Mechanisms of Vertebral Column Injury
Spinal Cord Injury Mechanisms
Vertebral Column Injury
Cervical Spine Fractures
Thoracic and Lumbar Fractures
Spinal Cord Injury
Initial Assessment and Care
Emergency Room Care
Imaging and Diagnostic Studies
Magnetic Resonance Imaging
Sequence of Imaging Studies
Patient Care Until the Spine is Cleared
Current Treatment Options
Authors’ Preferred Treatment
Pearls and Pitfalls
Outcomes of Spine Injury
Pain and Function
Problems with Stability Assessment in and Instability of Vertebral Column Spinal Injuries
Administration of Steroids in Acute Spinal Cord Injury
Limitations of Inferences from Biomechanical Studies
Data from Blackmore CC, Emerson SS, Mann FA, et al. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology. 1999;211(3):759–765; and Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology. 1999;212(1):117–125.
Data from Bracken MB, Collins WF, Freeman DF, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984;251(1):45–52; Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20): 1405–1411; and Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997;277(20):1597–1604.
ASIA, American Spinal Injury Association; NASCIS, National Acute Spinal Cord Injury Study.
Data from Piepmeier JM, Lehmann KB, Lane JG. Cardiovascular instability following acute cervical spinal cord trauma. Cent Nerv Syst Trauma. 1985;2:153–160; Zipnick RI, Scalea TM, Trooskin SZ, et al. Hemodynamic responses to penetrating spinal cord injuries. J Trauma. 1993;35:578–582; and Ducker TB, Salcman M, Perot PL Jr, et al. Experimental spinal cord trauma, I: correlation of blood flow, tissue oxygen and neurologic status in the dog. Surg Neurol. 1978;10:60–63.
From White AA III, Johnson RM, Panjabi MM, et al. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res. 1975;109:85–96.
We recommend discontinuing routine administration of steroids in acute spinal cord injury. The magnitude of observed neurologic improvement is minimal and controversial compared with risk of infection and gastrointestinal bleeding complications. We recommend a screening CT scan to image the cervical spine in obtunded patients and discontinuing cervical spine immobilization and mobility precautions if the study is normal (Fig. 43-10). Decompression should be achieved expediently in patient with spinal cord injury, whether complete or incomplete. For medically stable, examinable patients with cervical spine dislocation and severe neurologic injury, such as complete tetraplegia, we recommend emergent closed reduction prior to MRI or other time-consuming interventions.
Errors in the emergency room management of patients have serious adverse consequences for subsequent care. For optimal spine evaluation of trauma patients and reducing risk of complications, we recommend observing the following principles.
From Fletcher DJ, Taddonio RF, Byrne DW, et al. Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine. 1995;20:1136–1146.
From University of Alabama. Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL: University of Alabama SCI National Statistical Center; 2008.
ASIA, American Spinal Injury Association; NLI, neurologic level of injury; SCI, spinal cord injury.