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SPINAL CORD
TRAUMA
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and
medical author. He graduated from Ross
University School of Medicine and has
completed his clinical clerkship training
in various teaching hospitals throughout
New York, including King’s County
Hospital Center and Brookdale Medical
Center, among others. Dr. Jouria has
passed all USMLE medical board exams, and has served as a test prep tutor and
instructor for Kaplan. He has developed several medical courses and curricula for a
variety of educational institutions. Dr. Jouria has also served on multiple levels in the
academic field including faculty member and Department Chair. Dr. Jouria continues
to serves as a Subject Matter Expert for several continuing education organizations
covering multiple basic medical sciences. He has also developed several continuing
medical education courses covering various topics in clinical medicine. Recently, Dr.
Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human
Anatomy & Physiology.
ABSTRACT
Most spinal trauma cases do not generally involve complete severance
of the spinal cord. Spinal trauma usually includes fracture and
compression of the vertebrae, such as crush injuries and nerve cell
destruction. Some spinal cord trauma may eventually heal with
complete recovery while others result in complete paralysis. New hope
exists for spinal trauma cases with improved emergency care for
individuals with spinal cord injuries, including aggressive treatment
and rehabilitation that can minimize damage to the nervous system
and even restore limited abilities.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 3.5 hours. Nurses may only
claim credit commensurate with the credit awarded for completion of
this course activity. Pharmacy content is 0.5 hours (30 minutes).
Statement of Learning Need
Individuals with spinal trauma and permanent damage may face
challenges to healing and lifelong recovery. The effects of damage to
the spinal cord also influence other body systems, which require health
clinicians to engage in continuous learning to improve patient
knowledge of their spine injury and treatment plan.
Course Purpose
This course will provide advanced learning for health clinicians
interested in the management of the patient with spinal trauma during
initial stabilization, early treatment and ongoing interventions that
promote recovery and healing.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. The annual incidence of spinal cord injuries in the U.S., is
approximately
a.
b.
c.
d.
22
35
40
65
cases
cases
cases
cases
per
per
per
per
million.
million.
million.
million.
2. True or False: Spinal stenosis is a condition caused by the
compression or narrowing of the spinal canal.
a. True
b. False
3. The thoracic vertebrae are located in what region of the
body?
a.
b.
c.
d.
Coccyx
Upper and middle back
Neck
Lower back
4. Central cord syndrome involves hyperextension injuries as
well as
a.
b.
c.
d.
spinal cord ischemia, and cervical spinal stenosis.
a cervical lesion always with lower extremity motor weakness.
a burning sensation in the lower extremities only.
All of the above
5. Spinal stabilization surgery involves
a. removal of bone fragments.
b. restoring vertebral alignment to reduce spinal cord
compression.
c. a 72-hour minimum delay in all cases.
d. Answers a., and b., above
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Introduction
Spinal cord trauma affects a number of individuals each year, and the
injuries can be life threatening. There are approximately 200,000
people living with spinal cord injuries in the United States. Additionally,
there are approximately 12,000 to 20,000 new cases of spinal cord
trauma annually.1 Spinal cord trauma is primarily caused by motor
vehicle accidents, falls, industrial accidents, assault, sports related
injuries, and gunshot wounds.2 Spinal cord injury (SCI) is an important
contributing factor to morbidity and mortality in the United States.
Most spinal injuries don't completely sever the spinal cord. Instead, a
spinal injury is more likely to cause fractures and compression of the
vertebrae, which then crush and destroy nerve cells that carry signals
up and down the spinal cord between the brain and the rest of the
body.3
Early Identification And Treatment
A patient may experience an incomplete or complete spinal injury
depending on the location and extent of damage. Each type of injury
requires different treatment and will affect the patient differently.
Some spinal cord injuries will allow almost complete recovery, and
others will result in complete paralysis.4 Early identification and
treatment is crucial for minimizing the initial damage and preventing
secondary injuries, which are common with spinal cord trauma. In
recent years, the diagnosis and management of spinal cord injuries
has improved with advancements in technology and treatment options.
There are a number of options available for the diagnosis of spinal cord
injuries, including Computed Tomography (CT) scans, Magnetic
Resonance Imaging (MRIs), X-Rays, and other advanced imaging
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procedures. In addition, improved emergency care for people with
spinal cord injuries and aggressive treatment and rehabilitation have
made it easier to manage spinal cord injuries in the trauma patient.
The availability of these advanced measures enable the treatment
providers to minimize damage to the nervous system and even restore
limited abilities.
Definition of Spinal Cord Trauma
Spinal cord trauma is defined as any injury that occurs in the spinal
column. Spinal injuries are often the result of accidents that cause
significant impact, and often occur in conjunction with other traumatic
injuries such as head or abdominal injuries.5
Patients who experience spinal trauma will present with different
injuries, depending on the location of the injury, the cause of the
injury, and the severity of the injury. Since a spinal injury can occur in
any region of the spinal column, the patient will experience a variety of
symptoms.2
To fully understand the complexity of spinal cord trauma, the health
clinician must be familiar with the anatomy of the spinal column. The
spinal column is composed of thirty-one bones, which are called the
vertebrae. The vertebrae are further categorized, based on the type
and location of the bones.6
The following table highlights the different names and regions of the
vertebrae.7
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Name
Region
Number of vertebrae
Cervical Vertebrae
Neck
7
Thoracic Vertebrae
Upper and Middle Back
12
Lumbar Vertebrae
Lower Back
5
Sacral Vertebrae
Sacrum
5
Fused Coccygeal
Vertebrae
Coccyx (commonly known
as the tailbone)
2
Each of the vertebrae is part of a distinct region and they each
function as independent vertebral bodies. In fact, each vertebra is part
of an independent vertebral body and vertebral arch.8 The vertebral
arch and vertebral body come together to form a vertebral foramen,
which is an enclosed opening. Each vertebra is stacked on top of
another vertebra. The stacked vertebra form the vertebral foramen,
which is the formation for the spinal column.9
The spinal column contains the spinal cord, which is responsible for
communication between the brain and the rest of the body.10 The
spinal cord is a bundle of nerves that extends from the brain and
branches outward peripherally.11 The spinal cord is very fragile, and
trauma to the spinal column may affect the spinal cord, thereby
causing neurologic impairments. These impairments may be temporary
or permanent and will range in severity.12
The central nervous system is comprised of the spinal cord and the
brain, and both components work together to control the body’s
functions. The spinal cord is responsible for coordinating movement
and sensation.8 The nerves within the spinal cord serve as transmitters
of signals to the brain. These signals initiate the functions controlled
by the spinal cord. When the nerves in the spinal cord are damaged,
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they are not able to regenerate.9 Therefore, the patient often
experiences permanent damage as the result of spinal cord trauma.13
The spinal cord, while small, is very complex. It is comprised of
neurons and axons that both transmit signals to the brain. The axons
are responsible for sending signals downward from the brain using
descending pathways. Axons also send signals upward to the brain
using ascending pathways.11 A substance called myelin, which acts as
a sheath over the nerve structure, protects the axons. The myelin is
whitish, which is why the region they are contained in is referred to as
“white matter.”10 The neurons contain branching structures called
dendrites. These structures are responsible for receiving signals from
other nerve cells. The dendrites have a greyish appearance, which is
why the region that contains them is called “grey matter.”14 The grey
matter is contained in a section of the spinal cord that is butterfly
shaped.
The entire spinal cord is enclosed within three membranes, known as
the8

