Download 75 - Spine Trauma and Spinal Cord Injury

75 Spine Trauma and Spinal Cord Injury
Michelle Lin and Swaminatha V. Mahadevan
KEY POINTS
• Patients with spinal pain and spine fractures should
receive a thorough neurologic examination to look for
spinal cord injury.
• Spine fractures are associated with a high incidence of
concurrent noncontiguous spine fractures and spinal
cord injuries.
• The National Emergency X-radiography Utilization Study
criteria or the Canadian Cervical-Spine Rule criteria can
be used to identify low-risk patients who do not need
cervical spine imaging.
• Imaging with plain films versus computed tomography
of the cervical spine should be based on the pretest
probability of a significant injury and the irradiation risk
with computed tomography.
• Spinal shock, or transient physiologic transection of the spinal cord as a result of trauma, is different from
neurogenic shock, which is physiologic sympathectomy
of the upper spinal cord leading to peripheral
vasodilation.
• Patients with a spinal cord injury caused by blunt
trauma are often given high-dose corticosteroids within
8 hours of injury, although such therapy is controversial.
EPIDEMIOLOGY
The estimated annual cost of spine injuries, including inability
to work and health care costs, exceeds $5 billion in the United
States.1
In the emergency department (ED), all trauma victims are
screened for vertebral fractures, ligamentous disruptions, and
spinal cord injuries because of the potentially devastating
neurologic consequences of overlooking these injuries.
Patients with a delayed diagnosis of spinal fracture are 7.5
times more likely to sustain secondary neurologic deficits.2
Neurologic deficits from spinal cord injury may be subtle and
can easily be missed if not specifically evaluated. Adding to
these difficulties, plain film radiographs of the spine, though
an adequate screening tool for other fractures, can miss 23%
to 42% of cervical spinal fractures3,4 and 13% to 50% of
lumbar fractures.5,6
PATHOPHYSIOLOGY
In the setting of spinal trauma, the bone, ligaments, spinal
cord, and vascular structures may be injured. Anatomically,
the vertebral bony spine can be divided into structural columns.
The cervical spine is traditionally divided into two columns—
anterior and posterior. The anterior column consists of the
load-bearing vertebral bodies, intervertebral disks, anterior
longitudinal ligament, and posterior longitudinal ligament
(Fig. 75.1). The posterior column consists of the more posterior structures, including the pedicles, laminae, and transverse
and spinous processes (Fig. 75.2).
In contrast, the thoracic and lumbar vertebral spines are
divided into three columns based on the modified Denis
model—anterior, middle, and posterior (Fig. 75.3). The
anterior column consists of the anterior longitudinal ligament,
the anterior two thirds of the vertebral body, and the intervertebral disk. The middle column consists of the posterior
longitudinal ligament, the posterior third of the vertebral
body, and the intervertebral disk. Any disruption of the
middle column predisposes a patient to significant spinal
cord injury because the middle column abuts the spinal canal.
The posterior column consists of the remaining posterior
structures.
The C1 and C2 vertebrae are anatomically unique (Fig.
75.4). C1 (atlas) is a ring-link structure without a vertebral
body. It articulates superiorly with the occipital condyles. This
articulation allows 50% of normal neck flexion and extension.
C2 (axis) projects the dens superiorly to articulate with C1.
The transverse ligament tethers the dens to the anterior arch
of C1. This atlantoaxial articulation allows 50% of normal
neck rotation left and right.
The spinal cord spans from the foramen magnum to the L1
level, whereupon the spinal cord tapers into the conus medullaris and cauda equina, a collection of peripheral lower lumbar
and sacral nerve roots. Because the spinal cord is thickest in
the cervical spine, there is relatively less spinal canal space
in the cervical levels than in the thoracic or lumbar spine.
Thus spinal cord injuries occur more frequently with cervical
spine trauma than with thoracic or lumbar spine trauma. The
neurologic dermatomes can help localize the injury (Table
75.1).
The vertebral arteries branch off the subclavian arteries
and course superiorly within the transverse foramina of C2 to
C6. These arteries then merge to form the basilar artery.
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SECTION VIII
TRAUMATIC DISORDERS
Annulus fibrosus
(disk)
Nucleus pulposus
(disk)
Spinous process
Transverse process
Spinal canal
Vertebral body
Intervertebral disk
Vertebral body
Transverse foramen
Transverse process
Pedicle
Superior articular facet
Spinal canal
Lamina
Cervical spine columns:
Spinous process
Lower cervical spine
Fig. 75.1 Bony anatomy of a typical lower cervical vertebra
(C3-C7): superior axial view with the anterior aspect oriented
upward and the posterior aspect oriented downward.
Thoracic-lumbar spine
columns
Anterior
Posterior
Anterior Middle Posterior
Fig. 75.3 Schematic diagram illustrating the lateral view
of the anatomic columns of the cervical and thoracic/lumbar
spine. Note that the cervical spine’s anterior column is composed
of the same structures as the thoracic/lumbar spine’s anterior and
middle columns.
C1 atlas
Annulus fibrosus
(disk)
Nucleus pulposus
Anterior arch
Lateral mass
(disk)
Transverse foramen
Transverse process
Posterior arch
Vertebral body
Pedicle
Transverse
ligament
Dens
C2 axis
Spinal canal
Pedicle
Transverse process
Superior articular facet
Transverse foramen
Transverse process
Superior articular facet
Lamina
Spinous process
Spinous process
Thoracic/lumbar spine
Fig. 75.2 Bony anatomy of a typical thoracic and lumbar
vertebra (T1-L5): superior axial view with the anterior aspect
oriented upward and the posterior aspect oriented downward.
PRESENTING SIGNS AND SYMPTOMS
Patients with vertebral fractures usually have significant
midline spinal tenderness on palpation. High-risk findings
include spinal soft tissue swelling, ecchymosis, and step-off
misalignment of the spine. Pain radiating along a dermatomal
distribution suggests an associated radiculopathy. Thoracic
spine fractures are uncommon because the articulating ribs
provide stability to the spinal column; however, the thoracolumbar junction (encompassing the T10 to L2 vertebral levels)
is commonly injured because the spine curvature changes
from the kyphotic thoracic spine to the lordotic lumbar
spine.
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Fig. 75.4 Bony anatomy of the upper cervical spine (C1 and
C2): posterolateral view. The C1 lateral masses articulate with the
occipital condyles. The C2 dens projects cephalad, articulates with
the C1 anterior arch, and is stabilized by the C1 transverse
ligament.
