsal root ganglia of the spinal
nerves. The spinothalamic tract transmits pain and temperature sensation. As the axons of the first neurons
enter the spinal cord, most ascend one or two levels before entering the dorsal grey matter of the spinal cord,
where they synapse with the second neuron of the spinothalamic tract. The second neuron immediately crosses
the midline in the anterior commissure of the spinal cord and ascends in the anterolateral funiculus as the
lateral spinothalamic tract. When the spinothalamic tract is damaged in the spinal cord, the patient
experiences loss of pain and temperature sensation in the contralateral half of the body. The (pain and
temperature) sensory loss begins one or two segments below the level of the damage.
The dorsal columns transmit vibration and proprioceptive information. Neurons enter the spinal cord proximal
to pain and temperature neurons. They differ from pain and temperature neurons in that they do not
immediately synapse in the spinal cord. Instead, these axons enter the ipsilateral dorsal column and do not
synapse until they reach the gracile or cuneate nuclei of the medulla. From these nuclei, fibers cross the
midline and ascend in the medial lemniscus to the thalamus. Injury to one side of the dorsal columns will result
in ipsilateral loss of vibration and position sense. The sensory loss begins at the level of the lesion. Light touch
is transmitted through both the spinothalamic tracts and the dorsal columns. Therefore, light touch is not
completely lost unless there is damage to both the spinothalamic tracts and the dorsal columns.
Each spinal nerve is named for its adjacent vertebral body. In the cervical region, there is an additional pair of
spinal nerve roots compared to the number of vertebral bodies. The first seven spinal nerves are named for the
first seven cervical vertebrae, each exiting through the intervertebral foramen above its corresponding vertebral
body. The spinal nerve exiting below C7, however, is referred to as the C8 spinal nerve, although no eighth
cervical vertebra exists. All subsequent nerve roots, beginning with T1, exit below the vertebral body for
which they are named.
During fetal development, the downward growth of the vertebral column is greater than that of the spinal cord.
Because the adult spinal cord ends as the conus medullaris at the level of the lower border of the first lumbar
vertebra, the lumbar and sacral nerve roots must continue inferiorly below the termination of the spinal cord to
exit from their respective intervertebral foramina. These nerve roots form the cauda equina. A potential
consequence of this arrangement is that injury to a single lower vertebra can involve multiple nerve roots in
the cauda equina. For example, an injury at the L3 vertebra can involve the L3 nerve root as well as the lower
nerve roots that are progressing to a level caudal to the L3 vertebra.
Anterior Cord Syndrome
The anterior cord syndrome results from damage to the corticospinal and spinothalamic pathways, with
preservation of posterior column function. This is manifested by loss of motor function and pain and
temperature sensation distal to the lesion. Only vibration, position, and crude touch are preserved. This
syndrome may occur following direct injury to the anterior spinal cord. Flexion of the cervical spine may
result in cord contusion or bone injury with secondary cord injury. Alternatively, thrombosis of the anterior
spinal artery can cause ischemic injury to the anterior cord. Anterior cord injury can also be produced by an
extrinsic mass that is amenable to surgical decompression. The overall prognosis for recovery of function

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historically has been poor and remains so today.6
Central Cord Syndrome
The central cord syndrome is usually seen in older patients with preexisting cervical spondylosis who sustain a
hyperextension injury. As named, this injury preferentially involves the central portion of the cord more than
the peripheral. The centrally located fibers of the corticospinal and spinothalamic tracts are affected. The
neural tracts providing function to the upper extremities are most medial in position compared with the
thoracic, lower extremity, and sacral fibers that have a more lateral distribution. Clinically, patients with a
central cord syndrome present with decreased strength and, to a lesser degree, decreased pain and
temperature sensation, more in the upper than the lower extremities. Spastic paraparesis or spastic
quadriparesis can also be seen. The majority will have bowel and bladder control, although this may be
impaired in the more severe cases. Prognosis for recovery of function is good; however, most patients do not
regain fine motor use of their upper extremities.
Brown-SéQuard Syndrome
The Brown-Séquard syndrome results from hemisection of the cord. It is manifested by ipsilateral loss of
motor function, proprioception, and vibratory sensation, and contralateral loss of pain and temperature
sensation. The most common cause of this syndrome is penetrating injury. It can also be caused by lateral cord
compression secondary to disk protrusion, hematomas, bone injury, or tumors. Of all of the incomplete cord
lesions, Brown-Séquard syndrome has the best prognosis for recovery.
Cauda Equina Syndrome
The cauda equina is composed entirely of lumbar, sacral, and coccygeal nerve roots. An injury in this region
produces a peripheral nerve injury rather than a direct injury to the spinal cord. Symptoms may include
variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and
“saddle anesthesia” (loss of pain sensation over the perineum). Because peripheral nerves possess the
ability to regenerate, the prognosis for recovery is better than that for spinal cord lesions.
Neurogenic Shock
Injury to the spinal cord at the level of the cervical or thoracic vertebrae causes peripheral sympathetic
denervation. The loss of sympathetic arterial tone results in decreased systemic vascular resistance and blood
pressure. Loss of sympathetic innervation to the heart (T1 through T4 cord levels) leaves the parasympathetic
cardiac innervation via the vagus nerve unopposed, resulting in bradycardia, or an absence of reflex
tachycardia. In general, patients with neurogenic shock are warm, peripherally vasodilated, and
hypotensive with a relative bradycardia. Patients tend to tolerate hypotension relatively well, as peripheral
oxygen delivery is presumably normal. Bradycardia is characteristic but not universal. Loss of sympathetic
tone and subsequent inability to redirect blood from the periphery to the core may cause excessive heat loss
and hypothermia.8
The diagnosis of neurogenic shock should be one of exclusion. Certain clues—such as bradycardia and warm,
dry skin—may be evident, but hypotension in the trauma patient can never be presumed to be caused by