Pia Mater – inner layer

Arachnoid – middle layer

Dura Mater – outer layer
The entire spinal cord is divided into segmented areas that fall along
the length of the column. Each area is comprised of specific nerves
that control distinct regions of the body. The following table lists each
segment and the region it controls.15
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Segment
Name
C1 – C8
Cervical Region
Responsibility
Controls signals to the neck,
arms, and hands
T1 – T12
Thoracic Region
(Upper Back Region)
L1 – L5
Lumbar Region
(Mid-Back Region)
S1 – S5
Sacral Region
Relays signals to the torso and
parts of the arms
Controls signals to the hips
and legs
Control signals to the groin,
toes, and parts of the legs
Damage to specific regions of the spinal cord will result in problems
with functions in the areas of the body connected to those regions.
Therefore, if a patient experiences trauma to the lumbar region, he or
she will experience problems with hip and leg movement or feeling.16
The uninjured spinal cord coordinates all of the movement and
sensation throughout the body. The higher segments are responsible
for controlling these functions in the upper regions of the body, while
the lower segments of the spinal cord control the functions of the
lower regions of the body. Damage to any area of the spinal cord will
most likely affect movement and sensation in one or more areas of the
body.17
The exact injury and resulting disability caused by spinal cord trauma
will vary depending on a number of factors, including the type of
injury, the severity of the injury, the segment of the cord that is
injured, and which nerves are damaged. In severe trauma, the
damage to the spinal cord causes paralysis to the region controlled by
the cord, as well as a complete loss of sensation in the associated
area.18 If the trauma affects a significant portion of the spinal cord, the
patient will experience full paralysis. Further complications may
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develop after a patient experiences trauma to the spinal cord such as
the result of damage to the body’s functions.12
A spinal cord injury typically occurs when a patient experiences a
sudden blow to the spine. In many instances, this impact will cause
fractures and dislocations within the vertebrae, which will result in
damage to the patient’s spinal region.19 Initial damage occurs during
impact, and often manifests as displaced bone fragments, ruptured
discs, or bruises and/or tears in the ligaments and spinal cord tissue.15
This initial damage will often cause damage to the axons and neural
cell membranes, which cannot be repaired. In some patients, the
impact will cause the blood vessels to rupture, thereby resulting in
bleeding in the spinal grey matter and other areas of the spinal cord.3
Many patients will experience swelling of the spinal cord, which will
happen within a short period of time. The spinal cord will typically
swell enough to fill the cavity of the spinal canal, thereby reducing or
cutting off blood flow and oxygen to the spinal cord tissue.20 In
addition, patients may experience a drop in blood pressure, which will
interfere with the activity of the neurons and axons. Once a patient
experiences the symptoms listed above, he or she is at risk of spinal
shock, which can last for a number of days.21 Approximately fifty
percent of spinal trauma patients will experience spinal shock.22 It is
more common in patients who experience severe injury.19 When a
patient experiences spinal shock, he or she will temporarily lose the
function of most of the spinal cord, which will often result in lack of
sensation and reflexes. Some patients may experience complete
paralysis.16
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After the initial trauma phase, the spinal column will continue to
experience damage. It is especially common for the patient’s axons
and neurons to be destroyed, which will cause an inflammatory
response in the patient’s immune system.23 This response will result in
additional damage to other parts of the patient’s body and can occur in
the days or weeks following an injury. In many instances, this
additional damage will cause the patient’s long-term complications to
become even more severe and long lasting.19 Therefore, it is important
to begin treating the patient as soon as possible to minimize any
further damage.
The following table provides an overview of the changes that will occur
in the days and weeks following the initial trauma.24
Changes in Blood
The major reduction in blood flow to the site following the
Flow Cause
initial injury can last for as long as 24 hours and become
Ongoing Damage
progressively worse if there is continued compression of
the cord due to swelling or bleeding. Because of the
greater blood flow needs of gray matter, the impact is
greater on the central cord than on the outlying white
matter.
Blood vessels in the gray matter also become leaky,
sometimes as early as 5 minutes after injury, which
initiates spinal cord swelling. Cells that line the still-intact
blood vessels in the spinal cord also begin to swell, and
this further reduces blood flow to the injured area. The
combination of leaking, swelling, and sluggish blood flow
prevents the normal delivery of oxygen and nutrients to
neurons, causing many of them to die.
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Excessive Release
of
Neurotransmitters
Kills Nerve Cells
After the injury, an excessive release of neurotransmitters
(chemicals that allow neurons to signal each other) can
cause additional damage by over-stimulating nerve cells.
The neurotransmitter glutamate is commonly used by
axons in the spinal cord to stimulate activity in other
neurons. But when spinal cells are injured, their axons
flood the area with glutamate and trigger additional nerve
cell damage. This process kills neurons near the injury
site and the myelin-forming oligodendrocytes at and
beyond the injured area.
An Invasion of
Immune System
Cells Creates
Under normal conditions, the blood-brain barrier keeps
potentially destructive immune system cells from entering
the brain or spinal cord.
Inflammation
This barrier is a naturally occurring result of closely
spaced cells along the blood vessels that prevent many
substances from leaving the blood and entering brain
tissues. But when the blood-brain barrier breaks down,
immune system cells — primarily white blood cells — can
invade the spinal cord tissue and trigger an inflammatory
response. This inflammatory response can cause
additional damage to some neurons and may kill others.
Free Radicals
Attack
Nerve Cells
Another consequence of inflammation is the increased
production of highly reactive forms of oxygen molecules
called free radicals — chemicals that modify the chemical
structure of other molecules in damaging ways, for
example, damaging cell membranes. Free radicals are
produced naturally as a by-product of normal oxygen
metabolism in small enough amounts that they cause no
harm. But injury to the spinal cord causes cells to
overproduce free radicals, which destroy critical molecules
of the cell.
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Nerve Cells
Self-destruct
For reasons that are still unclear, spinal cord injury sets
off apoptosis, which is a normal process of cell death that
helps the body get rid of old and unhealthy cells.
Apoptosis kills oligodendrocytes in damaged areas of the
spinal cord days to weeks after the injury. Apoptosis can
strip myelin from intact axons in adjacent ascending and
descending pathways, causing the axons to become
dysfunctional and disrupting the spinal cord’s ability to
communicate with the brain.
Scarring Occurs
Following a spinal cord injury, astrocytes (star-shaped
glial cells that support the brain and spinal cord) wall off
the injury site by forming a scar, which creates a physical
and chemical barrier to any axons which could potentially
regenerate and reconnect. Even if some intact myelinated
axons remain, there may not be enough to convey any
meaningful information to or from the brain.
Epidemiology
Spinal cord trauma affects a number of individuals each year, and the
injuries can be life threatening. There are approximately 200,000
people living with spinal cord injuries in the United States. Additionally,
there are approximately 12,000 to 20,000 new cases of spinal cord
trauma annually.2 Spinal cord trauma is primarily caused by motor
vehicle accidents, falls, industrial accidents, assault, sports related
injuries, and gunshot wounds.1 Approximately twenty-five percent of
all spinal cord traumas involve alcohol.25
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The following table, provided by the National Spinal Cord Injury
Statistical Center, gives a full overview of the epidemiological
breakdown of spinal cord injuries.26
Incidence
It is estimated that the annual incidence of spinal cord
injury (SCI), not including those who die at the scene of the
accident, is approximately 40 cases per million population
in the U.S., or approximately 12,000 new cases each year.
Since there have not been any incidence studies of SCI in
the U.S., since the 1990's it is not known if incidence has
changed in recent years.
Prevalence
The number of people in the United States who are alive in
2012 who have SCI has been estimated to be
approximately 270,000 persons, with a range of 236,000 to
327,000 persons. (Note: Incidence and prevalence statistics
are estimates obtained from several studies. These
statistics are not derived from the National SCI Database).
Age at Injury
SCI primarily affects young adults. From 1973 to 1979, the
average age at injury was 28.7 years, and most injuries
occurred between the ages of 16 and 30. However, as the
median age of the general population of the United States
has increased by approximately 9 years since the mid1970, the average age at injury has also steadily increased
over time. Since 2005, the average age at injury is 41
years.
Other possible reasons for the observed trend toward older
age at injury might include changes in either referral
patterns to model systems, the locations of model systems,
survival rates of older persons at the scene of the accident,
or age-specific incidence rates.
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Gender
Overall, 80.6% of spinal cord injuries reported to the
national database have occurred among males. Over the
history of the database, there has been a slight trend
toward a decreasing percentage of males. Prior to 1980,
81.8% of new spinal cord injuries occurred among males.
Race/Ethnicity
A significant trend over time has been observed in the
racial/ethnic distribution of persons in the database. Among
persons injured between 1973 and 1979, 76.8% were
Caucasian, 14.2% were African American, 1.9% were
Native American and 0.9% were Asian. However, among
those injured since 2005, 66.0% are Caucasian, 26.2% are
African American, 0.9% are Native American and 2.1% are
Asian.
Hispanic origin increased from 5.9% in 1970’s to 12.5% in
2000-2004 and 8.3% since 2005. This trend is due in part
to trends in the United States general population and also
possibly explained by the changing locations of model
systems, referral patterns to model systems, or racespecific incidence rates.
Etiology
Since 2005, motor vehicle crashes account for 39.2% of
reported SCI cases. The next most common cause of SCI is
falls, followed by acts of violence (primarily gunshot
wounds). The proportion of injuries that are due to sports
has decreased over time while the proportion of injuries
due to falls has increased. Violence caused 13.3% of spinal
cord injuries prior to 1980, and peaked between 1990 and
1999 at 24.8% before declining to only 14.6% since 2005.
Neurologic
Persons with tetraplegia have sustained injuries to one of
Level and
the eight cervical segments of the spinal cord; those with
Extent of
paraplegia have lesions in the thoracic, lumbar, or sacral
Lesion
regions of the spinal cord.
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Since 2005, the most frequent neurologic category at
discharge of persons reported to the database is incomplete
tetraplegia (40.8%), followed by complete paraplegia
(21.6%), incomplete paraplegia (21.4%) and complete
tetraplegia (15.8%). Less than 1% of persons experienced
complete neurologic recovery by hospital discharge. Over
the last 15 years, the percentage of persons with
incomplete tetraplegia has increased while complete
paraplegia and complete tetraplegia have decreased.
Occupational
More than half (57.1%) of those persons with SCI admitted
Status
to a model system reported being employed at the time of
their injury. At one year after injury, 11.7% of persons with
SCI are employed. By 20 years post-injury, 35.2% are
employed and a similar level of employment is observed
through post-injury year 35.
Residence
Overall, 89.3% of all persons with SCI who are discharged
alive from the system are sent to a private, noninstitutional residence (in most cases their homes before
injury). Only 6.6% are discharged to nursing homes. The
remaining are discharged to hospitals, group living
situations or other destinations.
Marital Status
Considering the youthful age of most persons with SCI, it is
not surprising that most (51.7%) are single when injured.
Among those who were married at the time of injury, as
well as those who marry after injury, the likelihood of their
marriage remaining intact is slightly lower when compared
to the general population. The likelihood of getting married
after injury is also reduced.
Length of Stay
Overall, median days hospitalized in the acute care
medical/surgical unit for those who enter a model system
immediately following injury has declined from 24 days
between 1973 and 1979 to 11 days since 2005.
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Substantial downward trends are noted for days in the
rehab unit (from 98 to 37 days). Overall, median days
hospitalized (during acute care and rehab) were greater for
persons with neurologically complete injuries.
Types Of Spinal Injuries
Overview
There are a number of different types of spinal cord injuries, which
vary depending on the location and severity of the injury. At the most
basic level, spinal injuries are divided into two distinct categories of
1) complete injury, and 2) incomplete injury.
Complete Injury
In a complete injury, the spinal cord is sufficiently damaged across the
whole of its width such that there is no function (either sensation or
muscle control) below the level of injury.
Incomplete Injury
In an incomplete injury, the injury does not spread across the whole of
the spinal cord; some areas away from the injury remain intact or at
least intact enough to retain some function. People with incomplete
injuries have some sensation and/or movement control below the level
of injury. Sometimes, one side of the body is more affected than the
other.27
The two categories of spinal injury are used to distinguish spinal
injuries. However, clinicians also use these categories during spinal
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assessment to identify the type and severity of the injury. The
American Spinal Injury Association further breaks down the categories
into an assessment scale that can be used to determine the extent of
spinal injury. The following are the categories that comprise the
American Spinal Injury Association Impairment Scale.28
A = Complete:
No sensory or motor function is preserved in the sacral segments S4-S5.
B = Sensory Incomplete:
Sensory but not motor function is preserved below the neurological level and
includes the sacral segments S4-S5 (light touch, pin prick at S4-S5: or deep
anal pressure (DAP)), AND no motor function is preserved more than three
levels below the motor level on either side of the body.
C = Motor Incomplete:
Motor function is preserved below the neurological level, and more than half of
key muscle functions below the single neurological level of injury (NLI) have a
muscle grade less than 3 (Grades 0-2).
D = Motor Incomplete:
Motor function is preserved below the neurological level, and at least half (half
or more) of key muscle functions below the NLI have a muscle grade > 3.
E = Normal:
If sensation and motor function as tested with the ISNCSCI are graded as
normal in all segments, and the patient had prior deficits, then the AIS grade is
E. Someone without an initial SCI does not receive an AIS grade.
For an individual to receive a grade of C or D, i.e. motor incomplete status,
they must have either (1) voluntary anal sphincter contraction or (2) sacral
sensory sparing with sparing of motor function more than three levels below
the motor level for that side of the body. The Standards at this time allows
even non-key muscle function more than 3 levels below the motor level to be
used in determining motor incomplete status (AIS B versus C).
NOTE: When assessing the extent of motor sparing below the level for
distinguishing between AIS B and C, the motor level on each side is used;
whereas to differentiate between AIS C and D (based on proportion of key
muscle functions with strength grade 3 or greater) the single neurological
level is used.
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An incomplete spinal cord injury will cause different injury patterns
depending on the type, location and severity of injury. Therefore,
there are standard classifications that are used to identify incomplete
injuries; and, these are shown below.29
Anterior Cord
Syndrome
Results from damage to the motor and sensory
pathways in the anterior areas of the spinal cord.
Effects include loss of movement and overall
sensation, although some sensations that travel by
way of the still intact pathways can be felt.
Central Cord
Syndrome
Results from injury to the center of the cervical area
of the spinal cord. The damage affects the
corticospinal tract, which is responsible for carrying
signals between the brain and spinal cord to control
movement.
Patients of central cord syndrome experience
weakness or paralysis in the arms and some loss of
sensory reception.
The loss of strength and sensation is much less in the
legs than in the arms. Many patients with central
cord syndrome spontaneously recover motor
function, and others experience considerable
recovery in the first six weeks following the injury.
Brown-Sequard
Syndrome
Results from injury to the right or left side of the
spinal cord. On the side of the body where the injury
occurred, movement and sensation are lost below the
level of the injury. On the side opposite the injury,
temperature and pain sensation are lost due to the
crossing of these pathways in the spinal cord.
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Cauda Equina
Cauda equina syndrome refers to a characteristic
pattern of neuromuscular and urogenital symptoms
resulting from the simultaneous compression of
multiple lumbosacral nerve roots below the level of
the conus medullaris (see the image below).
These symptoms include low back pain, sciatica
(unilateral or, usually, bilateral), saddle sensory
disturbances, bladder and bowel dysfunction, and
variable lower extremity motor and sensory loss.
Conus Medullaris
The conus medullaris syndrome may involve
disturbances of urination (usually from a denervated,
autonomic bladder that manifests clinically with
overflow incontinence) and sphincter impairment or
sexual dysfunction. Sensory involvement may affect
the sacral and coccygeal segments, resulting in
saddle anesthesia.
Pure lesions of the conus medullaris are rare.
Injuries to Individual
Nerve Cells
Result in loss of sensory and motor function in the
area of the body to which the injured nerve root
corresponds. Thus, symptoms from these injuries
vary depending on the location and function of the
particular nerve root.
Spinal Contusions
The most common type of spinal cord injury. The
spinal cord is bruised, not severed, but the
consequence is inflammation and bleeding from blood
vessels near the injury. A spinal contusion results in
temporary (usually one to two days) incomplete or
complete debilitation of the spinal cord.
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Cuts to the Spinal Cord
In some trauma situations, a patient will experience direct cuts to the
spinal cord. Cuts are especially common in instances when the bones
or disks of the spinal region have been weakened.6 Cuts can be caused
directly by the accident, especially in instances involving shrapnel,
gunshots, or knives.30 In other instances, the cut to the spinal cord will
occur as a secondary injury. Secondary cuts are often the result of
fragments of bone that have broken off during impact.31
Spinal Compression
Spinal compression can occur as the result of a number of different
injuries and incidents and is considered a neurological emergency.20
Early identification and diagnosis is imperative as untreated spinal
compression can cause long-term damage, such as permanent loss of
function. Spinal cord compression will range in severity and
distinguishing factors, depending on the type, location and severity of
injury.
The following is a list of the different patterns of injury that will occur
when a patient experiences spinal compression.3
Complete Cord Injury

Absence of any motor or sensory function below the level of
the injury.