Patients with spinal cord injuries may have a spectrum of
findings ranging from subtle neurologic deficits to grossly
obvious paralysis. Spinal cord injuries should be suspected in
any trauma victim who complains of neck or back pain, especially pain exacerbated by movement. Neurologic symptoms
suggesting spinal cord injury include numbness, tingling, paresthesias, focal weakness, and paralysis. Other worrisome
symptoms include urinary or fecal incontinence and urinary
retention. Unconscious patients and those with impaired consciousness secondary to intoxication may harbor occult spinal
cord injuries. Physical examination should focus on the spine
and areas where associated injuries may occur (Tables 75.2
to 75.4).
Table 75.1 Individual Spinal Sensory Dermatomes, Motor Function, and Reflex Arcs
SPINAL LEVEL
SENSORY DISTRIBUTION
MOTOR FUNCTION
REFLEX
C2
Occiput
C3
Thyroid cartilage
C4
Suprasternal notch
Spontaneous respiration
C5
Infraclavicular area
Shoulder shrugging
Biceps
C6
Thumb
Elbow flexion
Triceps
C7
Index finger
Elbow extension
C8
Little finger
Finger flexion (with T1)
T4
Nipple line
T10
Umbilicus
L1
Inguinal ligament
Hip flexion (with L2)
L2
Medial thigh
Hip flexion
L3
Medial thigh
Hip adduction
L4
Medial foot
Hip abduction
L5
Web space between big toe and second toe
Foot dorsiflexion
S1
Lateral foot
Foot plantar flexion (with S2)
S2
Perianal area (with S3, S4)
Foot plantar flexion
S3-4
Perianal area
Rectal sphincter tone
Patellar
Achilles
Table 75.2 Physical Examination Findings Associated with Vertebral Fractures and Spinal Cord Injuries
INJURY
Vertebral
fracture
PHYSICAL
EXAMINATION AREA
Spine
Neurologic
Chest
Abdomen/pelvis
Extremity
Spinal
cord
injury
Neurologic, motor
(anterior column)
Neurologic, sensory
(spinothalamic tract)
Neurologic, sensory
(dorsal column)
Neurology, deep
tendon reflex
Anogenital
Head-to-toe
examination
ASSOCIATED FINDINGS
Tenderness of the neck and/or back. Examine the entire spine because vertebral fractures may
occur in multiples.
See spinal cord injury below.
Thoracic spine fractures: Check for chest tenderness, unequal breath sounds, and arrhythmia,
which are suggestive of an associated intrathoracic injury or myocardial contusion.
Thoracolumbar and lumbar spine fractures: Check for abdominal or pelvic tenderness. For
instance, up to 50% of patients with a transverse process fracture7 and 33% of patients with
a Chance fracture8 have concurrent intraabdominal pathology. A transverse area of ecchymosis
on the lower abdominal wall (seat belt sign) increases the chance of an abdominopelvic injury.
Thoracolumbar and lumbar spine fractures: Check for calcaneal tenderness because 10% of
calcaneal fractures are associated with a low thoracic or lumbar fracture. Mechanistically,
these areas are fractured as a result of axial loading.
Assess motor function on a scale of 0 to 5 (see Table 75.3). Motor level is defined as the most
caudal segment with at least 3/5 strength. Injuries to the first eight cervical segments result in
tetraplegia (previously known as quadriplegia); lesions below the T1 level result in paraplegia.
Assess sensory function via pinprick and light touch on the following scale: 0 = absent; 1 =
impaired; 2 = normal. The sensory level is defined as the most caudal segment of the spinal
cord with normal sensory function. The highest intact sensory level should be marked on the
patient’s spine to monitor for progression.
Assess vibratory sensory function on a scale of 0 to 2 by using a tuning fork over bony
prominences. Assess position sense (proprioception) by flexing and extending the great toe.
On a scale of 0 to 4, assess the deep tendon reflexes in the upper (biceps, triceps) and lower
(patellar, Achilles) extremities (see Table 75.4).
Assess rectal tone, sacral sensation, signs of urinary or fecal retention or incontinence, and
priapism. Also check the anogenital reflexes: an anal wink (S2-S4) is present if the anal
sphincter contracts in response to stroking the perianal skin area. The bulbocavernosus reflex
(S3-S4) is elicited by squeezing the glans penis or clitoris (or pulling on an inserted Foley
catheter), which results in reflexive contraction of the anal sphincter.
A spinal cord injury may mask a patient’s ability to perceive and localize pain. Imaging of
high-risk areas, such as the abdomen, and areas of bruising or swelling may be required to
exclude occult injuries.
SECTION VIII
TRAUMATIC DISORDERS
Table 75.3 Graded Assessment of Motor Function
GRADE
ASSESSMENT ON PHYSICAL EXAMINATION
0
No active contraction
1
Trace visible or palpable contraction
2
Movement with gravity eliminated
3
Movement against gravity
4
Movement against gravity and resistance
5
Normal power
Spinal shock is a neurologic phenomenon resulting from
physiologic transection of the spinal cord. It results in flaccid
paralysis and loss of reflexes below the level of the spinal cord
lesion. Spinal shock is temporary, commonly lasting for 24 to
48 hours, although it can persist for weeks. Patients suffering
from spinal shock may appear (clinically) to have a complete
spinal cord injury only to “miraculously” recover once the
spinal shock has passed. Termination of spinal shock is identified by return of segmental reflexes; anogenital reflexes are
the earliest to recover.
Neurogenic shock may occur in patients with cervical or
high thoracic spinal cord injuries. It is a neurocardiovascular
phenomenon resulting from impairment of the descending
sympathetic pathways in the spinal cord. As a result, vasomotor tone is lost and visceral and peripheral vasodilation and
hypotension ensue. Diminished sympathetic innervation to
the heart also occurs and results in relative bradycardia despite
the presence of hypotension.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
INDICATIONS FOR CERVICAL SPINE IMAGING
In the year 2000, in the hope of reducing the number of lowrisk patients undergoing cervical spine plain film radiography,
a multicenter study by the National Emergency X-radiography
Utilization Study (NEXUS) group validated a set of five lowrisk criteria for determining which patients do not require
radiographic imaging if all the criteria are met (Box 75.1).