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neurogenic shock until other possible sources of hypotension have been excluded.9 A large percentage of
patients will have significant concomitant injuries, with blood loss as the cause of their hypotension.9,10 A
search for hemorrhage should be conducted before hypotension can be attributed solely to neurogenic shock.
Treatment of Neurogenic Shock
Loss of sympathetic innervation during neurogenic shock results in blood pooling in the distal circulation.
Infusion of IV crystalloid will correct this relative hypovolemia. Adequate fluid resuscitation should be
undertaken, with the aim of keeping the mean arterial blood pressure at 85 to 90 mm Hg for the first 7 days
after acute spine injury.11 Though a bit arbitrary, it has been determined by collective clinical experience that
this level of pressure provides adequate perfusion and minimizes the effects of secondary cord injury.12 The
aggressive use of fluids in neurogenic shock should be performed with careful monitoring, as there is danger of
excessive fluid replacement, with resultant heart failure and pulmonary edema.13 The placement of a
pulmonary artery catheter and its resultant pressure measurements can be of tremendous benefit in helping to
prevent excess fluid administration. If IV fluids are not adequate to maintain organ perfusion, positive
inotropic pressor agents may be beneficial adjuncts to improve cardiac output and raise perfusion
pressure.14 Optimal combinations and doses of these agents are variable and should be titrated to the patient’s
hemodynamic response.
Bradycardia, when present, usually occurs within the first few hours or days after spinal cord injury because of
a predominance of vagal tone to the heart. In cases of hemodynamically significant bradycardia, atropine may
be needed. In rare instances, patients will have an atrioventricular conduction block, with significant
bradycardia requiring a pacemaker.
Spinal Shock
The syndrome neurogenic shock must be differentiated from spinal shock; the two terms have very different
meanings and are not interchangeable. Spinal shock refers to the temporary loss or depression of spinal
reflex activity that occurs below a complete or incomplete spinal cord injury. The lower the spinal cord
injury, the more likely that all distal reflexes will be absent.15 Loss of neurologic function that occurs with
spinal shock can cause an incomplete spinal cord injury to mimic a complete cord injury. Therefore, cord
lesions cannot be deemed complete until spinal shock has resolved. The bulbocavernosus reflex is among the
first to return as spinal shock resolves. The duration of spinal shock is variable; it generally persists for days to
weeks.
General Approach to Patients with Spinal Injury
Prehospital Care
The prehospital treatment of patients with spinal injury involves recognition of patients at risk, appropriate
immobilization, and triage to an appropriate facility (see Chapter 1, Emergency Medical Services, and Chapter
2, Prehospital Equipment and Adjuncts). A basic EMS principle is that patients who have complaints of neck
or back pain or who have tenderness on prehospital assessment should be presumed to have a spine injury until

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proven otherwise. In addition, patients with significant injury above the clavicles are also presumed to have
cervical spine injury, regardless of related complaints. Also, patients with neurologic complaints should be
presumed to have a spinal cord injury. Sometimes this is obvious, as in a patient with flaccid paraplegia. More
often, symptoms are much more subtle (numbness or tingling in an extremity). Transport to an appropriate
facility is important, as the outcome of treatment of these injuries is somewhat time related. Therefore, initial
triage to a center that is capable of rapid diagnostics and therapeutics is important to optimize outcome
following spinal injury.
Field assessment can be difficult. Patients may have a concomitant head injury that makes them unable to
describe their injuries and hence does not allow for neurologic assessment. Other injuries may preclude
accurate neurologic assessment. The mechanism of injury is an important criterion on which prehospital
providers can rely. High-speed or rollover vehicular crashes, falls from a substantial height (injuries to the
thoracolumbar junction), and diving and surfing accidents typically produce cervical spine injuries. A patient at
risk by mechanism of injury may also be presumed to have a spinal cord injury. Although this may result in a
substantial rate of overtriage, this is acceptable because the consequences of undertriage can be devastating.
Prehospital care for spinal injuries involves immobilization of the entire spine at the scene, with
immobilization maintained during transport. The cervical spine can be immobilized with a rigid cervical collar
supplemented with external rigid objects placed bilaterally (e.g., sandbags or solid foam blocks) and with tape
or self-adhesive straps applied across the forehead to hold the head to the backboard. The thoracic and lumbar
spine can be immobilized using a long backboard, and patients are usually “papoosed” onto the board to
maintain spinal alignment during transport. As described, efforts should be made to transport patients with
symptomatic spinal injuries to the regional spine center to avoid delays engendered by initial transport to a
different site that may result in delays to definitive care.
ED Stabilization
ED evaluation of the patient with potential spinal injury should not differ substantially from that of any patient
with multiple injuries. Consideration should be given to immediate airway control in patients with cervical
spine injuries, no matter how apparently stable at the time of presentation. The higher the level of spinal injury,
the more compelling the indication for early airway intervention. The roots of the phrenic nerve, which supply
the diaphragm, emerge at the third, fourth, and fifth cervical vertebral levels. Thus, any patient with an
injury at C5 or above should have his or her airway secured via endotracheal intubation. It may be
prudent to intubate patients with cervical cord lesions even below this level. Significant spinal cord edema may
progress rostrally to involve the roots of the phrenic nerve. Many patients can initially support ventilatory
function utilizing intercostal muscles or abdominal breathing, but they eventually tire and subsequently
develop respiratory failure.
If possible, the neurologic assessment should be performed before patients are intubated and sedated. Spinal
immobilization should be maintained while securing the airway. This is usually accomplished using
orotracheal intubation with in-line cervical stabilization (without distraction force) and cricoid pressure.
Injudicious motion of an unstable cervical spine fracture can worsen or produce spinal cord injury.
Hypotension is initially treated with IV crystalloid. Because hypotension in patients with spinal cord injuries
may be due to neurogenic shock, blood loss, cardiac injury, or a combination, it should never be assumed that
a patient with hypotension and bradycardia is suffering from isolated neurogenic shock. Vital signs cannot be
relied upon to differentiate among these causes; patients in hemorrhagic shock with intraperitoneal bleeding
may have a vagal response and not be able to mount a tachycardic response. Blood loss should be presumed