Minimal chance of functional recovery.
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Anterior Cord Syndrome

Caused by direct anterior cord compression, flexion injuries of
cervical spine, or thrombosis of anterior spinal artery.

Leads to variable paralysis below lesion level with loss of pain
and temperature perception.

Dorsal columns (proprioception and vibration sense) are
mainly preserved.

Poor prognosis.
Brown-Séquard's Syndrome

Caused by hemi-transection or unilateral compression of the
cord.

Ipsilateral spastic paresis and loss of proprioception and
vibration sense.

Contralateral loss of pain and temperature perception.

Moderately good prognosis.
Central Cord Syndrome
 Caused by hyperextension injuries, spinal cord ischemia and
cervical spinal stenosis.
 Usually involves a cervical lesion, with greater motor weakness
in the upper extremities than in the lower extremities.
 The pattern of motor weakness shows greater distal
involvement in the affected extremity than proximal muscle
weakness.
 Sensory loss is variable, with pain and/or temperature
sensation more likely to be affected than proprioception
and/or vibration.
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 Burning sensation, especially in the upper extremities, is
common.
 There is usually sacral sensory sparing.
Posterior Cord Syndrome

Very rarely occurs in isolation.

Caused by penetrating trauma to the back or hyperextension
injury associated with vertebral arch fractures.

Loss of proprioception and vibration sense.

Motor and pain/temperature sensation preserved.
Spinal Cord Concussion

Rarely occurs.

Temporary cessation of spinal cord neurological function, but
spontaneous recovery occurs within 48 hours.
Spinal Shock

Spinal shock results from autonomic dysfunction and the
interruption of sympathetic nervous system control in acute
spinal cord injuries.

Spinal shock is characterized by severe autonomic dysfunction,
resulting in hypotension, relative bradycardia, peripheral
vasodilation and hypothermia.

It occurs with spinal cord injuries above T6 but does not
usually occur with injuries below the level of T6 (hypotension
and/or shock with acute spinal cord injury at or below T6 is
usually caused by hemorrhage).

Areflexia, which is loss of sensation and flaccid paralysis below
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the level of the lesion, and flaccid bladder and loss of rectal
tone, as well as bradycardia and hypotension.
Spinal Cord Injury Without Radiological Abnormality (SCIWORA)

SCIWORA can be diagnosed only after scans have shown no
bony or ligamentous injury.

This is more common in children (as their spine is more flexible
and less likely to sustain vertebral fracture) and carries a poor
prognosis.
Displacement of the Spine
In some instances, the spine will become displaced. This occurs as the
result of direct impact to the spine during accidents. Spinal
displacement can cause more significant problems in the patient as the
displacement will often cause swelling and bruising in the spinal
region.32
Some patients will experience displacement in areas of the spinal
column that will affect mobility and other functions. In most instances,
the displacement can be repaired. However, some patients will
experience permanent damage from spinal displacement.33
Bleeding and Fluid Buildup
In many instances, bleeding and fluid buildup will occur as the result of
spinal trauma. The blood and fluid are often caused by the initial
injury. However, they can also cause additional secondary injuries. In
most instances, the accumulation of blood or excess fluid will cause
pressure in the spinal region. This increase in pressure will often
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damage the spinal cord, and can sometimes kill spinal cord neurons.34
Excess blood and fluid must be reduced immediately to avoid these
complications.19
Swelling
Many patients will experience swelling immediately following a spinal
cord injury. Swelling is caused by the initial damage, but will expand
to other regions of the spinal column within a short period of time.35
The spinal cord will typically swell enough to fill the cavity of the spinal
canal. Thereby reducing or cutting off blood flow and oxygen to the
spinal cord tissue.22
Common Causes Of Spine Trauma
Motor Vehicle Accidents
Motor Vehicle accidents account for the highest number of trauma
cases in the United States.36 Of those, a number involve spinal cord
trauma injuries. The U.S. Department of Transportation breaks motor
vehicles into categories involving, among other things, the type of
vehicle (i.e., passenger car, light truck, motorcycle, etc.), fatal versus
non-fatal accidents, pedestrian, and statistics for accidents involving
alcohol.37 When discussing spinal cord trauma caused by motor vehicle
accidents, all of the types listed above are included.
In 2009, approximately 2.3 million adults were admitted to emergency
departments for treatment for injuries sustained during a motor
vehicle accident.38 Most injuries sustained during a motor vehicle
accident cause significant trauma to the patient as they impact a
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number of areas on the body. In addition, motor vehicle accidents are
one of the leading causes of death in the United States.39
Motor vehicle accidents that cause injuries are often severe and result
in significant damage to the driver and passengers.38 Due to the blunt
force caused by the accident, as well as the amount of flying debris
caused by breaking glass, shards of metal and other random objects,
injuries often occur both internally and externally. It is rare for a
patient to sustain only spinal cord injuries during a motor vehicle
accident.
In most instances, the patient will present with a number of injuries,
including but not limited to spinal cord injuries.40 Many injuries
sustained during a motor vehicle accident cause permanent damage
and often result in a significant lifelong disability.41 While motor vehicle
accidents pose a significant risk of causing spinal cord trauma, the
chances are increased by a number of factors.

Increased Speed:
Increased speed has a direct impact on the potential for a crash
as well as the amount of damage and severity of injuries that
result from the crash.

Drinking and Driving:
Drinking and driving often increases the severity and type of
injuries caused. Intoxicated drivers and passengers are also at a
higher risk of sustaining severe injuries due to their limited
response time and relaxed physical state.
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
Seat Belts and Child Restraints:
Many drivers and passengers choose not to wear a seatbelt or a
proper child restraint system. Not being properly secured in the
vehicle can cause the individual to be propelled from the vehicle,
most often through the windshield or other window, during an
accident. If an individual is not propelled through the windshield,
he or she will still be thrown around the vehicle during the
accident, which can cause additional injuries.

Helmet Use (Motorcycles):
Motorists who fail to wear a helmet when riding on a motorcycle
risk sustaining severe head, neck and spinal cord injuries during
an accident. The motorist is not protected in any way during a
motorcycle crash, and the blunt trauma that occurs to the head
without the protection of a helmet is severe and significant.
According to the World Health Organization (WHO), wearing a
helmet during a motorcycle accident reduces the chance of a
severe injury by approximately 70 percent.

Distracted Driving:
While distracted driving directly increases the chances of a motor
vehicle accident, it is also responsible for increasing the chances
that the motorist will sustain more severe injuries. Distracted
driving can occur for a variety of reasons, including the use of
mobile devices, not paying attention to the road, talking to other
motorists, applying makeup, etc. However, the most common
cause of distracted driving is the use of mobile devices. Drivers
who use mobile devices when driving are at an increased risk of
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sustaining severe injuries as the driver is not properly engaged
with the vehicle.36
Violent Assault Injuries
Violent assault injuries comprise approximately fifteen percent of
spinal cord trauma cases.2 Assault injuries can be caused by either
blunt or penetrating trauma and will often result in extensive, severe
damage.42 The type and severity of the injury will vary depending on
the cause of the trauma, and will have to be treated accordingly. The
majority of assault injuries are caused by physical attacks, the force of
an individual being thrown to the ground, or by stabbing or gunshot
trauma.6
Industrial and Occupational Accidents
Industrial and occupational accidents include a variety of different
events and have differing effects on the individual. Industrial accidents
account for the majority of occupational related accidents.43 However,
many different occupations pose a risk of accidents that can result in
trauma. Due to the vast differences between occupations, it is difficult
to categorize and define occupational trauma. Each occupation poses
its own risk. Treatment will depend on the type of accident.
In the case of industrial occupations, individuals typically sustain
injuries from coming into contact with machines. In many cases,
trauma is caused when an individual falls into or is pulled into a
machine.44 This often results in extensive damage to the internal
organs and bones. Other occupations also pose a risk of accidents that
can cause spinal trauma. The construction trade is highly dangerous
and is responsible for a number of occupational trauma cases.
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According to the Occupation Health and Safety Administration (OHSA),
there are distinct causes of death and severe injury in the construction
industry, and they are listed below.45

Falls:
Construction workers are often situated well above the ground
while they are working. Therefore, the highest incidence of
workplace injuries occurs as the result of falls. Falls result in
both internal and external trauma. Common fall related injuries
include head trauma, broken bones, spinal trauma and internal
organ damage.

Flying or Falling Object:
Objects often strike individuals as part of construction work.
These objects may be small flying objects or they may be large
falling objects. Each type of flying object will inflict different
types of damage on the individual. Smaller objects will often
pierce the skin and may also cause trauma to internal organs.
Large objects have the potential to crush the individual and
cause severe head and spinal trauma.