This clinical decision tool demonstrated a sensitivity of 99.6%
and a specificity of 12.9% for detecting clinically significant
cervical spine fractures. It was thus extrapolated that 4309
(12.6%) of the 34,069 patients enrolled could have avoided
plain film radiography.9
Following development of the NEXUS criteria, the Canadian Cervical-Spine Rule (CCR) was developed (Fig. 75.5).
The validated sensitivity and specificity for this decision rule
were 99.4% and 45.1%, respectively.10
The CCR study excluded the following subjects: patients
younger than 16 years; patients with an abnormal Glasgow
Coma Scale score, abnormal vital signs, injuries more than
48 hours old, penetrating trauma, paralysis, and history of
vertebral disease; patients seen previously for the same injury;
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Table 75.4 Graded Assessment of Deep Tendon
Reflexes
GRADE
ASSESSMENT ON PHYSICAL EXAMINATION
0
Reflexes absent
1
Reflexes diminished but present
2
Normal reflexes
3
Reflexes increased
4
Clonus present
BOX 75.1 NEXUS Low-Risk Criteria
for a Cervical Spine Injury
A patient does not require cervical spine radiographic imaging
if all five of the following low-risk conditions are met:
1. No posterior midline neck pain or tenderness
2. No focal neurologic deficit
3. Normal level of alertness
4. No evidence of intoxication
5. No clinically apparent, painful distracting injury*
From Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt
trauma. N Engl J Med 2000;343:94-9.
NEXUS, National Emergency X-radiography Utilization Study.
*Defined as a condition thought by the clinician to be producing pain sufficient to distract patients from a second (neck) injury.
and pregnant patients. Because these cases were not studied,
the CCR guidelines should not be applied to such patients.
CHOOSING THE IMAGING MODALITY TO
EVALUATE THE CERVICAL SPINE (Fig. 75.6)
When patients have at least one high-risk criterion for a spinal
fracture, imaging begins with either plain films or computed
tomography (CT) scans. The pros and cons of both imaging
approaches are listed in Table 75.5.
Patients with symptoms suggestive of a spinal cord injury
should undergo CT and magnetic resonance imaging (MRI)
of suspicious areas of the spine. Although plain films and CT
do not directly reveal spinal cord injuries, they may supply
indirect evidence of such injuries. Spinal cord injury without
radiographic abnormality (SCIWORA) is a traumatic myelopathy in which no abnormalities can be identified on plain films
or CT.
Computed Tomography
With increasing evidence in the literature showing that CT is
much more sensitive (98%) than plain film radiography (53%)
in detecting cervical spine fractures, future recommendations
will probably recommend cervical spine CT as the first-line
diagnostic approach for most patients because of the neurologic significance of a missed cervical spine injury.11 Conventional radiography is especially difficult to interpret in the
high cervical spine (occiput, C1, C2) and cervicothoracic
CHAPTER 75
Spine Trauma and Spinal Cord Injury
Fulfills ALL eligibility requirements?
• Age ≥ 16 years
• GCS score of 15
• Normal vital signs (RR, 10-24 breaths/min; SBP > 90 mm Hg)
• Injury within 48 hours
• Blunt (not penetrating) neck trauma mechanism
• No acute paralysis
• No known vertebral disease
• Not evaluated previously for the same injury
• Not pregnant
Yes
Presence of ≥1 high-risk finding?
• Age ≥ 65 years
• Dangerous mechanism
Fall from ≥3 feet or 5 stairs
Axial loading to the head
Motor vehicle crash at >62 mph (100 km/hr)
Motor vehicle crash with rollover or ejection
Motorized recreational vehicle crash
Bicycle crash
• Extremity paresthesias
Yes
High risk:
Obtain imaging
No
Moderate risk:
Obtain imaging
No
Moderate risk:
Obtain imaging
No
Presence of ≥1 low-risk finding?
• Simple rear-end motor vehicle crash
• In a sitting position in the ED
• Ambulatory at any time after the trauma
• Delayed onset of neck pain
• Absence of midline cervical spine tenderness
Yes
Able to rotate neck 45° left and right actively?
Yes
Low risk:
Cervical spine clinically cleared
Fig. 75.5 Canadian Cervical-Spine Rule (CCR) algorithm for clinical clearance of the cervical spine. The green box signifies a
low-risk, negative work-up and clinical cervical spine clearance. Orange boxes signify a moderate-risk condition, and the red box signifies a
high-risk condition, both of which require plain film radiography. ED, Emergency department; GCS, Glasgow Coma Scale; RR, respiratory
rate; SBP, systolic blood pressure. (Data from Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS
low-risk criteria in patients with trauma. N Engl J Med 2003;349:2510-8.)
junction (C6, C7, T1), where coincidentally most cervical
spine fractures occur.12 It is important to obtain sagittal CT
reconstructions, in addition to the traditional axial views, to
adequately assess spinal alignment.
Cost analyses have shown that cervical spine CT scans are
actually less expensive than conventional radiography in highrisk patients. These studies factored personnel time, delays in
patient management while obtaining films, and the neurologic
sequelae of initially missing a cervical spine injury. Cost
savings are especially evident if the patient is already undergoing CT imaging of other body parts, such as head scanning
for a closed head injury. With multidetector scanners being
more readily available, an additional cervical spine scan
would add less than 5 minutes of scan time at a relatively
small cost.13
The risk for cancer from irradiation serves as the major
deterrent against universally performing CT in all patients
with neck trauma. It is estimated that up to 2% of cancers in
the United States are attributable to CT studies.14 The thyroid
gland, breast tissue, and lens are exposed to especially high
levels of radiation in cervical spine CT, thus placing the
patient at high risk for the development of thyroid cancer,
breast cancer, and cataracts. Patients receive an effective dose
of 0.2 millisievert (mSv) and 6 mSv for cervical spine plain
films and CT, respectively. In contrast, the effective dose of a
posteroanterior and lateral chest radiograph is just 0.1 mSv.15
The overall lifetime carcinogenic risk from CT imaging,
however, varies depending on the patient’s age at the time of
irradiation. Younger patients have greater risk, partly because
they have more years of life left for the development of cancer.
649
650
Yes
Normal
CT
Abnormal
films
Yes
Low risk:
Clinically clear cervical spine
Apply semirigid cervical collar and
refer for flexion-extension
films in 7-10 days
No
Can the patient actively flex
and extend the neck 30°?