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to be the cause of hypotension until proven otherwise. More than 90% of hypotensive patients with
penetrating spinal cord injury have blood loss to at least partly explain their hypotension.9,10
Patients with spinal injury can have associated intrathoracic, retroperitoneal, intraperitoneal, or pelvic
hemorrhage. A chest radiograph will usually identify significant blood loss within the thorax. Retroperitoneal
bleeding may occur with concomitant pelvic fractures or may be secondary to lumbar arterial bleeding from
spine fractures, especially in patients with substantial falls from a height. Retroperitoneal bleeding should be
suspected in patients without evidence of intra-abdominal blood loss who develop abdominal distention or
tenderness.16 Retroperitoneal hemorrhage is usually found on CT scanning. Intraperitoneal hemorrhage is
usually associated with solid organ damage and may be detected by sonographic or CT imaging. Pelvic
hemorrhage can be more difficult to diagnose and treat; angiography may be necessary for both diagnosis and
treatment of active bleeding.
Neurologic Examination
Once patients are stabilized and other life-threatening injuries have been excluded or treated, a detailed
neurologic assessment should be performed. Details of history include whether the patient has had a loss of
consciousness or other neurologic symptoms at the scene. A patient who was asymptomatic in the field and
experiences subsequent neurologic deterioration in the ED requires emergent assessment. The presence of
urinary or fecal incontinence or priapism identifies a patient at high risk for spinal cord injury.
Physical examination should delineate the level of spinal cord injury (Figure 255-15). An appropriately
detailed initial neurologic examination is important to allow for comparison later should a patient deteriorate.
The presence or absence of neck or back tenderness should be noted. Motor function for muscle groups should
be tested (Table 255-4). The level of sensory loss should be determined (Figure 255-16). Proprioception or
vibratory function should be investigated to examine posterior column function. Deep tendon reflexes should
be tested. Anogenital reflexes should also be tested because “sacral sparing” with preservation of the
reflexes denotes an incomplete spinal cord level, even if the patient has complete sensory and motor loss.
To test the bulbocavernosus reflex, the penis is squeezed to determine whether the anal sphincter
simultaneously contracts. Rectal tone can be assessed at the same time. The cremasteric reflex is tested by
running a pin or a blunt instrument up the medial aspect of the thigh. If the scrotum rises, there is some spinal
cord integrity. The area around the anus should be tested with a pin. An “anal wink reflex” (contraction of the
anal musculature) indicates at least some sacral sparing. Conversely, priapism implies a complete spinal cord
injury.
Figure 255-15.
Spinal cord level. The spinal cord level of injury can be delineated by physical examination, including a
detailed neurologic examination.
Table 255-4 Motor Grading System
Grade Movement
0 No active contraction
1 Trace visible or palpable contraction
2 Movement with gravity eliminated

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3 Movement against gravity
4 Movement against gravity plus resistance
5 Normal power
Figure 255-16.
Dermatomes for sensory examination.
Diagnostic Imaging
Patients with suspected spine or spinal cord injury should have diagnostic imaging; the challenge is identifying
the appropriate patient and selecting the appropriate imaging modality. It is not practical nor prudent to image
the spine in every patient who presents to the ED after sustaining trauma. Therefore, clinical guidelines have
been developed to assist the physician’s judgment in deciding whom to image. In addition, the different
imaging modalities have their own particular value in detecting injuries to the bone, ligamentous structures,
and spinal cord.
Cervical Spine Imaging
Patients with head or neck trauma who are not fully alert (Glasgow Coma Scale score of <15) should undergo
imaging of their cervical spine. The frequency of cervical spine injury in association with blunt head trauma is
approximately 2% to 5%, but frequency increases to almost 9% in patients with significant head injury, defined
as a Glasgow Coma Scale score of <10 in one study.17
The utility of imaging of the cervical spine in patients who are alert, oriented, and have no neck or back pain
or tenderness is negligible. Two clinical decision rules have been defined, which target low-risk trauma
patients, to avoid unnecessary radiography. These rules are intended for alert, stable adult trauma patients who
have no neurologic deficits. The National Emergency X-Radiography Utilization Study (NEXUS) group
determined that cervical spine imaging would be unnecessary in patients who demonstrate five clinical criteria
(Table 255-5).18 In the original study, the NEXUS criteria were 99.6% sensitive for detecting clinically
significant cervical spine injuries, but only 12.9% specific.
Table 255-5 National Emergency X-Radiography Utilization Study Criteria: Cervical Spine Imaging
Unnecessary in Patients Meeting These Five Criteria
Absence of midline cervical tenderness
Normal level of alertness and consciousness
No evidence of intoxication
Absence of focal neurologic deficit
Absence of painful distracting injury
The Canadian Cervical Spine Rule for Radiography was developed for alert, stable trauma patients to reduce
practice variation and inefficiency in the ED use of cervical spine radiography.19 The Canadian Rule consists
of three questions or assessments; if the answer to any one of the three is “no,” then imaging is performed