Crushed Between Two Objects:
Much like industrial accidents, construction accidents are often
caused when an individual falls into a machine or when the
individual is crushed between two objects. This will cause severe
internal damage and may also result in spinal damage.
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Sports Injuries
Many sports related accidents do not cause spinal trauma; however,
some accidents have the potential to do so. These accidents typically
involve a blunt force from physical contact or an injury caused by a
fall.46 Physical contact sports such as football and hockey pose the risk
of severe head, neck and spinal injury due to the impact caused from
hitting into another player of from hitting objects such as the wall or
the ground.47
Other sports also present the risk for spinal trauma. These sports
include hiking, skiing, rafting, and snowboarding.48 Each sport
presents a specific risk. For example, skiing and snowboarding
accidents often involve significant falls and/or crashes involving trees
or other objects. These accidents typically result in severe head and
spinal trauma.2 Hiking accidents typically involve falls, which can result
in spinal trauma.
While they are not commonly considered sport related injuries, injuries
caused by recreational vehicles are included in this category. This
includes all terrain vehicles (ATV’s), snowmobiles and four wheelers.
These vehicles are not included in the section on motor vehicle related
accidents, as they are not considered motor vehicles. Therefore, they
are included in this section as recreational vehicles, which are often
considered sporting vehicles.
Recreational vehicles are responsible for a significant number of the
trauma cases each year. Regardless of the type of recreational vehicle,
the driver and passenger travel at high speeds in unsafe conditions
(snow, mud, trails), with minimal protective gear.49 Most recreational
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vehicle accidents cause the driver and passenger to be thrown some
distance from the vehicle and often involve impact with another object
(tree, ground, vehicle, building). Therefore, the injuries sustained
during recreational vehicle accidents are quite severe. It is common for
individuals to sustain head, neck and spinal injuries as the result of a
recreational vehicle accident.46
Ballistic Trauma
Ballistic trauma, which is the trauma caused by firearms, is often
severe, if not fatal. There are approximately 500,000 gunshot wounds
per year in the United States, and these wounds typically cause severe
damage.50 The amount and severity of injury caused by firearms
depends on a number of factors, and these are listed below.51
•
Type of weapon or bullet used
•
Distance from weapon
•
Location and trajectory/path of injury
•
Permanent versus temporary cavity
All firearm injuries are not the same. Injury and trauma level depends
on the type of firearm used. Typically, firearm injuries are categorized
as either low velocity injuries or high velocity injuries, and they are
classified based on the type of firearm used and the projectile impact
that is caused.52 Low velocity injuries are primarily caused by firearms
with a muzzle velocity of less than 600 meter per second (m/s). Most
low velocity firearm injuries are caused by handguns and are more
prevalent than other types of injuries.50 High velocity injuries are
caused by firearms with a muzzle velocity of more than 600 meter per
second.
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Military weapons or high-powered hunting rifles cause most high
velocity injuries.52 Injury severity and pattern differs depending on
whether it is a low velocity injury or a high velocity injury.
Gunshots cause injuries upon impact and can affect all different parts
of the body depending on the location of initial impact. Therefore,
multiple traumas can occur externally and internally and may be
located in one specific area of the body, such as the head, spine or the
chest.53 However, when a bullet makes impact with the body, it can
produce extensive damage as it moves throughout the body. Upon
initial impact, the bullet crushes the tissue of the individual. From
there, the bullet propels forward and creates a tunnel that expands
throughout the path of projection to create a larger tunnel. The tunnel
is temporary, but it causes damage to the tissue and ligaments in the
surrounding areas. Damage is caused by compression, deformation
and shear force. Once the bullet has passed through the temporary
cavity, the cavity decreases in size and returns to normal. However,
the bullet does leave behind a permanent cavity in the location of
cavitation. The tissue in this area will be permanently damaged.54
Damage is often dependent on the type of bullet used. Bullets that are
encased with hard shells produce deeper penetration and more
significant cavitation. Bullets with soft or hollow points typically deform
or fragment and often ricochet inside the body.52 This can produce
damage to more areas. The actual injuries are influenced by a number
of factors, including the point of entry and the distance that the victim
is from the weapon.55 Some guns, such as shotguns, contain small
pellets that spread apart when they are released from the barrel. This
produces a blast that spreads over a larger area and will often cause
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damage to numerous areas of the body rather than one specific point
of entry. However, these produce less damage when fired from a
greater distance.50
Gunshot wounds are not limited to the point of entry. Gunshots also
have the potential to create exit wounds as the bullet may leave the
body after tunneling through.51 In addition, gunshots can produce
contact wounds, which occur when a gun is held directly against the
skin. Exit wounds can be more severe than entrance wounds as the
bullet often expands within the body.52 The impact of the bullet, the
path it takes, and the injuries it causes are dependent upon a number
of factors. If a bullet deforms or fragments once it enters the body, it
can cause damage to numerous bones and organs.53
Contributing Factors And Complications
While spinal trauma can be severe and damaging on its own, there are
a number of contributing factors that will increase an individual’s
susceptibility to spinal damage following a trauma situation. In
addition, spinal trauma can further exacerbate spinal issues that are
already present in the patient, as well as cause life long spinal
complications.
Rheumatoid Arthritis
Rheumatoid arthritis can weaken the spinal column, thereby increasing
the patient’s chances of experiencing a spinal injury.56 In patients with
rheumatoid arthritis, the spine is already weak. When the patient
experiences spinal trauma, the weakened area is more prone to
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damage than it would be in a patient who does not have rheumatoid
arthritis.57
Osteoporosis
Osteoporosis is a frequent consequence of spinal cord injury and is
present in almost every instance of spinal cord trauma.58 However, the
osteoporosis experienced as the result of spinal cord trauma differs
from that caused by other issues such as endocrine disorders.59
Trauma-related osteoporosis will produce a different bone loss pattern
and will typically cause an increase in lower extremity fractures.60 The
amount of bone loss caused by trauma related osteoporosis will vary
depending on the type and severity of injury, the age and sex of the
patient, and the patient’s muscle spasticity.61 Regardless of the extent
of damage, trauma related osteoporosis will cause fragility to the
bones and will increase the patient’s risk of fracture.58
Spinal Stenosis
Spinal stenosis is a condition that is caused by compression of the
spinal canal. This condition is often referred to as narrowing of the
spinal canal. When the spinal canal is compressed, it causes the spinal
cord and nerve roots to become pinched, which results in increased
pain, cramping, weakness and numbness.62 Spinal stenosis is often
caused by factors such as osteoarthritis. However, it can also occur as
the result of spinal trauma. When spinal stenosis is caused by trauma,
the location of the narrowing will depend on the type and location of
the injury.
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The symptoms that a patient can experience will vary, which depends
on the location of the injury and the subsequent narrowing.
Depending on the location of narrowing, patients will typically
experience symptoms in the lower back, legs, neck, shoulders, or
arms.63
Patients may not experience the symptoms of spinal stenosis
immediately following spinal trauma. In many patients, the symptoms
will develop over time as the compression worsens.62 Most symptoms
will begin slowly and worsen over time. Eventually, the symptoms will
be severe enough that they will limit a patient’s ability to carry out
daily functions such as walking short distances. In many instances, the
patient will require frequent breaks and will need to lean forward onto
a solid surface to ease the pain associated with spinal stenosis.64
Spinal Trauma Injury Levels
Spinal trauma will vary depending on the region of the spinal column
that is injured. Therefore, spinal cord injuries are classified based on
the region they affect. The following table provides descriptions for
each injury level.6
Cervical Spinal
Cord Injury
C1 – C8
Cervical level injuries cause paralysis or weakness in both
arms and legs (quadriplegia). All regions of the body below
the level of injury or top of the back may be affected.
(Quadriplegia,
also known as
Tetraplegia)
Sometimes this type of injury is accompanied by loss of
physical sensation, respiratory issues, bowel, bladder, and
sexual dysfunction. This area of the spinal cord controls
signals to the back of the head, neck and shoulders, arms
and hands, and diaphragm.
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Since the neck region is so flexible it is difficult to stabilize
cervical spinal cord injuries. Patients with cervical level
injuries may be placed in a brace or stabilizing device.
Thoracic Spinal
Thoracic level injuries are less common because of the
Cord Injury
protection given by the rib cage. Thoracic injuries can
T1- T12
cause paralysis or weakness of the legs (paraplegia) along
with loss of physical sensation, bowel, bladder, and sexual
dysfunction.
In most cases, arms and hands are not affected. This area
of the spinal cord controls signals to some of the muscles
of the back and part of the abdomen. With these types of
injuries most patients initially wear a brace on the trunk to
provide extra stability.
Lumbar Spinal
Cord Injury
L1-L5
Lumbar level injuries result in paralysis or weakness of the
legs (paraplegia). Loss of physical sensation, bowel,
bladder, and sexual dysfunction can occur. The shoulders,
arms, and hand function are usually unaffected.
This area of the spinal cord controls signals to the lower
parts of the abdomen and the back, the buttocks, some
parts of the external genital organs, and parts of the leg.
These injuries often require surgery and external
stabilization.
Sacral Spinal Cord
Sacral level injuries primarily cause loss of bowel and
Injury
bladder function as well as sexual dysfunction. These types
S1 – S5
of injuries can cause weakness or paralysis of the hips and
legs. This area of the spinal cord controls signals to the
thighs and lower parts of the legs, the feet, and genital
organs.
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Symptoms for Spinal Injuries
The symptoms for spinal injuries will differ depending on the type and
location of the injury. When observing and analyzing symptoms, the
spinal injuries are broken into the following regions:

Cervical (near the neck)

Thoracic (chest region)

Lumbar Sacral (lower back)
The following section provides an overview of the various symptoms
that may be present during spinal cord trauma.34
Cervical (Near The Neck) Injuries
When spinal cord injuries occur near the neck, symptoms can affect
both the arms and the legs. These symptoms are outlined below as:

Breathing difficulties (from paralysis of the breathing muscles)

Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms)

Numbness

Sensory changes

Spasticity (increased muscle tone)

Pain

Weakness, paralysis
Thoracic (Chest-Level) Injuries
When spinal injuries occur at chest level, symptoms can affect the legs
and result in a variety of symptoms, such as:

Breathing difficulties (from paralysis of the breathing muscles)
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
Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms)

Numbness

Sensory changes

Spasticity (increased muscle tone)

Pain

Weakness, paralysis
Injuries to the cervical or high-thoracic spinal cord may also result in
blood pressure problems, abnormal sweating, and trouble maintaining
normal body temperature.
Lumbar Sacral (Lower-Back) Injuries
When spinal injuries occur at the lower-back level, varying degrees of
symptoms can occur and affect the legs, such as:

Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms)

Numbness

Pain

Sensory changes

Spasticity (increased muscle tone)

Weakness and paralysis
Symptoms vary depending on the level of spinal trauma, which is
diagnosed through the use of an assessment scale and other
diagnostic techniques. The performance of a physical exam, including
neurological evaluation of reflexes, and other tests to ensure a prompt
and accurate diagnosis is discussed further in the section below.
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Diagnosis Of Spinal Trauma
It is imperative that spinal trauma be diagnosed immediately so that
the patient can receive the appropriate treatment. Since spinal
damage will worsen over time, immediate treatment is necessary to
minimize the long term effects.65 The initial diagnosis utilizes
diagnostic imaging techniques such as X-rays, MRIs, and CT Scans. In
addition, the clinician will conduct a thorough neurologic examination.
The purpose of the neurologic examination is to measure the patient’s
limb and trunk reflexes, as well as sensation and muscle tone.7 Once
the assessments are complete, the results will be compiled on an
American Spinal Injury Association (ASIA) Classification of Spinal
Injury Scale. This scale provides a means for categorizing the injury
and identifying appropriate treatment.
Computed Tomography Scan/Magnetic Resonance Imaging
The two most common diagnostic assessments used in instances of
spinal trauma are computed tomography (CT) scan and magnetic
resonance imaging (MRI).
Computed Tomography Scan
Computed tomography scan is a diagnostic imaging procedure that
produces horizontal, or axial, images of the body. These images are
often called “slices”.66 The CT scan uses a combination of X Ray
imaging and computer technology to obtain the images in a
noninvasive format.67 A CT scan is an important diagnostic tool as it is
able to provide detailed images of different parts of the body. It is
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especially useful in obtaining images of the bones, muscles, fat and
organs.68
Computed tomography scans are used more frequently than standard
X-rays because the images are more detailed.69 Standard X-rays use a
single beam of energy that is aimed at the specific body part being
analyzed. The image is captured on a plate that is placed behind the
body, once the beam of light passes through the various body parts
(skin, bone, muscle, and tissue).70
An X-ray is limited in its ability to provide detailed imaging, as X-ray
cannot capture images of internal organs and other structures of the
body. Therefore, a CT scan is often the primary assessment used. A CT
scan uses a moving X-ray beam to capture the images. The beam
circles around the body, thereby capturing a number of different views
of the same body part.71 The information is transmitted to a computer,
which then interprets the data and creates a two-dimensional form.
The form is displayed on a monitor, which is then reviewed by the
radiologist.72 CT scans are conducted in two ways, as explained below.
Contrast CT:
During a contrast CT scan patients ingest a substance orally, or
receive an injection intravenously. The contrast solution enables the
radiologist to view the specific body part or region more clearly.
Non-Contrast CT:
The non-contrast CT scan is conducted without the use of any
solution.73 CT scans are used frequently in instances of spinal trauma
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as they provide thorough views of the brain and the spine. A CT scan
is especially useful for detecting the following injuries in spinal trauma
patients:74