Yes
Yes
Is significant persistent cervical No
spine tenderness present?
Normal
films
Neurologic or orthopedic
spine consultation
Abnormal
films
Obtain flexion-extension
plain films
Normal
films
Low risk:
Clinically clear cervical spine
Fig. 75.6 Diagnostic algorithm for a patient with neck pain resulting from blunt trauma. CCR, Canadian Cervical-Spine Rule; CT,
computed tomography; MRI, magnetic resonance imaging; NEXUS, National Emergency X-radiography Utilization Study.
No
Low risk:
Obtain plain films
Is a neurologic
deficit present?
No
Low risk:
Cervical spine cleared
Spinal cord injury risk:
Obtain cervical spine MRI
If concurrent
neurologic
deficit
Neurosurgical or orthopedic
spine consultation
Abnormal
CT
Moderate-high risk:
Obtain cervical spine CT
Yes
Presence of ≥ 1 high-risk or cost-effective criteria?
• Age ≥ 65 years
• Significant mechanism
• Significant neck tenderness
• Chronic corticosteroid treatment
• History of vertebral disease
• Body habitus likely to preclude adequate plain
film acquisition
• Going to CT for another body area
• A neurologic deficit consistent with a cervical
spinal cord injury
• A thoracic or lumbar spine injury
No
Is clinical clearance possible by
NEXUS or CCR criteria?
Low risk:
Cervical spine cleared
SECTION VIII
TRAUMATIC DISORDERS
CHAPTER 75
Spine Trauma and Spinal Cord Injury
Table 75.5 Advantages and Disadvantages of Plain Film Imaging and Computed Tomography of the Cervical Spine
PLAIN FILM RADIOGRAPHY
COMPUTED TOMOGRAPHY
Advantages
Less irradiation of the thyroid, breast, and lens
Can be performed at the bedside
98% sensitivity in detecting fractures
More cost-effective than plain films
Less delay in patient management, especially if the patient is
already going to CT scanner for imaging of another body
part
Disadvantages
Only 53% sensitivity in detecting fractures
Three-view films are inadequate >50% of the time,
especially films of the cervicocranial and
cervicothoracic junction
Inefficient use of radiology personnel, who are
often repeating films because of image
inadequacy
A suspicious fracture or one detected on plain
films requires additional evaluation by CT for
confirmation and further delineation
More irradiation of the thyroid, breast, and lens
Requires the patient to be hemodynamically stable because
of being transported out of the emergency department to
the CT scanner
Furthermore, children are more radiosensitive. If irradiated
after 40 years of age, the risk reaches its nadir, with an estimated lifetime attributable risk for death from cancer of less
than 0.2%.14
Because of such concerns for radiation exposure, low-risk
patients should undergo conventional radiography. Only
patients with radiographic evidence of an injury on plain films
should subsequently undergo CT scanning. For moderate- to
high-risk patients, cervical spine CT should be the first-line
imaging modality, especially for patients scheduled for CT
scanning of another body part.
Flexion-Extension Plain Film Radiography
A normal cervical CT image adequately excludes a cervical
spine fracture but cannot sufficiently evaluate ligamentous
instability. In patients who have sustained significant flexion,
extension, or rotational injury to the neck and have persistent
neck pain, ligamentous stability should be assessed within
10 days either in the ED or by a neurosurgeon or orthopedic
spine specialist.
In the ED, patients who are awake and alert and can actively
flex and extend their neck 30 degrees may undergo flexionextension plain film radiography to evaluate for spinal
stability. Vertebral body subluxation or focal widening of
the spinous processes suggests an unstable ligamentous
injury. Because no serious adverse outcomes have resulted
from voluntary neck movement by an awake, alert patient
without neurologic deficits, manual manipulation of the
patient’s neck should be avoided during flexion-extension
radiography.
Many acutely injured patients have such severe associated
cervical muscle spasms that they have limited neck mobility.
As a result, flexion-extension films are often inadequate,
and these patients should be immobilized in a semirigid
cervical collar (e.g., a Philadelphia or Miami J collar) and
undergo delayed flexion-extension plain film radiography
after 7 to 10 days, when the cervical muscle spasm
diminishes.
Magnetic Resonance Imaging
MRI is the best available modality for detection and characterization of spinal cord injury, but it is less sensitive than CT
for cervical spine fractures. In an acute trauma patient with
potential spinal injury, indications for emergency MRI include
(1) complete or incomplete neurologic deficits suspicious for
a spinal cord injury, (2) deterioration of spinal cord neurologic
function, and (3) signs of unstable ligamentous injury. Abnormal MRI findings may include the presence of spinal canal
compromise, disk herniation, and spinal cord edema or
hemorrhage.
OLDER AND OSTEOPENIC PATIENTS
Patients older than 65 years old and those taking corticosteroids on a long-term basis are probably osteopenic. They can
sustain spinal fractures with mild trauma, such as a fall from
a standing position, and often exhibit minimal associated pain.
Specifically, patients older than 65 years have an increased
risk for cervical spine fracture (relative risk of 2.09).16 In
addition, acute back pain in chronic corticosteroid users is
correlated with 99% specificity for a spinal compression fracture.17 Thus, imaging should be performed in these potentially
osteopenic patients in the setting of neck or back pain.
CLINICAL CLEARANCE OF THE CERVICAL SPINE
Not all patients require cervical spine imaging. To clinically
clear a cervical spine, the patient’s neck should be reevaluated
for tenderness. First, unfasten the cervical collar. Next, palpate
the posterior aspect of the patient’s neck while applying the
other hand to the patient’s forehead to prevent spontaneous
and reflexive head lifting. In the absence of significant midline
tenderness, remove your hands and instruct the patient to
actively lift the head off the gurney and place the neck through
a range of motion by looking right, left, caudad, and cephalad.
Do not assist the patient.
If the patient is able to move spontaneously and easily
without pain or neurologic symptoms, the patient’s neck is
considered to be “clinically cleared” and the collar may be
removed.
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SECTION VIII
TRAUMATIC DISORDERS
CLASSIC FRACTURE PATTERNS (Tables 75.6
to 75.8; Figs. 75.7 to 75.9)
FACTS AND FORMULAS
Ten percent of spinal fractures have a second noncontiguous fracture along the vertebral spine.
Ten percent of patients with a calcaneal fracture have an
associated thoracic or lumbar fracture.