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(Table 255-6). In the original study, the Canadian Cervical Spine Rule had 100% sensitivity and 42.5%
specificity for identifying patients with “clinically important” cervical spine injuries, suggesting that this
clinical rule could significantly reduce the use of imaging ordered for alert, stable trauma patients.
Table 255-6 Canadian Cervical Spine Rule for Radiography: Cervical Spine Imaging Unnecessary in Patients
Meeting These Three Criteria
Question or Assessment Definitions
There are no high-risk factors
that mandate radiography.
High-risk factors include:
Age 65 years or older
A dangerous mechanism of injury (fall from a height of >3 ft; an axial loading
injury; high-speed motor vehicle crash, rollover, or ejection; motorized
recreational vehicle or bicycle collision)
The presence of paresthesias in the extremities
There are low-risk factors that
allow a safe assessment of
range of motion.
Low-risk factors include:
Simple rear-end motor vehicle crashes
Patient able to sit up in the ED
Patient ambulatory at any time
Delayed onset of neck pain
Absence of midline cervical tenderness
The patient is able to actively
rotate his/her neck.
Can rotate 45 degrees to the left and to the right
These two decision tools were developed for slightly different purposes and had a different outcome definition,
so it is not appropriate to conclude that one rule is diagnostically better than the other.20,21 In experienced
hands, either rule is useful for its intended purpose.21
The NEXUS and Canadian Cervical Spine rules were designed to identify “low-risk” patients (e.g., with a risk
of <0.5% or <5 per 1000 for cervical spine injury) who do not require imaging. Other decision rules have been
developed to identify “high-risk” patients (e.g., with a risk >5% or > 50 per 1000 for cervical spine injury)
who should undergo early advanced imaging (Table 255-7).22,23
Table 255-7 Patients at High Risk for Cervical Spine Injury
Injury mechanism
High speed (>35 mph or 56 kph combined impact) motor vehicle crash
Motor vehicle crash with death of an occupant
Pedestrian stuck by moving vehicle
Fall from height >10 ft or 3 m
Primary clinical assessment
Significant or serious closed head injury*
Neurologic symptoms or signs referable to the cervical spine
Pelvic or multiple extremity injuries
Additional information Intracranial hemorrhage seen on CT
*The definition of significant or serious head injury is subjective, but may include intracranial hemorrhage,
parenchymal contusion, skull fracture, or persistent altered level of consciousness or unconsciousness.

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Cervical Spine Plain Radiography
Standard radiography for the identification of bony cervical injury includes three views of the cervical spine:
lateral, anteroposterior, and odontoid. These views allow for imaging of the entire cervical spine. It is
important that all seven cervical vertebrae be imaged, including the junction between the seventh cervical and
the first thoracic vertebrae. A single lateral cervical spine film will identify approximately 90% of injuries to
bone and ligaments.24 The lateral view should be inspected for proper alignment (Figure 255-17). The
anterior vertebral body line, posterior vertebral body line, and spinolaminar line should all be smooth and
uninterrupted. The loss of normal cervical lordosis is indicative of muscle spasm and may indicate spinal
injury. The soft tissues should be examined for the presence or absence of prevertebral swelling. Prevertebral
swelling is generally secondary to a hematoma and is consistent with spinal column injury. The prevertebral
space anterior to C3 should be <5 mm. The predental space should be <3 mm in an adult. The open-mouth
odontoid view will identify many of the remaining abnormalities. Cervical spine immobilization should be
maintained during imaging. If the initial lateral view is normal and the patient is neurologically intact, the
anteroposterior and open-mouth views can be delayed until other injuries are adequately stabilized. If optimal
radiographs are obtained, the combination of lateral, anteroposterior, and odontoid views is generally adequate
to identify, or at least raise the suspicion of, most clinically important cervical spine injuries.
Figure 255-17.
Lateral cervical spine alignment. Vertebral alignment of the lateral cervical spine: (1) anterior vertebral body
line, (2) posterior vertebral body line, (3) spinolaminar line, and (4) spinous processes line.
Cervical radiography has limitations. Plain films are poor for imaging C1 and C2. In addition, visualization of
the entire cervical spine via plain films is often problematic. Patients’ body habitus may not allow visualization
of all seven vertebral bodies. An alternative is a swimmer’s view, which is aimed through the axilla in an
attempt to image the lower cervical spine. Oblique views (45 degrees) can also be obtained. These views have
the added advantage of showing the neural foramina, visualizing the pedicles, and identifying the laminae.
Cervical Spine CT
High-speed, high-resolution multidetector CT scan has greatly enhanced the ability to image the cervical spine.
CT is more sensitive and specific than plain radiography for evaluating the cervical spine in trauma
patients, and can be performed in a more expeditious fashion.25–30CT can be used to visualize the entire
cervical spine and is particularly useful at the craniocervical and cervicothoracic regions, where plain films are
often limited.
The current trend in most trauma centers is to use CT as the initial imaging modality to evaluate the
cervical spine, and CT scanning is the imaging modality of choice for suspected cervical spine fractures.
Evaluation for Cervical Ligamentous Injury
Plain films, and even CT imaging of the cervical spine, may not identify patients with pure ligamentous
injuries. In these patients, the ligaments are disrupted, but the spine spontaneously reduces to a normal
position. The resulting instability risks subsequent neurologic injury if the spine moves.

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Flexion-extension radiographic views can be used to assess spinal column stability. They should only be done
in a fully awake, unsedated, cooperative patient who has pain or tenderness with normal plain radiographic
images. With direct physician observation, the seated patient carefully and slowly flexes and extends his or her
neck, with motion limited by increasing pain or the appearance of any neurologic symptom. Radiographs are
obtained in the flexed and extended positions with a step-off of 3.7 mm or an angulation of >11 degrees
denoting cervical spine instability.31 The role of flexion and extension views following an acute injury is
limited because it is possible to have normal flexion-extension films with ligamentous disruption, as muscle
tone can splint the bones in a stable configuration. Most patients in this latter category note pain improvement
with analgesics after a few days.
Reliable patients with persistent pain but normal imaging studies, including flexion/extension radiographs if so
obtained, can be discharged in a hard collar with outpatient follow-up in 3 to 5 days. Most patients’ symptoms
will resolve over a few days. A patient with persistent pain will require additional imaging. Unreliable patients
with persistent pain and normal plain radiographic or CT images should be considered for an MRI study,
although this is rarely indicated as part of the initial investigation.
Thoracic and Lumbar Spine Imaging
Many of the same principles used for cervical spine imaging can be applied to thoracic and lumbar imaging
(Table 255-8).32 The determination of a spinal column injury at one level should prompt imaging of the
remainder of the spine; approximately 10% of patients with a spine fracture in one segment will have a
second fracture at another.
Table 255-8 Indications for Thoracic and Lumbar Imaging after Trauma
Mechanism
Gunshot
High energy
Motor vehicle crash with rollover or ejection
Fall >10 ft or 3 m
Pedestrian hit by car
Physical examination
Midline back pain
Midline focal tenderness
Evidence of spinal cord or nerve root deficit
Associated injuries
Cervical fracture
Rib fractures
Aortic injuries
Hollow viscus injuries
Patients should be moved off the hard backboard and maintained in a flat, supine position on the gurney
mattress. Skin breakdown and pressure sores can develop very quickly, particularly in obese patients, from
laying on a hard surface, and the standard hospital mattress provides adequate spinal support. Patients
should be carefully moved with maintenance of spinal immobilization during transfers from bed to stretcher. It
may be helpful to place patients on a scoop stretcher or back on a backboard for the transportation phases of
their care. The thoracic spine has inherent stability from the rib cage, and few fractures in these patients will be
unstable.