Bone fractures

Bleeding

Spinal stenosis
Computed tomography scans are less useful in detecting injuries to the
spinal cord or any ligament injuries associated with an unstable
spine.75
Magnetic Resonance Imaging
Magnetic Resonance Imaging is a radiologic scan that produces images
of various body structures using a combination of magnetism, radio
waves and computer technology. The MRI is conducted using a large
circular magnet that surrounds a scanner tube.76 Placing the patient on
a movable surface and inserting him or her into the magnetic tube
allows images to be obtained. Once the patient is in the tube, a strong
magnetic field is created. This magnetic field aligns the protons of the
hydrogen atoms. Once the hydrogen atoms are aligned, they are
exposed to a beam of radio waves. The radio waves impact the
protons within the body, causing them to spin, thereby producing a
faint signal, which is easily detected by the MRI receiver. The
information obtained by the scanner is sent to a computer, where it is
processed to produce an image.74
An MRI utilizes high-resolution technology, which allows it to produce
highly detailed images that will show changes in many of the
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structures in the body.77 In some instances, additional agents will be
used to enhance the accuracy of the images. It is most common to use
contrast agents such as gadolinium, while keeping in mind that routes
of administration may have a negative effect on particular patients,
such as those with renal failure.21 Due to the MRI’s high level of
sensitivity, it is able to detect many injuries that are undetectable
using other methods.78 While an MRI and CT scan both use the slicing
technique for obtaining images, the process is different for each. The
MRI uses a magnetic field while the CT scan uses X-rays.76 As a result,
the MRI provides more detailed images than a CT scan and is able to
detect damage that is as small as 1 – 2 mm. A CT scan cannot detect
damage this small.71
Magnetic Resonance Imaging is used to assess both brain and spinal
injuries as it provides detailed images of areas of the spine that other
diagnostic imaging technology cannot obtain. An MRI can detect basic
injuries, as well as any bleeding and inflammation that may be
present. It is also useful in detecting injuries to the cervical spine
ligaments.79
Myelogram
A myelogram, or myelography, is a diagnostic imaging procedure that
utilizes a combination of contrast substance with a standard X-ray or a
CT scan. The myelogram is used when diagnosing and identifying
abnormalities present in the spinal canal.80 It is especially useful for
detecting abnormalities in the spinal cord, nerve roots and tissue. The
contrast dye is injected into the region that is being assessed and it
enables the radiologist to obtain a more detailed view of the area.70 In
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many instances, the myelogram will utilize a standard X-ray.
However, in some instances, the radiologist will use a CT scan.81
Regardless of the mechanism, a myelogram will provide a more
detailed image of the spinal canal, and is often used when another
diagnostic imaging method is inconclusive.82
Somatosensory Evoked Potential (SSEP)
A Somatosensory Evoked Potential (SSEP) detects and provides
images of the electrical signals of sensation that travel from the body
to the brain. This test is used to identify areas where there may be
problems with the nerves that connect to the spinal cord.83 The images
help the radiologist determine if the nerves are properly sending and
receiving sensory information. An SSEP is used in conjunction with
other diagnostic tools to identify and diagnose problems in the spinal
column.84 It is often used to detect areas of the spine that may be
pinched or damaged. It can also detect the presence of a bone spur,
herniated disc, or area of the spine that is compressed or experiencing
an increase in pressure.83 It is also used after surgery to ensure that
all nerves are working properly. An SSEP does not show the cause of
the problem, but it does show the damage that has been caused.
Additional diagnostic tests are used to determine what is causing the
nerve to be pinched or compressed.84
Cervical Spine X-ray
A cervical spine X-ray is used to identify any complications associated
with back and neck pain.95 A cervical X-ray is commonly used when a
patient presents with neck pain following a trauma situation of if the
patient is experiencing chronic neck pain in conjunction with upper
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limb weakness, numbness or tingling.68 A cervical spine X-ray is
commonly used to identify cervical vertebrae fractures (bone breaks),
vertebral misalignment, dislocation and degenerative spine disease.71
When a cervical spine X-ray is conducted as part of an emergency
trauma situation, the images are interpreted immediately so that
treatment can begin as soon as possible.7 Since the images are being
interpreted in an emergency department, it is often an emergency
physician who interprets them.70 Most often, it will be an emergency
physician, orthopedic surgeon, or general surgeon who is already
involved in the care and treatment of the patient. If a radiologist is
available, he or she will often be asked to interpret the images.71 The
following is a description of the process used to perform the cervical
spine X-ray.86
Cervical Spine X-Ray (C-Spine X-Ray) is performed by a
radiographer in an X-Ray room. The standard three views
taken are the AP (anteroposterior view, which looks at the
spine from the front); lateral (which looks at the spine
from the side) and peg view (this looks at the upper part
of the cervical spine and requires the patient to open the
mouth wide). The 5-series also includes flexion and
extension views. X-Rays are taken with the patient’s head
in full flexion (leaning as far forward as possible). The
patient will be asked to bend the head forward as far as
possible, and to extend the neck backwards as far as
possible.
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Appropriateness Criteria For Use Of Diagnostic Imaging
The evaluation of individuals with spine trauma involves a collaborative
approach between medical specialties and radiology. Although there
remains questions and controversy about which patient needs imaging
and the type or amount of imaging necessary, there are some
standard criteria to help guide patient care. The American College of
Radiology provides the following appropriateness criteria for the use of
diagnostic imaging in patients with suspected spinal trauma.87 These
are categorized according to the level or severity of injury, and are
age-specific. The appropriateness criteria is outlined in the tables
below specific to a particular condition related to suspected spinal
trauma, and lists each variant radiologic procedure and rating, along
with the relative radiation exposure encountered.
Major Recommendations ACR Appropriateness Criteria®
Clinical Condition: Suspected Spine Trauma
Variant 1: Cervical spine imaging not indicated by NEXUS or CCR
clinical criteria (patient meets low-risk criteria).
Radiologic Procedure
Rating
X-ray cervical spine
1
CT cervical spine without
contrast
1
CT cervical spine with
contrast
1
CT cervical spine without
and with contrast
1
Myelography and post
myelography CT cervical
spine
1
Comments
RRL
With sagittal and coronal
reformat.
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CTA head and neck with
contrast
1
MRI cervical spine without
contrast
1
O
MRI cervical spine without
and with contrast
1
O
MRA neck without and
with contrast
1
O
MRA neck without
contrast
1
O
Arteriography
cervicocerebral
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 2: Suspected acute cervical spine trauma
Imaging indicated by clinical criteria (NEXUS or CCR). Not otherwise
specified.
Radiologic Procedure
Rating
Comments
CT cervical spine
without contrast
9
With sagittal and coronal reformat.
X-ray cervical spine
6
Lateral view only. Useful if CT
reconstructions are not optimal.
CT cervical spine with
contrast
1
CT cervical spine
without and with
contrast
1
Myelography and post
myelography CT
cervical spine
1
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46
CTA head and neck
with contrast
1
See variant 6.
MRI cervical spine
without contrast
1
See variant 3.
O
MRI cervical spine
without and with
contrast
1
See variant 3.
O
MRA neck without and
with contrast
1
See variant 6.
O
MRA neck without
contrast
1
See variant 6.
O
Arteriography
cervicocerebral
1
See variant 6.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 3: Suspected acute cervical spine trauma
Imaging indicated by clinical criteria (NEXUS or CCR). Myelopathy.
Radiologic Procedure
CT cervical spine
without contrast
Rating
9
Comments
With sagittal and coronal reformat.
MRI and CT provide complementary
information. It is appropriate to
perform both exams.
RRL
MRI cervical spine
without contrast
9
MRI and CT provide complementary
information. It is appropriate to
perform both examinations.
O
X-ray cervical spine
6
Lateral view only. Useful if CT
reconstructions are not optimal.
Myelography and post
myelography CT
cervical spine
5
If MRI is contraindicated or
inconclusive.
CT cervical spine with
contrast
1
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CT cervical spine
without and with
contrast
1
MRI cervical spine
without and with
contrast
1
CTA head and neck
with contrast
1
See variant 6.
MRA neck without and
with contrast
1
See variant 6.
O
MRA neck without
contrast
1
See variant 6.
O
Arteriography
cervicocerebral
1
See variant 6.
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 4: Acute cervical spine trauma
Imaging indicated by clinical criteria (NEXUS or CCR). Treatment
planning for mechanically unstable spine.
Radiologic Procedure
CT cervical spine
without contrast
Rating
9
Comments
With sagittal and coronal reformat.
RRL
MRI cervical spine
without contrast
8
Useful for thorough evaluation of
ligamentous injury.
O
X-ray cervical spine
6
Either lateral views only, or AP,
lateral, open mouth, and oblique
views may be appropriate.
Individualized in consultation with
ordering physician for surgical
planning.
Myelography and post
myelography CT
cervical spine
4
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CT cervical spine with
contrast
1
CT cervical spine
without and with
contrast
1
MRI cervical spine
without and with
contrast
1
CTA head and neck
with contrast
1
See variant 6.
MRA neck without and
with contrast
1
See variant 6.
O
MRA neck without
contrast
1
See variant 6.
O
Arteriography
cervicocerebral
1
See variant 6.
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 5: Suspected acute cervical spine trauma
Imaging indicated by clinical criteria (NEXUS or CCR). Patient
persistently clinically unevaluable for >48 hours.
Radiologic
Procedure
CT cervical spine
without contrast
Rating
Comments
RRL
MRI cervical spine
without contrast
8
To look for ligamentous injury,
cord pathology, and edema. May
be complementary to MDCT (see
narrative).
O
X-ray cervical spine
4
Limited use when there are motion
artifacts on CT.
9
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CT cervical spine with
contrast
1
CT cervical spine
without and with
contrast
1
MRI cervical spine
without and with
contrast
1
Myelography and post
myelography CT
cervical spine
1
CTA head and neck
with contrast
1
MRA neck without and
with contrast
1
O
MRA neck without
contrast
1
O
Arteriography
cervicocerebral
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 6: Suspected acute cervical spine trauma.
Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or
imaging findings suggest arterial injury.
Radiologic
Procedure
CT cervical spine
without contrast
Rating
Comments
9
With sagittal and coronal reformat.
Another CT is not needed if already
done on initial evaluation.
CTA head and neck
with contrast
9
Either CTA or MRA can be performed
depending on institutional preference.
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MRA neck without
and with contrast
9
Either CTA or MRA can be performed
depending on institutional preference.
See statement regarding contrast in
text under "Anticipated Exceptions."
O
MRI cervical spine
without contrast
8
If neurological deficit present.
O
Arteriography
cervicocerebral
5
For treatment planning or problem
solving.
CT cervical spine with
contrast
1
CT cervical spine
without and with
contrast
1
MRA neck without
contrast
1
O
MRI cervical spine
without and with
contrast
1
O
X-ray cervical spine
1
Myelography and
post myelography CT
cervical spine
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 7: Suspected acute cervical spine trauma.
Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or
imaging findings suggest ligamentous injury.
Radiologic
Procedure
CT cervical spine
without contrast
Rating
9
Comments
Should be initial study.
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MRI cervical spine
without contrast
9
Procedure of choice for ligament
damage.
X-ray cervical spine
4
Flexion/extension views are not
helpful in acute stage because of
spasm.
CT cervical spine
with contrast
1
CT cervical spine
without and with
contrast
1
MRI cervical spine
without and with
contrast
1
Myelography and
post myelography
CT cervical spine
1
CTA head and neck
with contrast
1
MRA neck without
and with contrast
1
O
MRA neck without
contrast
1
O
Arteriography
cervicocerebral
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
O
O
Relative
Radiation
Level
Variant 8: Suspected cervical spine trauma.
Imaging indicated by clinical criteria (NEXUS or CCR). Follow-up
imaging on patient with no unstable injury demonstrated initially, but
kept in collar for neck pain. Returns for evaluation.
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Radiologic Procedure
X-ray cervical spine
Rating
7
Comments
AP, lateral, open-mouth,
obliques, and flexion/extension
views. Individualized based on
clinical findings.
CT cervical spine without
contrast
1
With sagittal and coronal
reformat. Not indicated unless
follow-up suggest an
abnormality.
CT cervical spine with
contrast
1
CT cervical spine without
and with contrast
1
Myelography/post
myelography CT cervical
spine
1
CTA head/neck with
contrast
1
MRI cervical spine without
contrast
1
MRI cervical spine;
without/with contrast
1
O
MRA neck without/with
contrast
1
O
MRA neck without contrast
1
Arteriography
1
cervicocerebral
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
O
May be appropriate if
radiographs suggest a further
problem. Not indicated unless
follow-up suggests an
abnormality.
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RRL
O
Relative
Radiation
Level
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Variant 9:
Blunt trauma that meets criteria for thoracic or lumbar imaging (with
or without localizing signs).
Radiologic
Procedure
CT thoracic or
lumbar spine
without contrast
Rating
Comments
9
Dedicated images with sagittal and coronal
reformat or derived from TAP scan.
MRI thoracic or
lumbar spine
without contrast
5
Myelography
and post
myelography CT
thoracic and
lumbar spine
3
If MRI contraindicated.
X-ray thoracic
or lumbar spine
3
Useful for localizing signs.
CT thoracic and
lumbar spine
with contrast
1
CT thoracic and
lumbar spine
without and
with contrast
1
MRI thoracic
and lumbar
spine without
and with
contrast
1
RRL
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
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O
Relative
Radiation
Level
54
Variant 10: Blunt trauma that meets the criteria for thoracic or lumbar
imaging.
Neurologic abnormalities.
Radiologic
Procedure
CT thoracic and
lumbar spine
without contrast
Rating
Comments
9
Dedicated images with sagittal and coronal
reformat or derived from TAP scan. CT and
MRI are complementary examinations, and
both should be performed.
MRI thoracic or
lumbar spine
without contrast
9
For cord abnormalities. CT and MRI are
complementary examinations, and both
should be performed.
Myelography
and post
myelography CT
thoracic and
lumbar spine
7
If MRI is not possible.
X-ray thoracic
and lumbar
spine
4
For surgical planning purposes.
CT thoracic and
lumbar spine
with contrast
1
CT thoracic and
lumbar spine
without and
with contrast
1
MRI thoracic
and lumbar
spine without
and with
contrast
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
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RRL
O
O
Relative
Radiation
Level
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Variant 11: Child, age <14 years, alert, no neck or back pain, neck
supple, no distracting injury.
Radiologic
Procedure
X-ray cervical
spine
Rating
1
Comments
CT cervical
spine without
contrast
1
With sagittal and coronal reformat.
CT cervical
spine with
contrast
1
CT cervical
spine without
and with
contrast
1
CT thoracic and
lumbar spine
without contrast
1
CT thoracic and
lumbar spine
with contrast
1
CT thoracic and
lumbar spine
without and
with contrast
1
RRL
Dedicated images with sagittal and
coronal reformat or derived from TAP
scan.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 12:
Child age <14 years, alert, no neck or back pain, neck supple,
fractured femur.
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Radiologic
Procedure
X-ray cervical
spine
Rating
5
Comments
AP, lateral, and open-mouth views.
Distracting injury alone is not an indication
for thoracolumbar imaging.
CT cervical
spine without
contrast
3
With sagittal and coronal reformat. Should
not be first-line evaluation.
CT thoracic and
lumbar spine
without contrast
3
Dedicated images with sagittal and coronal
reformat or derived from TAP scan. If TAP
CT performed for other reasons, then look
at the spine.
CT cervical
spine with
contrast
1
CT cervical
spine without
and with
contrast
1
CT thoracic and
lumbar spine
with contrast
1
CT thoracic and
lumbar spine
without and
with contrast
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
RRL
Relative
Radiation
Level
Variant 13: Child age <14 years, with known cervical fracture.
Radiologic
Procedure
X-ray
thoracic/lumbar spine
CT thoracic/lumbar
spine without
contrast
Rating
9
Comments
Not needed if fracture is visualized on
TAP scan. Preferred modality.
9
Dedicated images with sagittal and
coronal reformat or derived from TAP
scan.
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57
CT thoracic/lumbar
spine with contrast
1
CT thoracic/lumbar
spine without and
with contrast
1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
Relative
Radiation
Level
Variant 14: Child age <14 years, with known thoracic or lumbar
fracture.
Radiologic
Procedure
X-ray cervical
spine
Rating
9
CT cervical
spine without
contrast
7
CT cervical
spine with
contrast
1
CT cervical
spine without
and with
contrast
1
Comments
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be
appropriate; 7,8,9 Usually appropriate
RRL
Relative
Radiation
Level
Treatment Of The Patient With Spinal Trauma
Spinal trauma treatment begins with initial stabilization of the patient
and continues through long-term rehabilitation. Throughout the
process, the focus is on eliminating and/or treating any initial damage,
while preventing any further damage. The specific treatment
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administered will vary depending on the type, severity and location of
the injury.
Stabilization
When an individual experiences an injury, the primary goal is
stabilization. The patient’s airway, breathing and circulation will be
assessed and any issues will be treated. Patients who experience
spinal trauma will often have extensive spinal damage. Therefore,
initial treatment will be administered to stabilize any potential damage.
Until a spinal injury has been ruled out, the patient will be treated as if
one is present.88 Therefore, the patient will often be placed on a
stabilization board and will be required to maintain spinal stabilization
until an injury is ruled out.7 The following fact sheet provides thorough
information regarding the stabilization of patients with a suspected
spinal injury.89
The spine should be protected at all times during the management of the patient.
The ideal position is with the whole spine immobilized in a neutral position on a
firm surface. This may be achieved manually or with a combination of semi-rigid
cervical collar, side head supports and strapping. Strapping should be applied to
the shoulders and pelvis as well as the head to prevent the neck becoming the
center of rotation of the body.
Pre-hospital
Manual spinal protection should be instituted immediately. The application of
definitive immobilization devices should not take precedence over life-saving
procedures.
If the neck is not in the neutral position, an attempt should be made to achieve
alignment. If the patient is awake and co-operative, they should actively move
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their neck into line. If unconscious or unable to co-operate this is done passively.
If there is any pain, neurological deterioration or resistance to movement the
procedure should be abandoned and the neck splinted in the current position.
Long spine (rescue) boards are valuable primarily for extrication from vehicles.
Repeated transfers to and from the board may compromise spinal protection and
induce a significant amount of spinal movement. Patients may also be transferred
on a scoop stretcher and/or vacuum mattress. There is little place for the short
spine board or spinal extrication devices in the prehospital environment.
In-hospital
The spine board should be removed as soon as possible once the patient is on a
firm trolley. Prolonged use of spine boards can rapidly lead to pressure injuries.
Full immobilization should be maintained. Manual protection should be reinstated
if restraints have to be removed for examination or procedures (i.e., intubation).
The log-roll is the standard maneuver to allow examination of the back and
transfer on and off backboards. Four people are required, one holding the head
and coordinating the roll, and three to roll the chest, pelvis and limbs. The
number and degree of rolls should be kept to an absolute minimum. Rigid transfer
slides (i.e., Patslide) are useful for transferring the patient from one surface to
another (i.e., CT scanner, operating table). Patients who are agitated or restless
due to shock, hypoxia, head injury or intoxication may be impossible to
immobilize adequately. Forced restraints or manual fixation of the head may risk
further injury to the spine. It may be necessary to remove immobilization devices
and allow the patient to move unhindered.
Anesthesia may be necessary to allow adequate diagnosis and therapy. Intubation
of the trauma victim is best achieved via rapid sequence induction of anesthesia
and orotracheal intubation, though the technique used should ultimately depend
on the skills of the operator.
The collar should be removed and manual, in-line protection re-instituted for the
maneuver. The routine use of a gum elastic bougie is recommended, minimizing
cervical movement by allowing intubation with minimal visualization of the larynx.
Spinal immobilization is a priority in multiple trauma, spinal clearance is not.
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Transfer to Secondary Units
Patients may require transfer to other units for definitive care of other injuries
such as head or pelvic trauma. There should be no unnecessary delays in the
transport of these patients. Transfer should not wait for unnecessary diagnostic
procedures that will not alter management. This includes radiological imaging of
the spine.
The spine should be immobilized and protected for the transfer. Split-scoop
stretchers and vacuum mattresses are more appropriate for transfer than rigid
spinal (rescue) boards, which should be reserved for primary extrication from
vehicles, rather than as devices for transporting patients.
Management of a Spinal Injury
Once a patient is stabilized, treatment will focus on minimizing and
repairing any damage to the spinal region. Various treatments will be
used depending on the type, location and severity of damage. The goal
with initial treatment is to reduce pain and swelling, repair initial
damage, and prevent secondary damage. There has been much
advancement in the field of spinal cord injury and treatment, which
have improved the patient’s opportunity for recovery.
In recent years, improvements in diagnostic imaging techniques have
made the process of diagnosing spinal injuries more accurate, while
advancements in drug and other therapies have improved the
management of spinal injuries. Currently, the management of spinal
injuries includes three components:18