The most commonly fractured cervical spine level is C2,
especially in the elderly.
Approximately 20% of computed tomography–confirmed
burst fractures in the thoracic and lumbar spine appear
as wedge fractures on plain film radiography.18
High-dose methylprednisolone is administered as a 30-mg/
kg bolus and then as a 5.4-mg/kg/hr infusion for 24 hours
(if started within 3 hours of injury) or for 48 hours (if
started within 8 hours of injury).
Consider early endotracheal intubation in spinal cord injury
patients with a negative inspiratory force of less than
−25 cm H2O or a vital capacity of less than 15 mL/kg.
CERVICAL SPINE INJURIES
Based on the NEXUS study of 818 patients with cervical
spine injury, fractures occurred most commonly at the
level of C2 (24% of all fractures), C6 (20%), and C7 (19%).
Anatomically, the most commonly fractured part of the cervical spine was the vertebral body, which accounted for 30% of
fractures at the C3 to C7 levels. It was more common than
fractures of the spinous process (21%), lamina (16%), and
articular process (15%). Subluxations occurred most commonly at the C5-C6 (25%) and C6-C7 (23%) levels.19
THORACIC AND LUMBAR SPINE INJURIES
Similar to patients undergoing cervical spine assessment, lowrisk patients may selectively be cleared clinically without
radiographic imaging. Although no large studies of thoracic
and lumbar spine injuries equivalent to the NEXUS and CCR
Table 75.6 Classic Upper Cervical Spine Injury Patterns (C1-C2)*
INJURY
MECHANISM
STABILITY
FIGURE
COMMENTS
Atlantooccipital
dislocation
Flexion
Unstable
75.7, A
Often instantly fatal
More common in children because of small, horizontally oriented
occipital condyles
Dislocation can be anterior (most common), superiorly distracted, or
posterior
Anterior
atlantoaxial
dislocation
Flexion
Unstable
75.7, B
Associated with rupture of the transverse ligament
Most commonly occurs in patients with rheumatoid arthritis and
ankylosing spondylitis from ligament laxity
Widening of the predental space seen on lateral plain films
Jefferson fracture
(C1 burst
fracture)
Axial
compression
Unstable
75.7, C
33% with associated C2 fracture
Low incidence of neurologic injury because of a wide C1 spinal canal
Usually involves fractures of both the anterior and posterior C1
arches, often with 3 or 4 fracture fragments
Complication: transverse ligament rupture, especially if the C1 lateral
masses are ≥7 mm wider than expected (MRI recommended);
vertebral artery injury (CT angiography recommended)
C1 posterior arch
fracture
Extension
Stable
75.7, C
An associated C2 fracture (occurs 50% of time) makes a posterior
arch fracture unstable
On plain films, no displacement of lateral masses on the odontoid
view and no prevertebral soft tissue swelling, unlike a Jefferson
burst fracture
C2 dens fracture
Flexion
Variable
75.7, D
Type I (stable): Avulsion of the dens with an intact transverse ligament
Type II (unstable): Fracture at the base of the dens; 10% have an
associated rupture of the transverse ligament—MRI provides a
definitive diagnosis of ligament rupture
Type III (stable): Fracture of the dens extending into the vertebral body
Hangman’s fracture
(C2
spondylolisthesis)
Extension
Unstable
75.7, E
Bilateral C2 pedicle fractures
At risk for disruption of the PLL, C2 anterior subluxation, and C2-C3
disk rupture
Low risk for spinal cord injury because of C2 anterior subluxation,
which widens the spinal canal
Extension teardrop
fracture
Extension
Unstable
75.7, F
Small triangular avulsion of the anteroinferior vertebral body at the
insertion point of the ALL
Occurs most frequently at the C2 level but can occur in the lower
cervical spine
Complication: central cord syndrome as a result of the ligamentum
flavum buckling during hyperextension
Requires CT differentiation from a very unstable flexion teardrop
fracture (see “flexion teardrop fracture” in Table 75.7)
ALL, Anterior longitudinal ligament; CT, computed tomography; MRI, magnetic resonance imaging; PLL, posterior longitudinal ligament.
*Listed in progressive order from the occiput, to C1, to C2.
652
CHAPTER 75
projects have been conducted, recommendations can be
extrapolated from the relevant literature.
Based on the NEXUS criteria, patients with (1) significant
back pain or tenderness, (2) clinical evidence of drug- or
alcohol-related intoxication, (3) lower extremity neurologic
deficits, (4) Glasgow Coma Scale score lower than 15, or (5)
a distracting injury cannot be cleared clinically for a thoracic
Spine Trauma and Spinal Cord Injury
or lumbar fracture. Patients with alcohol intoxication, for
example, should not be cleared clinically until they are sober
and found to fulfill no other high-risk criteria.
Furthermore, based on the CCR criteria and the American
Healthcare Research and Quality “red flag” indications for
imaging, injured patients who are (1) older than 65 years with
any degree of back pain or tenderness, (2) are receiving
Anterior atlantoocciptal
dislocation
Anterior dislocation
of C1 over C2
Dens
Skull
Brain
C1 atlas
C2 axis
Ruptured
transverse ligament
B
Stretched
spinal cord
Type I
Type II
Dens
A
Type III
C1 burst fracture
Anterior arch
Lateral mass
D
Transverse ligament
Posterior arch
C
Neck
extension
C1
Risk for C2
subluxation
from PLL rupture
C2
C1
C2
Bilateral C2
pedicle fracture
Avulsion of
C2 body
Risk for
C2-C3
disk rupture
ALL
F
E
Fig. 75.7 A, Cross-sectional sagittal view of anterior atlantooccipital dislocation with associated spinal cord injury. B, Posterolateral view
of anterior atlantoaxial dislocation from rupture of the transverse ligament. C, Posterolateral view of a C1 Jefferson burst fracture through
the anterior and posterior arch and an isolated C1 posterior arch fracture. D, Posterolateral view of the three types of C2 dens fractures.
E, Sagittal view of a hangman’s fracture with bilateral C2 pedicle fracture. PLL, Posterior longitudinal ligament. F, Sagittal view of a C2
extension teardrop fracture. ALL, Anterior longitudinal ligament.