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Plain radiographs of the thoracic and lumbar spine may be obtained as the initial imaging of these spinal
levels, but improvements in CT technology has rendered the role for plain films in thoracic or lumbar injury
more limited. Anterior and lateral films are generally obtained and examined for abnormality. Patients with
point tenderness and normal plain radiographs are a clinical dilemma; CT imaging can be useful in this subset,
although the yield for detecting fractures is low.
As with the cervical spine, CT has assumed a much more important role in the imaging of thoracic and lumbar
injuries. Newer-generation multidetector CT scanning is rapid and allows for complete three-dimensional
imaging of bone structures. CT scanning is indicated in almost all patients with proven bony spinal injury,
subluxations, neurologic deficits (but no apparent abnormalities on plain films), severe neck or back pain (with
normal plain films), and when the thoracic and lumbar spine should be examined to define the anatomy of a
fracture and the extent of impingement on the spinal canal. Rather than obtaining separate plain radiographs or
dedicated CT images, the thoracic and abdominal CT scans obtained to evaluate the multiple trauma patient
can be reformatted and used to reconstruct images of the thoracic and lumbar spine.33,34 CT can reveal the
anatomy of an osseous injury, grade the extent of spinal canal impingement by bone fragments, and assess the
stability of an injury.
MRI is not as sensitive as CT for detecting or delineating bone injuries, but is superb at defining neural,
muscular, and soft tissue injury.35,36 MRI is the diagnostic test of choice for describing the anatomy of
nerve injury. Entities such as herniated disks or spinal cord contusions can also be delineated on MRI.
Although many of the neural or soft tissue injuries may require only supportive therapy, some require acute
surgical intervention, and early identification helps plan therapy for all. MRI is indicated in patients with
neurologic findings with no clear explanation after plain films and CT scanning. CT myelography is an
alternative when MRI is unavailable and immediate diagnosis of a spinal cord or other neurologic lesion is
required. If the patient is neurologically stable and MRI is unavailable, delayed MRI or transfer to a tertiary
care facility may be appropriate.
Treatment of Spinal Injuries
The goals of treatment are to prevent secondary injury, alleviate cord compression, and establish spinal
stability. Spinal immobilization should be maintained and movement kept to a minimum.
After initial patient stabilization, if a neurologic deficit is present or the patient has an unstable spinal column,
subspecialty consultation should be requested emergently. The consultant, be it a neurosurgeon or orthopedic
surgeon, should have the opportunity to perform an appropriate neurologic examination early in the patient’s
course. Patients with progressive neurologic deterioration may require urgent surgical intervention.
Corticosteroids
High-dose methylprednisolone remains a controversial treatment in acute blunt spinal cord injury. In
1990, the National Acute Spinal Cord Injury Study (NASCIS) group published the results of a series of multi-
institutional studies to evaluate the efficacy of methylprednisolone in spinal trauma.37 The articles reported
that methylprednisolone infusion resulted in improvement of both motor and sensory function in
patients with complete and incomplete neurologic lesions. This positive outcome was dependent upon
dosage of steroids and time of administration (Table 255-9).

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Table 255-9 The National Acute Spinal Cord Injury Study Protocol
Indications
Blunt trauma
Neurologic deficit referable to the spinal cord
Treatment can be started within 8 h of injury
Treatment
Methylprednisolone, 30 milligrams/kg bolus, is administered IV over 15 min
Followed by a 45-min pause
Methylprednisolone, 5.4 milligrams/kg/h, is then infused for 23 h
This protocol was evaluated only in patients with blunt spinal cord injury; penetrating injuries were excluded
from the study. Massive steroid therapy has not been found to be effective in penetrating spinal cord
injury, and in fact, may impair recovery of neurologic function.38
The major neuroprotective mechanism by which high-dose methylprednisolone is believed to work is its
inhibition of free radical–induced lipid peroxidation. Other proposed beneficial actions include its ability to
increase levels of spinal cord blood flow, increase extracellular calcium, and prevent loss of potassium from
injured cord tissue. Methylprednisolone is advocated in preference to other steroids because it crosses cell
membranes more rapidly and completely.
The results of the NASCIS clinical trials have been criticized as not providing sufficient clinical evidence to
support the use of steroids in acute spinal cord injury. Reassessment and meta-analysis by other authors have
questioned the validity of the NASCIS trials and the effectiveness of high-dose steroid therapy in these
patients.39,40 The current guidelines of the American Association of Neurological Surgeons, published in
2002, state that there is insufficient evidence to support the use of methylprednisolone as a treatment standard
or guideline, and that “methylprednisolone for either 24 or 48 hours is recommended as an option in the
treatment of patients with acute spinal cord injuries that should be undertaken only with the knowledge that the
evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit.”41
Potential complications associated with prolonged, high-dose steroids, such as pneumonia, sepsis, wound
infection, thromboembolism, GI bleeding, and delayed healing are frequently cited concerns.
Penetrating Injury
There are additional considerations in evaluating and treating penetrating spinal trauma (Figure 255-18).
Optimal treatment of these injuries has been the subject of debate. One concern is that of infectious
complications related to the presence of foreign bodies and contamination associated with transperitoneal and
transintestinal trajectories of gunshot wounds to the spine. In gunshot wounds with a transabdominal
trajectory, prophylactic broad-spectrum IV antibiotics are indicated and should be given in the ED. Surgical
debridement with laminectomy has not proven effective in reducing the incidence of infectious complications,
as most are managed nonoperatively.
Figure 255-18.
Algorithm for gunshot injury to spine. *Consider bullet removal in thoracolumbar region.
As with blunt trauma, there is general agreement that progressive neurologic deficits warrant surgical