Diagnosis and treatment of immediate damage to provide relief
and minimize the risk of secondary injuries.
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
Stabilizing the vertebrae and repairing structural damage.

Long-term care and rehabilitation to address and improve the
physical and neurological effects of the injury.
These treatment goals are accomplished using a variety of treatment
options. The specific treatment protocol will depend on the type,
location and severity of the injury as well as the patient’s individual
needs.
Corticosteroids
For quite a while, methylprednisolone has been used to treat spinal
cord injures. Methylprednisolone is a corticosteroid that has significant
anti-inflammatory properties. It is a derivative of prednisolone and
belongs to the glucocorticoid family of corticosteroids.90 In many
instances, patients who receive methylprednisolone within eight hours
of a spinal injury experience an improvement in sensory and motor
functions.91
According to three trials conducted by the National Spinal Cord Injury
Study (NASCIS), there is evidence that acute steroid therapy reduces
the cellular damage that occurs as a result of secondary injury
process, including but not limited to lipid peroxidation.92 However,
there is some controversy surrounding these results due to the
inconsistencies in improvement levels and the risk of the
administration of high doses of steroids.93 While there is some
controversy, the results of these trials have prompted the regular and
consistent use of high dose steroids in the management of acute spinal
injuries.94 Recently, the use of these steroids was challenged as a
result of many patients experiencing significant negative results after
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receiving high doses of steroids. The following effects were reported
frequently and caused significant problems for the patients:95

immunosuppression with increased susceptibility to infections
(pneumonia, sepsis, etc.)

increased risk of gastrointestinal disturbances (ulcers, bleeding,
and ileus)

adult respiratory distress syndrome

hyperglycemia

deep venous thrombosis (DVT)

pulmonary embolism
As a result of the negative consequences experienced by patients,
experts are now recommending against the use of high dose steroids
immediately following a spinal injury. Recently, the Congress of
Neurological Surgeons (CNS) and the American Association of
Neurological Surgeons (AANS) released an updated document on the
management of acute cervical spine and spinal cord injuries. Within
this document, both groups recommend against the use of high dose
steroids immediately following cervical spine and spinal cord injuries.96
Surgical Intervention
Once a patient has been stabilized and the initial damage has been
treated, management of the injuries will shift to stabilizing the
vertebrae and repairing structural damage. In many instances, this will
include surgical intervention and repair. Patients will often be
recommended for surgery for the following conditions:93

removal of bone fragments

presence of foreign objects
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
blood clots

herniated disks

fractured vertebrae

anything that appears to be compressing the spine

spinal stabilization
Many patients will require spinal stabilization surgery following a spinal
injury. Spinal stabilization surgery “removes bone fragments and
restores the alignment of the vertebrae thus reducing compression on
the spinal cord. Stabilization can occur within the first 72 hours or it
may be delayed until after the body has been medically stabilized.
There is no evidence to support an advantage for either early or
delayed treatment.”6
Some patients may require spinal fusion surgery. This procedure is
performed when a patient’s vertebrae in the spinal column are
unstable. Spinal fusion surgery is used to stabilize the vertebrae. This
procedure “may be done with metal plates, screws, wires and/or metal
rods; sometimes small pieces of bone from other areas of the body
(usually the hip or knee) or from a cadaver (bone bank) are used.
Bone grafts help the patient's bones grow, thus serving to fuse the
vertebrae. In cervical injuries the stabilization can be done through the
throat (anterior) or through the neck (posterior) or both. Thoracic and
lumbar injuries are usually approached through the back.”6
The specific type of surgery will depend on the type, location and
severity of the patient’s injury. The surgeon will assess the patient and
determine the specific approach based on information obtained from
diagnostic imaging procedures, such as an X Ray, CT Scan or MRI. In
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some instances, the surgery will be performed posteriorly, which is
from the back of the spine. While, in other instances, the surgery will
be performed anteriorly, which is from the front of the spine. In rare
instances, the surgeon may need to use both approaches, but these
will be done as two separate surgeries.97
The following is a list of the different types of spinal surgery:98

Lumbar discectomy
Surgical procedure used to remove all or part of a herniated or
ruptured disc in the lower part of the spine.

Cervical discectomy
Surgery used to remove one or more discs from the neck.

Microdisectomy
Microdisectomy involves minimally invasive surgery on a
ruptured disc in the neck or back. This procedure aims at
removing a small part of the ruptured disc in order to alleviate
pain while avoiding any possible instability in the spine.

Spinal fusion
Surgical procedure for fusing or joining two or more vertebrae.
There are different types of this surgery for different areas of the
spine, as highlighted here.
 Anterior Lumbar Interbody Fusion
In this procedure, the spine is operated on from the
front. The surgeon removes a disc from the lower part
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of the spine and replaces it with bone graft. The desired
result is for the two surrounding vertebrae to grow or
fuse together into one solid bone.
 Posterior Lumbar Interbody Fusion
This procedure is virtually the same as the anterior
fusion except that the surgeon approaches the spine
from the back.
 Transforaminal Lumbar Interbody Fusion
In this procedure, the spine is approached from the
side.
 Laparoscopic Fusion
This is a minimally invasive surgical alternative to open
surgery that requires a much smaller incision in the
back to gain access to the spine. Recuperation time and
pain levels are significantly reduced compared to other
types of spinal fusion surgery.