653
SECTION VIII
TRAUMATIC DISORDERS
Table 75.7 Classic Lower Cervical Spine Injury Patterns (C3-C7)
INJURY
MECHANISM
STABILITY
FIGURE
COMMENTS
Articular mass
fracture
Flexionrotation
Stable
75.8, A
Associated with transverse process and vertebral body fractures
Uncommon
Burst fracture
Axial
compression
Stable
75.8, B
Compressive fracture of the anterior and posterior vertebral body
Intact ALL and PLL
Complication: spinal cord injury because of a retropulsed vertebral
body fragment (especially anterior cord syndrome)
Clay shoveler’s
(spinous process)
fracture
Flexion
Stable
75.8, B
Spinous process fracture from forceful neck flexion
Most commonly occurs in the lower cervical levels, usually C7
Not associated with neurologic injury
Extension teardrop
fracture
Extension
Unstable
75.7, F
Most commonly occurs at C2
See Table 75.6
Facet dislocation,
bilateral
Flexion
Unstable
75.8, C
Significant anterior displacement (>50%) of the spine when bilateral
inferior facets displace anterior to the superior facets below
At risk for injuring the disk, vertebral arteries, and spinal cord
Facet dislocation,
unilateral
Flexionrotation
Stable
75.8, D
Usually causes 25-50% anterior displacement of the spine
Complication: vertebral artery injury (CT angiography recommended)
Flexion teardrop
fracture
Flexion and
axial loading
Unstable
75.8, E
One of the most unstable fractures in the lower cervical spine
because it involves both columns
Fracture and anterior displacement of the anteroinferior vertebral
body (appears similar to an extension teardrop fracture except that
it is much more unstable)
Unique findings for flexion (versus extension) teardrop fractures
include same-level fractures and displacement of posterior
structures
Rupture of both ALL and PLL complexes
Usually occurs at C5 or C6
Can result from diving into shallow water or a football tackling injury
Often associated with spinal cord injury and tetraplegia
Subluxation, anterior
Flexion
Unstable
75.8, F
Anterior slipping of a vertebra over another
Ruptured PLL such that the anterior and posterior vertebral lines are
disrupted
Complication: vertebral artery dissection (CT angiography
recommended)
May be evident only during flexion views by conventional radiography
when the interspinous distance widens and the vertebral body
subluxates anteriorly
Transverse process
fracture
Lateral flexion
Stable
75.8, A
Complication: vertebral artery injury because it travels within the
transverse foramina (CT angiography recommended); associated
cervical radiculopathy and brachial plexus injuries in 10% of cases
Wedge fracture
Flexion
Stable
75.8, G
Compression fracture of only the anterosuperior vertebral body end
plate
Disruption of the anterior vertebral line
Intact posterior vertebral body and posterior vertebral line
ALL, Anterior longitudinal ligament; CT, computed tomography; PLL, posterior longitudinal ligament.
chronic corticosteroid therapy, or (3) have a history of vertebral disease should undergo radiography.
Classic patterns of thoracic and lumbar spine injuries are
shown in Table 75.8.
CLASSIFICATION OF SPINAL CORD
INJURIES
COMPLETE INJURY
A spinal cord injury is classified as physiologically complete
if the patient has no demonstrable motor or sensory function
654
below the level of injury. During the first few days following
injury, this diagnosis cannot be made with certainty because
of the possibility of concurrent spinal shock.
INCOMPLETE INJURY
A spinal cord injury is incomplete if motor function, sensation, or both are partially present below the level of the injury.
Signs of an incomplete injury may include (1) the presence
of any sensation or voluntary movement in the lower extremities or (2) evidence of sacral sparing. Signs of sacral sparing
include perianal sensation, voluntary anal sphincter contraction, and voluntary great toe flexion.
CHAPTER 75
Spine Trauma and Spinal Cord Injury
Vertebral body
Transverse foramen
C3
Transverse
process fracture
Fracture through
articular pillar
Superior
articular
facet
C4 burst
fracture
C5
A
Both C4 inferior facets “jump”
over C5 articular facets
C5 spinous
process fracture
C4 inferior
articular facet
C4
Posterior vertebral line
Anterior vertebral line
>50% anterior
displacement
C5
C5 superior
articular facet
B
Axial loading
C5 inferior
articular facet
Posterior
displacement
Flexion
C4
C
Posterior
ligamentous
instability
C5 flexion
teardrop
fracture
Single C4 inferior facet “jumps”
over C5 articular facet
C6
C4 inferior
articular facet
C4
E
C5
C5 superior
articular facet
C5 inferior
articular facet
D
Fig. 75.8 A, Superior axial view of an articular pillar fracture and transverse process fracture. B, Sagittal view of a C4 burst fracture and
C5 clay shoveler’s (spinous process) fracture. C, Sagittal view of bilateral C4 facet dislocation. D, Sagittal view of unilateral C4 facet
dislocation. E, Sagittal view of a C5 teardrop fracture.
Continued
655
C5 wedge fracture
with disruption of anterior vertebral line
C4 anterior subluxation
with disrupted anterior and posterior
vertebral lines
C4
C4
Posterior
ligamentious
instability
C5
Flexion
C5
Posterior vertebral line
Posterior vertebral line
Anterior vertebral line
Anterior vertebral line
G
F
Fig. 75.8, cont’d F, Sagittal view of C4 anterior subluxation. G, Sagittal view of a C5 wedge fracture.
Table 75.8 Classic Thoracic and Lumbar Spine Injury Patterns
INJURY
MECHANISM
STABILITY
Wedge
fracture
Flexion
Stable,
usually
75.8, G
Most common fracture in the thoracic spine
Isolated anterior column fracture
Disruption of the anterior vertebral line with an intact posterior vertebral line
(classic)
Maintain a low threshold to obtain spine CT for differentiation of a wedge
from a burst fracture (up to 22% of burst fractures appear to have an intact
posterior vertebral line)
Burst
fracture
Axial loading
Variable
75.8, B
Fracture of the anterior and middle columns
Disruption of the anterior and posterior vertebral lines (classic)
65% have associated spinal cord injury because of middle column
compromise
Chance
fracture
Flexiondistraction
Unstable
75.9, A
Fracture through the anterior, middle, and posterior columns, progressing
from posterior to anterior
Usually located at the T12-L2 junction
Classically caused by a lap belt hyperflexion mechanism in a motor vehicle
collision
33-89% associated with intraabdominal injury
Spinal cord injury is uncommon because of the distraction mechanism
Stable
75.9, B
Most common fracture in the lumbar spine
Classically has a vertical fracture orientation
A horizontal transverse process fracture orientation suggests a distraction
injury (Chance fracture)
More than 50% of transverse process fractures are missed by conventional
radiography and detected on spine CT
Clinically insignificant, but a risk factor for other injury patterns
50% associated with an intraabdominal injury
30% associated with a pelvic fracture (especially an L5 transverse process
fracture)
L2 transverse process fracture is associated with renal artery thrombosis
Unstable
75.9, C
Significant spinal misalignment and vertebral column discontinuity
Fracture through the anterior, middle, and posterior columns
Extremely high incidence of spinal cord injury
Transverse
process
fracture
Fracturedislocation
Compression
or
distraction
CT, Computed tomography.