13/10/15 9:24
decompression. The indication for removal of bullet and bone fragments in those patients with nonprogressive
neurologic deficits is less clear. Wound location may determine the need for surgical intervention. Bullet
removal does not significantly improve the neurologic status of patients with stable cervical and thoracic spinal
cord lesions. In contrast, bullet removal from the thoracolumbar region (T11 to L2) may significantly improve
motor recovery in both complete and incomplete injuries.42 Most gunshot wounds to the spine are stable and
require only symptomatic treatment with a supportive orthosis and analgesics.
Patients who present with stab wounds to the spinal region with no neurologic deficits should receive
antibiotics and local wound care. CT may be performed to evaluate for a retained foreign body. If no metallic
foreign bodies are present, neurologic deficits are best evaluated with MRI. Progressive neurologic deficits are
generally treated surgically.
Stab wounds to the cervical spine may directly penetrate the spinal cord neural elements, produce spinal
infarction, or rarely cause a spinal epidural hematoma, as well as potentially injure other structures in the neck
(see Chapter 257, Trauma to the Neck). Vertebral instability is generally not an issue, and delayed deficits are
rare following a cervical spine stab wound. When they do occur, they are usually related to retained fragment
of blade within the spinal canal.
Nonoperative Spinal Stabilization
The goal of stabilization is to reduce deformities and then restrict motion and maintain alignment. In the
cervical spine, it is important to determine the adequacy of cervical bone reduction. Subluxations are generally
reduced using Gardner-Wells tongs, which are placed into the soft tissue of the temples under local anesthesia.
Spinal orthoses are used to immobilize well-reduced cervical fractures. The cervical spine is the region most
effectively stabilized by external splinting devices because there is less soft tissue separating the brace from
the spine at this level. In addition, some braces can be solidly secured by fixation points at the cranium and the
thoracic cage. Cervical orthoses consist of cervical and cervicothoracic types. Cervical collars fit around the
neck and contour to the mandible and occiput. They restrict flexion and extension in the middle and lower
cervical spine. Lateral bending and rotational movements, however, are poorly controlled. Examples of
cervical orthoses include the hard collar, the Philadelphia collar, and the Miami J collar (see Chapter 2,
Prehospital Equipment and Adjuncts). Cervicothoracic braces provide additional support, with the “gold
standard” being the halo cervical immobilizer, which provides the most rigid stabilization. Consisting of a halo
ring pinned to the skull, a vest, and upright posts, it can be used for traction and reduction of unstable
fractures, as well as immobilization.
Immobilization of the upper thoracic spine by orthoses is difficult, but, fortunately, an intact rib cage and
sternum provide relative stability. Although brace immobilization is not always necessary in the treatment of
these fractures, braces can provide additional comfort. Thoracic corsets provide minimal control of motion and
are appropriate only for minor injuries. Jewett and Taylor-Knight braces provide intermediate control of spinal
motion. Maximum limitation of motion is provided by the Risser jacket and the body cast.
The thoracolumbar junction and lower lumbar regions are also difficult to immobilize externally. Splints are
limited by lack of an adequate caudal fixation point. The functions of most thoracolumbosacral orthoses are
the following: to create an awareness and remind the patient to restrict movements, to support the abdomen
and relieve some of the load on the lumbosacral spine, to provide some restriction of motion of the upper
lumbar and thoracolumbar spine by three-point fixation, and to reduce lumbar lordosis in order to provide a
straighter, more comfortable lower back.

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Complications of external immobilization devices include pain, pressure, muscle weakness and disuse atrophy,
venous compromise, psychological dependence, ineffective stabilization, and pin-site complications (halo
vest).
Operative Management of Spine Injuries
The indication for operative stabilization is somewhat controversial and varies from institution to institution.
Those favoring an aggressive approach stress the importance of early mobilization of the multiply injured
patient, as it helps decrease pulmonary problems, skin breakdown, deep venous thrombosis, and pulmonary
embolus. Rigid fixation may also decrease time in hospital as well as long-term pain and deformities. Those
advocating a nonoperative approach point out the possibility of worsening neurologic performance by
operative manipulation. In addition, the long-term results with operative intervention may not be substantially
better than with nonoperative therapy.
All would agree that progressive neurologic deterioration is an indication for urgent surgery. In addition,
spinal instability should most often be managed operatively, even in the case of a complete spinal cord level,
as this helps prevent long-term deformity.
Pediatric Spine and Spinal Cord Injuries
Spinal injuries occur less frequently in children than in adults. However, when children sustain these injuries,
they are often devastating and result in debilitating long-term neurologic disability. Diagnosis of pediatric
injury can be challenging as young children are frequently unable to communicate their disabilities or describe
pain, and they may not readily cooperate with physical examination or diagnostic evaluation. Unique anatomic
features of the pediatric spine predispose children to different patterns of injury than adults. In addition,
imaging may not readily reveal radiographically occult injuries or may identify normal pediatric variants that
are difficult to interpret. Any child with a significant mechanism of injury or history suggestive of spinal cord
injury requires a thorough, systematic evaluation.
Motor vehicle crashes, sports-related injuries (e.g., football, diving, soccer, rugby, ice hockey), falls from
heights, and child abuse are the most common causes of spinal injury in children.43–45 Penetrating trauma
and gunshot wounds are rare in young children but increase in prevalence throughout adolescence.
Developmental Features of the Pediatric Spine
In children <10 years of age, spinal injury occurs mainly in the upper cervical vertebrae and is associated with
a high risk of neurologic sequelae (Table 255-10). Beyond 10 years of age, the fulcrum of cervical spine
movement approaches that of the adult patient, and the majority of injuries in older children occur in the lower
cervical spine, similar to adults. Multilevel spinal injuries occur more frequently in children, with
approximately 16% occurring at noncontiguous levels.43–45 This association stresses the importance of
complete examination of the entire vertebral column.
Table 255-10 Developmental Features Associated with Pediatric Cervical Spine Injury
Children <10 y of age: injury mainly in upper cervical vertebrae
Ligamentous laxity and hypermobility