Intradiscal Electrothermal Therapy
Minimally invasive treatment for lower back pain utilizes
fluoroscopic (X-ray) guidance and an electrothermal catheter to
heat up the affected lumbar disc. The goal is to destroy pain
receptors in the disc.
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
Surgical Decompression
A small portion of the bone over the nerve root is removed to
allow more space for the nerve root while helping it to heal.
There are different types of surgical decompression:
 Foraminotomy
The foramen, or opening where the nerve root comes
out of the spinal column, is widened by shaving away a
portion of the bone.
 Laminotomy
Partial removal of the lamina, or bony arches in the
canal of the spine
 Laminectomy
Complete removal of the lamina, or bony arches in the
canal of the spine
 Corpectomy
The entire degenerated vertebrae is removed and
replaced by bone graft.
 Laminoplasty
The lamina, or bony arches in the spinal canal, is cut
open on both sides to create an open flap to relieve
pressure on the spinal cord. The bone flap is propped
open with small wedges or pieces of bone.
 Kyphoplasty/Vertebroplasty
Kyphoplasty and vertebroplasty are both minimally
invasive procedures that treat pain and other symptoms
caused by a spine fracture resulting from osteoporosis.
Each procedure can also restore vertebral body height
lost due to a compression fracture.
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 Anterior Cervical Discectomy and Fusion
Surgical procedure used to treat neck problems
resulting from fractures, herniated discs and spinal
instability.

Spinal Cord Stimulation
This procedure uses an electrical current to treat chronic back
pain by implanting a small pulse generator in the back. The
pulse generator sends electrical pulses to the spine in order to
block the nerve signals, which causes a sensation of pain.
Patients who require surgery for their spinal injuries will typically need
additional care and time to recover following the surgery. Therefore,
many patients will remain in the Intensive Care Unit (ICU) for care and
monitoring.7 Many patients will require ventilator assisted breathing or
intravenous medications, especially for blood pressure maintenance.97
In some instances, patients will only require an overnight stay for
observation purposes. Most patients will require a cervical collar or
brace following surgery. This will prevent undue stress on the muscles
and bones and will aid in recovery. Some patients will be required to
wear a brace for a number of months.99
Bedrest Following Spinal Injury
Many patients will require bed rest immediately following a spinal
injury, and throughout the duration of initial treatment. Bed rest
improves the outcome as it reduces the pressure and stress to the
patient’s bones and muscles. Early treatment of a spinal cord injury
requires that the spine be properly stabilized. When a patient is
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mobile, there is increased risk of further damage to the spine, as the
area does not stay stable. Bed rest is used to ensure proper healing.
When a patient requires bed rest, the spine is typically immobilized
completely to ensure proper healing. Patients who undergo complete
bed rest have an increased chance of full recovery.100
Traction for Spine Stabilization
Many patients will require traction to help stabilize the spine or to
bring it into alignment so that further damage does not occur. The
specific type of traction used will depend on the patient’s individual
needs as well as the type and severity of injury. In more severe cases,
the patient will have metal braces, which are attached to weights, and
secured to the skull. This will prevent the head from moving. In some
instances, the patient will be immobilized with the use of a special bed.
However, some patients may only require the use of a rigid neck
collar.101
Physical Therapy
Most spinal cord trauma patients will require physical therapy as part
of the long-term management process. The specific types of physical
therapy used will vary by patient, and will address issues with sensory
and motor function.102 Physical therapists administer services based on
the domains included in the International Classification of Functioning,
Disability and Health (ICF), which are promoted by the World Health
Organization (WHO). The following is a list of the domains included in
the ICF and how they are applied to spinal cord injuries:103
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
body function and structure - impairments in sensation or motor
function, range of motion (ROM) limitations, musculoskeletal
pain, etc.

activity limitation - deficits in daily tasks such as rolling in bed or
propelling a wheelchair