656
FIGURE
COMMENTS
CHAPTER 75
Spine Trauma and Spinal Cord Injury
Intervertebral disk
Transverse
process
L1
Spinous
process
Vertebral body
L2
Transverse
process
Spinous process
L3
B
Spinal canal
Fracture from posterior
through anterior column
A
High risk for
spinal cord injury
L1
L2
L3
Spinal canal
C
Fig. 75.9 A, Sagittal view of an L2 Chance (flexion-distraction) fracture. B, Superior axial view of a transverse process fracture in a typical
lumbar spine. C, Sagittal view of an L1-L2 fracture-dislocation injury, which is at high risk for a spinal cord injury because of discontinuity of
the spinal canal.
Specific incomplete spinal cord injuries include central
and anterior cord syndromes, Brown-Séquard syndrome, and
conus medullaris syndrome. Patients with these syndromes
have certain characteristic patterns of neurologic injury with
distinct findings on physical examination.
CENTRAL CORD SYNDROME
Central cord syndrome is the most common spinal cord
syndrome and is usually due to neck hyperextension. Trauma
to the central portion of the cord results in injury to the
medially located corticospinal motor tracts of the upper
extremities. As a result, the upper extremities are predictably
and disproportionately weaker than the lower extremities.
Many patients exhibit bladder dysfunction (e.g., urinary
retention) and varying degrees of sensory loss. Elderly
patients are more at risk for central cord syndrome because
of underlying cervical spondylosis, a thickened ligamentum
flavum, or both.
ANTERIOR CORD SYNDROME
Anterior cord syndrome results from blunt or ischemic injury
to the anterior spinal cord. Affected patients have a complete
and usually bilateral motor deficit below the level of the injury
along with loss of pain and temperature sensation a few levels
below the lesion. Typically, posterior column function is
preserved.
BROWN-SÉQUARD SYNDROME
Brown-Séquard syndrome is a rare hemicord injury that is
usually associated with penetrating trauma. Patients have
crossed sensory and motor deficits: ipsilateral loss of motor
function and position sense below the level of the lesion and
contralateral loss of pain and temperature sensation one to two
levels below the injury.
CONUS MEDULLARIS SYNDROME
Conus medullaris syndrome results from injury to the spinal
cord with occasional involvement of the lumbar nerve roots.
It results in areflexia of the bladder, bowel, and lower extremities. Patients may exhibit perianal numbness. Motor and
sensory deficits in the lower limbs vary.
CAUDA EQUINA SYNDROME
Although cauda equina syndrome is not a direct spinal cord
injury because the cauda equina is composed entirely of
peripheral nerves (lumbar, sacral, and coccygeal nerve roots),
657
SECTION VIII
TRAUMATIC DISORDERS
RED FLAGS (PITFALLS)
Fig. 75.10 In-line cervical spine immobilization during
endotracheal intubation. Standing to the patient’s side, the
assistant uses both hands to stabilize the neck to prevent
hyperextension.
it still requires emergency neurosurgical intervention. Clinical
findings include asymmetric sensory loss, weakness of the
lower extremities, urinary retention or incontinence, decreased
rectal tone, and saddle anesthesia.
TREATMENT
Prehospital and ED management should include protection of
the spine and spinal cord until injuries can be identified or
excluded. A rigid backboard should typically be removed
promptly from beneath cooperative patients because a calm
person can maintain spinal column neutrality. Extended use
of a rigid backboard is associated with complications such as
back pain, respiratory impairment, aspiration, and decubitus
ulcers.
IN-LINE IMMOBILIZATION OF THE CERVICAL SPINE
During the initial resuscitation phase of trauma victims,
patients with a potential cervical spine injury may require
endotracheal intubation before a definitive diagnosis can
be made. By preventing neck hyperextension during
direct laryngoscopy, in-line cervical spine immobilization
during intubation maintains cervical spine neutrality (Fig.
75.10).
NEUROGENIC SHOCK
Neurogenic shock results from a sympathectomy-induced
reduction in blood pressure, heart rate, cardiac contractility,
and cardiac output. Overly vigorous fluid resuscitation can be
hazardous because of compromised cardiac output. Judicious
use of vasopressors such as phenylephrine hydrochloride,
dopamine, and norepinephrine is often indicated. Significant
bradycardia should be treated hemodynamically with atropine.
Systolic blood pressure lower than 80 mm Hg is rarely due
to neurogenic shock alone, and other causes of shock, primarily from hemorrhage, must be excluded. It should never be
assumed that hypotension is due to spinal shock until hemorrhage is excluded.
CORTICOSTEROID THERAPY FOR SPINAL CORD INJURY
Though controversial, treatment of blunt spinal cord injury
with high-dose methylprednisolone is common. This
658
Failure to identify occult injuries in hypoesthetic areas. For
example, in a patient with a midthoracic sensory level
deficit, occult intraabdominal injuries may be hidden
because the abdomen may be insensate.
Failure to consider a spinal cord injury in a patient with
normal radiographic and computed tomographic (CT)
findings.
Failure to repeat plain films or obtain CT imaging when plain
film radiographs of the cervical, thoracic, or lumbar spine
are inadequate.
Failure to exclude other causes of hypotension in a trauma
patient before assuming that it is neurogenic shock. A
search for occult blood loss should first be done.
Failure to consider a distracting injury, particularly fractures,
as a reason for a patient’s ability to localize neck and
back pain.
therapeutic recommendation is based on the findings of the
National Acute Spinal Cord Injury Study (NASCIS), which
demonstrated improved neurologic function in patients receiving high-dose corticosteroids within 8 hours of injury.
Improved neurologic function, however, was defined as a
modest gain in motor scores but not functional improvement.