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Incomplete ossification of cartilaginous elements
Horizontal orientation of shallow facet joints
Poorly developed, weak cervical musculature
Large head to body ratio
Children >10 y of age: majority of injuries in lower cervical spine
Clinical Features
As in adults, assessment and restoration of airway, breathing, and circulation occurs while maintaining neutral
cervical spine immobilization. A brief neurologic evaluation should be done as part of the primary survey.
If the history or mechanism of injury suggests spinal cord injury, it is important that spinal immobilization be
maintained until a complete assessment, including appropriate imaging studies, is accomplished. A modified
long board for spinal immobilization may be required to accommodate the relatively large occiput of small
children to prevent inadvertent flexion of the cervical spine. The risk of maintaining immobilization in an
uncooperative child, who may require sedation, must be balanced with that of secondary injury to a child
allowed to move freely with an unstable spinal injury. Clinical criteria may be applied by experienced
clinicians to cooperative patients with low-risk injuries to help determine the need for continued cervical spine
immobilization, but limited data exist to fully utilize the NEXUS or Canadian Cervical Spine Rule for
Radiography criteria with confidence in the pediatric population. Removal of helmets and shoulder pads to
obtain radiographs must be conducted cautiously while maintaining in-line immobilization and gentle spinal
cord traction.
Given the difficulties of adequately evaluating an injured child, a high index of suspicion must be maintained
for all those at risk for spinal injuries. In addition, there is a high incidence of concomitant injuries in children
with spine injuries, including head (25% to 50%), extremity (30%), and thorax (21%).46–48 A thorough
secondary survey is necessary to avoid missed injuries.
Specific Spine Injuries in Pediatric Patients
Occipitoatlantal dislocation is a rare occurrence following motor vehicle crashes and falls, with young children
at particular risk. This injury commonly causes cardiorespiratory arrest and anoxic brain damage.
Occipitoatlantal dislocation is usually fatal, and most survivors suffer severe neurologic damage. Axial
compression resulting in a Jefferson burst fracture of C1 is rare in children. Typically, these fractures are seen
in teenagers following motor vehicle crashes and diving accidents.
Odontoid fractures are among the most common cervical spine injuries in children.49 These fractures must not
be confused with the normal anatomic variations in the odontoid due to synchondrosis between the body of the
axis and the odontoid, which may be seen in children up to 7 years of age. Fractures of the body and neural
arch of the axis (C2) are less common than fractures of the odontoid process and the atlas. The usual
mechanism involves hyperextension, resulting in a hangman’s fracture with bilateral fracture of the pars
interarticularis of the axis, horizontal tearing of the C2-C3 disk, and anterior subluxation of C2 on C3.
Neurologic damage occurs if the fracture extends to the vertebral foramina with injury to the vertebral artery. It
is considered an unstable fracture.
Injuries to the mid- and lower cervical spine more closely follow the adult-type pattern and account for 14% of

13/10/15 9:24
vertebral fractures in children.44,45 Facet disruption without associated fractures may occur in children
because of ligamentous laxity. Cervicothoracic junction injury is rarely reported in children <10 years of age.
Pure ligamentous injuries may result in delayed instability, even when initial radiographs appear normal.
Children present with persistent neck pain, stiffness, or muscle spasm. Prevertebral swelling, loss of lordosis,
widening of interspinous distances and the occasional dimple fracture of a vertebral body are clues to the
diagnosis.
Thoracolumbar fractures, though rare in children, can have devastating consequences. These injuries are
frequently overlooked during the pediatric trauma assessment. Significant morbidity and long-term neurologic
sequelae have been reported following thoracolumbar injuries. These fractures most commonly result from
high-impact or rapid deceleration, falls from heights, vehicular crashes, and contact sports. Mechanism of
injury is generally hyperflexion of the lower thoracic or upper lumbar vertebrae with subsequent posterior
ligamentous disruption. Diagnosis may be delayed or missed because of a lack of clinical signs. Long-term
structural or functional impairment may go unrecognized until later in childhood or adulthood.50
Associated Injuries
Spinal cord injury without radiologic abnormality, or SCIWORA, refers to the lack of evidence of vertebral
fracture or malalignment on plain radiographs and CT in a patient with spinal cord injury. It is more common
in younger children and occurs most frequently with cervical spine injuries. SCIWORA has been reported in
up to 55% of thoracolumbar injuries in the pediatric population.51 Despite the lack of findings on radiography
or CT, MRI has shown significant pathology in many of these patients.
Two theories have been described to explain SCIWORA: (1) developmental characteristics of the immature
spine allow for transient excessive movement during trauma, with subsequent cord distraction or compression;
and (2) cord ischemia occurs due to direct vessel injury or hypoperfusion.
Delayed onset of neurologic damage is usually apparent within 48 hours. Numbness, paresthesias, or
“shock-like” sensations in the extremities are suggestive of SCIWORA, and should be expeditiously
evaluated for evidence of spinal cord injury. MRI is indicated to differentiate cord edema from hemorrhage
as well as to assess ligamentous injury.52,53
Transient quadriparesis (referred to as “Stinger”) is seen relatively frequently in children, most often in young
boys after sports injuries. Clinically, there are paresthesias or weakness of the extremities, lasting from seconds
to minutes, with complete recovery within 48 hours. No radiologic abnormalities are found. However,
radiologic evidence of congenital spinal stenosis, acquired stenosis, cervical instability, or congenital
abnormalities such as Klippel-Feil syndrome are found with some degree of frequency. The etiology is thought
to be concussion of the spinal cord.53,54
“Shaken-baby syndrome” or child abuse should be suspected when there is a discrepancy between the
history and degree of physical injury, a delay in seeking treatment, history of repeated injuries, or when
informants appear inconsistent with their report of injury. Spinal injuries typically associated with
“shaken-baby syndrome” include flexion-extension type injuries, particularly at the cervicothoracic or
thoracolumbar junction. Compression fractures may also be seen. Skull fractures with intracranial hemorrhage,
rib and long bone fractures, blunt abdominal trauma, and retinal hemorrhages are all associated with child