In NASCIS, a loading dose of 30 mg/kg of methylprednisolone administered over a 15-minute period was followed by
an infusion of 5.4 mg/kg/hr and continued for 24 hours (in
patients treated within 3 hours of injury) or 48 hours (in
patients treated 3 to 8 hours after injury).20,21 No benefit was
found when steroids were administered more than 8 hours
after injury.
Steroid therapy is not indicated for penetrating injuries
and has not been adequately studied in children younger
than 13 years or in patients with cauda equina or spinal
root injury.
Finally, systemic corticosteroid therapy is not benign. Complications of steroid therapy include gastrointestinal hemorrhage and wound infection in patients treated with
corticos­teroid infusions for 24 hours and higher rates of
severe sepsis and severe pneumonia in those treated for 48
hours. The use of steroids for blunt traumatic spinal cord
injury is far from the standard of care.22 More research is
needed to verify or refute this controversial therapy.
SURGICAL MANAGEMENT OF SPINAL CORD INJURY
Timely reduction of the displaced spinal column plus decompression of the spinal cord has been associated with recovery
from otherwise devastating spinal cord injuries.23 The
optimal timing of surgery following a spinal injury remains
controversial. Some argue for immediate surgery, whereas
others advocate delayed surgery because of the initial posttraumatic swelling. The sole absolute indication for immediate surgery is progressively worsening neurologic status in
patients with spinal fracture-dislocations who initially have
incomplete or absent neurologic deficits.24
CHAPTER 75
PRIORITY ACTIONS
Provide pain control.
Maintain full spinal precautions until the spine can be cleared
radiographically or clinically.
If intubating a trauma patient, an assistant should provide
in-line cervical spine immobilization until the cervical
spine can be assessed more definitively at a later time.
Perform a careful initial neurologic examination, especially in
patients who are about to undergo sedation or neuromuscular blockade.
If a spinal fracture is suspected or detected, evaluate for
associated injuries:
• For the cervical spine, examine for associated head
and facial injuries.
• For the thoracic spine, examine for rib fractures and
pulmonary, cardiac, diaphragmatic, and mediastinal
injuries.
• For the lumbar spine, examine for intraabdominal injuries, pelvic fractures, and calcaneal fractures.
• For all spinal levels, examine for spinal cord injury.
Obtain urgent spine imaging if a fracture or spinal cord injury
is suspected.
Obtain emergency magnetic resonance imaging of the spine
if a spinal cord injury is suspected.
Consider administering corticosteroids if an adult patient has
sustained blunt spinal trauma and exhibits neurologic
deficits within 8 hours of injury.
TIPS AND TRICKS
Prolonged immobilization on a rigid backboard is uncomfortable for the patient and places the patient at risk for
aspiration and early pressure sores. Aim to remove the
backboard as soon as possible and ideally within 2 hours
of patient arrival. A standard hospital gurney provides
adequate thoracic and lumbar stability.
Perform serial neurologic examinations on patients with suspected or known spinal injuries to document neurologic
improvement or deterioration. Neurologic deterioration
involving the cervical and upper thoracic levels may
require empiric endotracheal intubation for impending
respiratory failure.
Once a spinal injury is detected, carefully reexamine the
entire cervical, thoracic, and lumbar spine. Obtain plain
films or computed tomography scans of any levels with
pain or tenderness because of the high risk for a second
spinal injury.
When performing “clinical clearance” of a patient’s cervical
spine or obtaining flexion-extension cervical spine plain
films, do not passively range the neck for the patient. This
may cause an iatrogenic spinal injury. Pain with active
movement will prevent the patient from overranging the
neck.
Spine Trauma and Spinal Cord Injury
In a series of patients with traumatic central cord syndrome,
those who underwent early surgery (<24 hours after injury)
and had an underlying disk herniation or fracture-dislocation
exhibited significantly greater overall motor improvement
than did those who underwent late surgery (>24 hours after
injury).25 Unfortunately, early decompressive surgery does not
uniformly improve outcome following spinal cord injury.
FOLLOW-UP, NEXT STEPS IN CARE, AND PATIENT EDUCATION
Most patients with traumatic spinal fractures are admitted to
the hospital because they fulfill at least one of four admission
criteria: (1) intractable pain, (2) fracture involvement of more
than one column, (3) a functionally unstable fracture pattern,
and (4) the presence or potential for development of a spinal
cord injury.
Patients who can be discharged home include those with
normal neurologic function and (1) an isolated, stable posterior column fracture (spinous process, transverse process) in
the cervical, thoracic, or lumbar spine or (2) a stable wedge
fracture in the thoracic or lumbar spine.
Patients with confirmed or suspected spinal cord injury
should be scheduled for early consultation with a neurosurgeon or orthopedist. This may require transfer of the patient
to a spine specialty center.
The level of the spinal cord injury, associated neurologic
deficits, and other traumatic injuries will determine whether
the patient should be admitted to the intensive care unit, neurosurgical observation unit, or general ward. Circular beds,
rotating frames, and serial inflation devices are used to protect
the patient from pressure sores.
Discharged patients without a fracture or spinal cord injury
require only conservative management. Discharged patients
with a stable spinal fracture require only conservative management with or without an immobilization device, such as a
cervical collar or thoracolumbar sacral orthosis back brace.
Soft collars and back braces are not recommended because
they predispose patients to stiffness of the neck and back,
respectively.
Discharged patients with persistent neck pain who are still
at risk for an unstable ligamentous injury should wear a semirigid cervical collar (e.g., Philadelphia or Miami J collar) for
7 to 10 days until adequate flexion-extension plain films can
be obtained. Discharge instructions should include information about the warning signs of spinal cord injury.
DOCUMENTATION
Document neck and back tenderness, along with the neurologic examination, in all trauma patients.
In spinal cord injury patients, mark the initial level of sensory
deficit to monitor progression of the patient’s neurologic
status.
For patients with neurologic deficits, perform and document
the bulbocavernosus reflex and sacral-sparing examination to assess for spinal shock.
659
SECTION VIII
TRAUMATIC DISORDERS
SUGGESTED READINGS
1. 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;277:1597-604.
2. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria
to rule out injury to the cervical spine in patients with blunt trauma. N Engl J
Med 2000;343:94-9.
660
3. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus
the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349:
2510-8.
REFERENCES
References can be found
www.expertconsult.com.
on
Expert
Consult
@
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