13/10/15 9:24
abuse.55,56 The presence of such injuries should prompt a thorough search for additional spinal injuries.
Acquired torticollis, spasm of the sternocleidomastoid muscle or “wry neck,” occurs far more frequently than
cervical spine injuries. It should be treated conservatively with mild analgesics; low-dose benzodiazepines can
be given. The contracted sternocleidomastoid muscle is on the side opposite the direction of head rotation.
Congenital Anomalies
There is increased risk of cervical spine injury associated with various congenital anomalies. These include
aplasia or hypoplasia of the odontoid and “os odontoideum,” block vertebrae, Klippel-Feil syndrome, Down
syndrome, skeletal dysplasias (e.g., Morquio syndrome and diastrophic dwarfism), and juvenile chronic
arthritis. “Os odontoideum” refers to an oval or round ossicle with a smooth cortical border located in the
position of the odontoid process. It is thought to arise from the nonunion of an unrecognized odontoid fracture.
Atlantoaxial instability is reported to occur in 10% to 20% of children with Down syndrome but is
symptomatic in only about 3%.
Imaging Studies
Patients at risk for spinal injury, who cannot have their cervical spines “cleared” clinically, require
radiographic evaluation. Plain radiographs of the cervical spine are often the initial imaging modality. A lateral
cervical spine radiograph visualizing all seven cervical vertebrae from the occiput to the cervicothoracic
junction and an anterior view should be obtained initially. If possible, an open-mouth odontoid view should
also be obtained, but in small children, this may be technically difficult.
In multiple trauma patients or patients with abnormal or inadequate plain films, a CT scan should be
performed. CT is particularly useful to visualize those portions of the cervical spine that are commonly
missed and frequently injured in children, such as the occipitoatlantal and cervicothoracic junctions.
Limited CT can be used in conjunction with plain radiographs to reduce radiation exposure. CT may detect
injuries not readily apparent on plain radiographs. Thin cut sections (2 to 3 mm) with sagittal and coronal
three-dimensional reconstruction are recommended and should be tailored to the plain radiographic findings.
CT provides detailed anatomic information and allows assessment of impingement of the thecal sac and spinal
cord from extradural sources such as retropulsed bony fragments or hematoma.
Because children are more likely than adults to suffer ligamentous injury, CT scanning in children <8 years of
age may have limited utility.47,51 MRI best assesses spinal cord, disk, and ligamentous disruption. MRI
can also detect soft tissue injury and hematoma not visualized by other imaging modalities. The
condition of the spinal cord on MRI is predictive of neurologic outcome. Spinal cord transection and major
hemorrhage are associated with poor outcome and significant neurologic sequelae. Minor hemorrhage or
edema is associated with moderate-to-good recovery. The absence of an abnormal signal is associated with full
recovery.
Choice of imaging modalities should be individualized for each patient. One should carefully consider which
diagnostic studies are needed to adequately evaluate all injuries that may be present. At the same time,
attempts should be made to avoid unnecessary studies that may predispose the patient to long-term, deleterious
effects associated with excessive radiation.
Pediatric Normal Variants

13/10/15 9:24
A number of normal variants may be present in pediatric cervical spine films that can make interpretation
especially difficult. Variations in alignment may appear as vertebral displacements, variations in curvature may
resemble muscle spasm or ligamentous injury, and the appearance of growth centers may be confused with
fractures (Table 255-11).
Table 255-11 Normal Variants of the Pediatric Cervical Spine
Absence of normal cervical lordosis in 14% of normal children.
“Pseudospread” of the atlas on the axis up to age 7 y old.
Anterior wedging of the vertebral bodies of up to 3 mm.
Over-riding of the anterior arch of C1 above the odontoid in up to 20% of children.
Lack of uniform angulation of the interspaces with flexion.
Pseudosubluxation:
The anterior and posterior spinal lines, joining the anterior and posterior borders of the cervical spine,
respectively, are useful in children >7 y of age. Pseudosubluxation of C2 on C3 or C3 on C4 is a normal
variant that can cause disruption of these lines. The spinous processes should form a straight line on anterior
view; any offset suggests unilateral facet dislocation.
Persistence of synchondrosis at the base of the odontoid, the apical odontoid epiphysis, and incomplete
ossification of the posterior arch of C1 and secondary ossification centers of the spinous processes may
resemble bony fractures in children.
Consultation
Emergency physicians should work closely with trauma surgeons to expedite the evaluation and treatment of
any child with spinal trauma. Neurosurgical/orthopedic consultation should be obtained promptly for any child
with an obvious neurologic deficit, altered mental status, or documented radiographic evidence of vertebral
fracture, dislocation, spinal cord damage, or associated bone injuries.
Disposition and Follow-Up
Children with documented spinal injury, neurologic deficits, or history of a high-risk mechanism of injury
should be admitted to a pediatric intensive care unit. If specialty expertise is unavailable, patients with
significant injuries should be stabilized and transferred to a regional trauma center.
Injury Prevention
Improper positioning of seat restraints and location of children within motor vehicles can result in significant
injury.57 All child restraint seat manufacturers provide information about the proper installation and use of this
equipment, and many local police departments can assist in their proper installation. Parents should be
instructed to maintain safety in their own home environment. Childproof gates on stairways, door locks, and
window guards should be installed. Helmets and appropriate padding should be used for all sports-related
recreational activities.
Athletic coaches should understand the need for protective equipment appropriate for the child’s physical
habitus as well as the degree of physical contact between participants. There is significant variability in heights
and weights between similarly aged children, and this can lead to a substantial mismatch between participants

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