participation - activities that contribute to social and leisure skill
roles, such as homemaker, sports participant, or college student.
Physical therapy can be administered over the duration of weeks,
months or years. The specific amount of time required will depend on
the patient’s needs, the limitations present, and the baseline level of
functioning. Throughout the duration of physical therapy, the goal is to
maximize patient independence, improve basic functioning, increase
mobility, and develop adaptations.104
Medication
Many patients will require medication to treat the various effects of
spinal cord injury. In some instances, patients will be given medication
to control symptoms directly caused by the injury itself, such as
medications to reduce the pain associated with injury or to control
muscle spasticity. In other instances, patients will be given
medications to minimize or improve the secondary effects of spinal
injury, such as bladder control or bowel control. The specific
medications administered will differ depending on the needs of the
patient.105
Other Therapies
In addition to the treatment options listed above, there are other
therapies that are used to treat spinal trauma. These other therapies
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are not used in every instance of spinal trauma, but they are options if
the patient presents with an injury that will benefit from additional
treatment. The following fact sheet provides descriptions of the
different treatment options available during spinal trauma.6
Neuroprotection
Therapeutic hypothermia (spinal cord cooling) is a medical treatment that lowers
the body temperature in order to protect the cells in the body from damage after a
traumatic brain or spinal cord injury, stroke or cardiac event. Body temperature
can be lowered by invasive methods, using catheters filled with saline to cool a
patient's blood as it leaves the heart, thus lowering the temperature of the whole
body. Non-invasive techniques use special blankets that have cold water running
through them. These blankets may be combined with ice packs or cold fans in
order to achieve more rapid temperature decline.
According to the American Association of Neurological Surgeons, there is currently
no published data that shows that SCI patients who are treated with therapeutic
hypothermia improve compared to others who are not treated using this method.
The use of local therapeutic hypothermia at the time of surgery appears safe but
no criteria for treatment guidelines have been established.
Currently, there is not enough evidence available to recommend for or against
therapeutic hypothermia with traumatic spinal cord injury.
Respiratory
The lungs themselves are not usually affected by paralysis but the muscles of the
chest, abdomen, and diaphragm may be. If complete paralysis occurs at level C3
or above, the phrenic nerve is no longer stimulated and the diaphragm will not
function.
Some individuals with lower level injuries may also need ventilator assistance for
short periods of time before they can breathe on their own (called being weaned
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off the ventilator). Successful weaning from a ventilator is impacted by many
factors: age, level of injury and time spent on the ventilator.
People injured at the mid-thoracic level or higher may have trouble taking deep
breaths and exhaling forcefully. This can lead to lung congestion and respiratory
infections. Ways of preventing respiratory complications include maintaining proper
posture, coughing regularly (if necessary, with assistance), following a healthy
diet, drinking plenty of fluids, eliminating smoking or being around smoke,
exercising, and getting vaccinated for influenza and pneumonia.
Spinal Injury Prognosis
The level of severity and the type of injury that a patient experiences
as the result of spinal trauma will vary. Therefore, the prognosis for
each patient with a spinal injury will differ. However, there are some
specific components that will be indicative of the potential outcome.
The prognosis for a complete injury is much worse than it is for an
incomplete injury. Incomplete injuries have a greater likelihood of
recovery than complete injuries. Most recovery occurs within the early
stages of the injury, with the majority of the recovery occurring in the
first 9 – 12 months post injury.19 In most instances, patients will only
recover partially. The specific amount and type of recovery will vary
depending on the type of spinal cord injury.
Lifestyle
It is well established that cigarette smoking adversely affects healing
after spine surgery. Smoking cessation after spine surgery promotes
improved healing and a faster rate of recovery.107
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The following chart provides information regarding the specific level of
Spinal Cord Injury and the resulting rehabilitation potential.106
Level of
injury
Possible impairment
Rehabilitation potential
C2 - C3
Usually fatal as a result of
inability to breathe
Totally dependent for all care
C4
Quadriplegia and breathing
difficulty
Dependent for all cares; usually
needs a ventilator
C-5
Quadriplegia with some
shoulder and elbow function
May be able to feed self using
assistive devices; usually can
breathe without a ventilator, but
may need other types of
respiratory support
C6
Quadriplegia with shoulder,
elbow, and some wrist function
May be able to propel a wheelchair
inside on smooth surfaces; may be
able to help feed, groom, and
dress self; dependent on others for
transfers
C7
Quadriplegia with shoulder,
elbow, wrist, and some hand
function
May be able to propel a wheelchair
outside, transfer self, and drive a
car with special adaptions; may be
able to help with bowel and
bladder programs
C8
Quadriplegia with normal arm
function; hand weakness
May be able to propel a wheelchair
outside, transfer self, and drive a
car with special adaptions; may be
able to help with bowel and
bladder programs
T1 - T6
Paraplegia with loss of function
below mid-chest; full control of
arms
Independent with self-care and in
wheelchair; able to be employed
full time
T6 - T12
Paraplegia with loss of function
below the waist; good control of
torso
Good sitting balance; greater
ability for operation of a
wheelchair and athletic activities
L1 - L5
Paraplegia with varying degrees
of muscle involvement in the
legs
May be able to walk short
distances with braces and assistive
devices
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Summary
Spinal cord trauma is a significant medical problem that affects a
number of individuals each year. In many instances, the injuries can
be life threatening. Spinal cord trauma is primarily caused by motor
vehicle accidents, falls, industrial accidents, assault, sports related
injuries, and gunshot wounds. Depending on the location and extent of
damage, a patient will experience an incomplete or complete spinal
injury. Each type of injury requires different treatment and will affect
the patient differently. Most spinal injuries will not lead to complete
severance of the spinal cord. Instead, a spinal injury is more likely to
cause fractures and compression of the vertebrae, which then crush
and destroy nerve cells that carry signals up and down the spinal cord
between the brain and the rest of the body. Some spinal cord injuries
will result in almost complete recovery while others will lead to
complete paralysis.
Early identification and treatment is crucial to minimize the initial
damage and to prevent secondary injuries, which are common with
spinal cord trauma. In recent years, the diagnosis and management of
spinal cord injuries has improved with advancements in technology
and treatment options. There are a number of options available for the
diagnosis of spinal cord injuries, including CT scans, MRIs, X-rays, and
other advanced imaging procedures. In addition, improved emergency
care for people with spinal cord injuries and aggressive treatment and
rehabilitation have made it easier to manage spinal cord injuries. The
availability of these advanced measures enable health clinicians to
minimize damage to the nervous system and to help restore limited
abilities.
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Once stabilization of the patient with a spinal injury is achieved,
treatment should focus on minimizing and repairing any damage to the
spinal region. Various treatments used will depend on the type,
location and severity of damage to the spine. The goal of the initial
treatment is to reduce pain and swelling, repair initial damage, and
prevent secondary damage. This course has highlighted that there has
been much advancement in the field of spinal cord injury and
treatment, which have improved the patient’s opportunity for recovery
and quality of life.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
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1. The annual incidence of spinal cord injuries in the U.S., is
approximately
a.
b.
c.
d.
22
35
40
65
cases
cases
cases
cases
per
per
per
per
million.
million.
million.
million.
2. True or False: Spinal stenosis is a condition caused by the
compression or narrowing of the spinal canal.
a. True
b. False
3. The thoracic vertebrae are located in what region of the
body?
a.
b.
c.
d.
Coccyx
Upper and middle back
Neck
Lower back
4. Central cord syndrome involves hyperextension injuries as
well as
a.
b.
c.
d.
spinal cord ischemia, and cervical spinal stenosis.
a cervical lesion always with lower extremity motor weakness.
a burning sensation in the lower extremities only.
All of the above
5. Spinal stabilization surgery involves
a. removal of bone fragments.
b. restoring vertebral alignment to reduce spinal cord
compression.
c. a 72-hour minimum delay in all cases.
d. Answers a., and b., above
6. True or False: Therapeutic hypothermia may be done to
protect body cells from damage after spinal cord injury.
a. True
b. False
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7. Spinal injuries are broken into the following regions:
a.
b.
c.
d.
Cervical,
Cervical,
Cervical,
Cervical,
Thoracic, Lumbar Sacral.
Cardio-pulmonary, Abdominal.
Thoraco-abdominal, Sacrococcygeal.
Thoracic, Abdominal.
8. The cervical vertebrae are located in the
a.
b.
c.
d.
tailbone.
pelvic region.
middle back.
neck.
9. Variant 12 of the ACS appropriateness criteria for spinal
injury involves:
a.
b.
c.
d.
Adult
Teen/Young adult ages 15 – 25
Child age >14 years
Child age <14 years
10. CT with contrast allows the radiologist to view a specific
body part or region more clearly. Typically, the patient will
a.
b.
c.
d.
ingest a substance orally or receive an injection intravenously.
ingest a substance orally.
receive an injection intravenously.
receive an injection intravenously or arterially.
11. In cervical injuries, surgery may be done to stabilize the
area through
a.
b.
c.
d.
the throat (anterior).
the neck (posterior).
both the throat and the neck.
All of the above
12. The ____________ is also commonly known as the
tailbone.
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a.
b.
c.
d.
sacrum
coccyx
posterior
lower back
13. True or False: Thoracic injuries are usually approached
through the front whereas lumbar injuries are usually
approached through the back.
a. True
b. False
14. Methylprednisolone is a corticosteroid with significant antiinflammatory properties often used within __________ of
a spinal injury for patients to experience an improvement
in sensory and motor functions.
a.
b.
c.
d.
2 hours
4 hours
8 hours
1-2 days
15. Traction helps to stabilize the spine, bringing it into
alignment so that further damage does not occur. In more
severe cases, the patient may
a.
b.
c.
d.
have metal braces attached to weights, secured to the skull.
strict bedrest with no weights, such as for 1 to 2 months.
require constant weights to all limbs.
require positioning on his sides, with frequent turning.
16. According to the Occupation Health and Safety
Administration, distinct causes of death and severe injury
in the construction industry include
a.
b.
c.
d.
falls, struck by object, and caught-in/between injuries.
falls, dislocation, and crush injuries.
blunt force, crush, and evisceration injuries.
blunt force, laceration and crush injuries.
17. ______________________ comprise approximately fifteen
percent of spinal cord trauma cases.
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a.
b.
c.
d.
Blast injuries
Motor vehicle injuries
Fall injuries
Violent assault injuries
18. After a spinal injury, an excessive release of the
neurotransmitter glutamate
a.
b.
c.
d.
protects nerve cells from further damage.
reduces swelling in the spinal cord.
may trigger additional nerve cell damage.
causes additional damage to the myelin.
19. True or False: Early identification and treatment is crucial
to prevent secondary injuries (common with spinal cord
trauma).
a. True
b. False
20. Intradiscal Electrothermal Therapy is a
a.
b.
c.
d.
minimally invasive treatment for lower back pain.
minimally invasive treatment for c-spine pain.
minimally invasive treatment using (freezing) cryotherapy.
major surgical procedure to treat pain in the thoracic spine.
21. Approximately ______ percent of spinal trauma patients
will experience spinal shock.
a.
b.
c.
d.
25
35
50
62
22. True or False: MRI’s are able to detect many injuries
undetectable with other methods. The MRI uses a magnetic
field as compared to CT X-Ray.
a. True
b. False
23. Spinal stenosis is a condition where
a. the spinal canal is compressed
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b. nerve roots become pinched
c. pain, cramping, weakness and numbness occur.
d. All of the above.
24. A substance called myelin, which acts as a sheath over the
nerve structure, protects the axons. The myelin is referred
to as
a.
b.
c.
d.
the spinal canal.
white matter.
grey matter.
the anterior cord.
25. True or False: Long-term care is generally not considered
part of the treatment planning for spinal injury cases, as it
is not part of the acute phase to improve the physical and
neurological effects of an injury.
a. True
b. False
26. A major reduction in blood flow to a trauma site following
the initial injury has a greater impact on ______________
due to its greater blood flow needs.
a.
b.
c.
d.
the myelin
white matter
grey matter
lower spine
27. Following a spinal injury, the normal delivery of oxygen
and nutrients to neurons may be hindered by leaks from
______________ in the gray matter, causing many of
neurons to die.
a.
b.
c.
d.
the
the
the
the
axons
blood-brain barrier
myelin sheath
blood vessels
28. True or False: Spinal cord injury sets off apoptosis, a
normal process of cell death that helps the body get rid of
old and unhealthy cells, because these injuries interrupt
oxygen and nutrients to the spinal cord.
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a. True
b. False
29. Microdisectomy involves minimally invasive surgery on a
ruptured disc in
a.
b.
c.
d.
the
the
the
the
lumbar region.
neck or back.
sacrum.
coccyx.
30. A patient with _________________ loses movement and
sensation below the level of the injury on the side where
the injury occurred, while opposite the side of the injury
temperature and pain sensation are lost.
a.
b.
c.
d.
conus medullaris
central cord syndrome
Brown-Sequard syndrome
cauda equina
CORRECT ANSWERS:
1. The annual incidence of spinal cord injuries in the U.S., is
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approximately
c. 40 cases per million.
p. 14: “It is estimated that the annual incidence of spinal cord
injury (SCI), not including those who die at the scene of the
accident, is approximately 40 cases per million population in
the U.S., or approximately 12,000 new cases each year.”
2. True or False: Spinal stenosis is a condition caused by the
compression or narrowing of the spinal canal.
a. True
p. 34: “Spinal stenosis is a condition that is caused by
compression of the spinal canal.”
3. The thoracic vertebrae are located in what region of the
body?
b. Upper and middle back
p. 7: “Thoracic Vertebrae: Upper and Middle Back”
4. Central cord syndrome involves hyperextension injuries as
well as
a. spinal cord ischemia, and cervical spinal stenosis.
p. 22: “Central cord syndrome: Caused by hyperextension
injuries, spinal cord ischemia and cervical spinal stenosis.”
5. Spinal stabilization surgery involves
a. removal of bone fragments.
b. restoring vertebral alignment to reduce spinal cord
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compression.
c. a 72-hour minimum delay in all cases.
d. Answers a., and b., above
p. 64: “Spinal stabilization surgery ‘removes bone fragments
and restores the alignment of the vertebrae thus reducing
compression on the spinal cord. Stabilization can occur within
the first 72 hours or it may be delayed until after the body
has been medically stabilized. There is no evidence to support
an advantage for either early or delayed treatment.’”
6. True or False: Therapeutic hypothermia may be done to
protect body cells from damage after spinal cord injury.
a. True
p. 71: “Therapeutic hypothermia (spinal cord cooling) is a
medical treatment that lowers the body temperature in order
to protect the cells in the body from damage after a traumatic
brain or spinal cord injury, stroke or cardiac event.”
7. Spinal injuries are broken into the following regions:
a. Cervical, Thoracic, Lumbar Sacral.
p. 37: “The symptoms for spinal injuries will differ depending
on the type and location of the injury. When observing and
analyzing symptoms, the spinal injuries are broken into the
following regions: Cervical (near the neck); Thoracic (chest
region); Lumbar Sacral (lower back).”
8. The cervical vertebrae are located in the
d. neck.
p. 7: “Cervical Vertebrae: neck”
9. Variant 12 of the ACS appropriateness criteria for spinal
injury involves:
d. Child age <14 years
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p. 56: “Variant 12: Child age <14 years, alert, no neck or
back pain, neck supple, fractured femur.”
10. CT with contrast allows the radiologist to view a specific
body part or region more clearly. Typically, the patient will
a. ingest a substance orally or receive an injection
intravenously.
p. 40: “CT scans are conducted in two ways, as explained
below: … Patients ingest a substance orally, or receive an
injection intravenously. The contrast solution enables the
radiologist to view the specific body part or region more
clearly.”
11. In cervical injuries, surgery may be done to stabilize the
area through
a.
b.
c.
d.
the throat (anterior).
the neck (posterior).
both the throat and the neck.
All of the above
p. 64: “In cervical injuries the stabilization can be done
through the throat (anterior) or through the neck (posterior)
or both. Thoracic and lumbar injuries are usually approached
through the back.”
12. The ____________ is also commonly known as the
tailbone.
b. coccyx
p. 7: “Coccyx (commonly known as the tailbone)”
13. True or False: Thoracic injuries are usually approached
through the front whereas lumbar injuries are usually
approached through the back.
b. False
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p. 64: “Thoracic and lumbar injuries are usually approached
through the back.”
14. Methylprednisolone is a corticosteroid with significant antiinflammatory properties often used within __________ of
a spinal injury for patients to experience an improvement
in sensory and motor functions.
c. 8 hours
p. 62: “Methylprednisolone is a corticosteroid that has
significant anti-inflammatory properties. It is a derivative of
prednisolone and belongs to the glucocorticoid family of
corticosteroids. In many instances, patients who receive
methylprednisolone within eight hours of a spinal injury
experience an improvement in sensory and motor functions.”
15. Traction helps to stabilize the spine, bringing it into
alignment so that further damage does not occur. In more
severe cases, the patient may
a. have metal braces attached to weights, secured to the
skull.
p. 69: “The specific type of traction used will depend on the
patient’s individual needs as well as the type and severity of
injury. In more severe cases, the patient will have metal
braces, which are attached to weights, and secured to the
skull.”
16. According to the Occupation Health and Safety
Administration, distinct causes of death and severe injury
in the construction industry include
a. falls, struck by object, and caught-in/between injuries.
p. 29: “According to the Occupation Health and Safety
Administration, there are distinct causes of death and severe
injury in the construction industry, and they are listed below
as: Falls, Struck by Object, and Caught-in/between Injuries.”
17. ______________________ comprise approximately fifteen
percent of spinal cord trauma cases.
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d. Violent assault injuries
p. 28: “Violent assault injuries comprise approximately fifteen
percent of spinal cord trauma cases.”
18. After a spinal injury, an excessive release of the
neurotransmitter glutamate
c. may trigger additional nerve cell damage.
p. 12: “The neurotransmitter glutamate is commonly used by
axons in the spinal cord to stimulate activity in other neurons.
But when spinal cells are injured, their axons flood the area
with glutamate and trigger additional nerve cell damage.”
19. True or False: Early identification and treatment is crucial
to prevent secondary injuries (common with spinal cord
trauma).
a. True
p. 74: “Early identification and treatment is crucial for
minimizing the initial damage and preventing secondary
injuries, which are common with spinal cord trauma.”
20. Intradiscal Electrothermal Therapy is a
a. minimally invasive treatment for lower back pain.
p. 66: “Intradiscal Electrothermal Therapy: Minimally invasive
treatment for lower back pain.”
21. Approximately ______ percent of spinal trauma patients
will experience spinal shock.
c. 50
p. 10: “Approximately fifty percent of spinal trauma patients
will experience spinal shock.”
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22. True or False: MRI’s are able to detect many injuries
undetectable with other methods. The MRI uses a magnetic
field as compared to CT X-Ray.
a. True
p. 42: “Due to the MRI’s high level of sensitivity, it is able to
detect many injuries that are undetectable using other
methods.”
23. Spinal stenosis is a condition where
a.
b.
c.
d.
the spinal canal is compressed
nerve roots become pinched
pain, cramping, weakness and numbness occur.
All of the above.
p. 34: “Spinal stenosis is a condition that is caused by
compression of the spinal canal. This condition is often
referred to as narrowing of the spinal canal. When the spinal
canal is compressed, it causes the spinal cord and nerve roots
to become pinched, which results in increased pain, cramping,
weakness and numbness. Spinal stenosis is often caused by
factors such as osteoarthritis. However, it can also occur as
the result of spinal trauma. When spinal stenosis is caused by
trauma, the location of the narrowing will depend on the type
and location of the injury.”
24. A substance called myelin, which acts as a sheath over the
nerve structure, protects the axons. The myelin is referred
to as
b. white matter.
p. 8: “A substance called myelin, which acts as a sheath over
the nerve structure, protects the axons. The myelin is whitish,
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87
which is why the region they are contained in is referred to as
‘white matter.’”
25. True or False: Long-term care is generally not considered
part of the treatment planning for spinal injury cases, as it
is not part of the acute phase to improve the physical and
neurological effects of an injury.
b. False
p. 62: “Long-term care and rehabilitation to address and
improve the physical and neurological effects of the injury.”
26. A major reduction in blood flow to a trauma site following
the initial injury has a greater impact on ______________
due to its greater blood flow needs.
c. grey matter
p. 11: “Because of the greater blood flow needs of gray
matter; the impact is greater on the central cord than on the
outlying white matter.”
27. Following a spinal injury, the normal delivery of oxygen
and nutrients to neurons may be hindered by leaks from
______________ in the gray matter, causing many of
neurons to die.
d. the blood vessels
p. 11: “Blood vessels in the gray matter also become leaky,
sometimes as early as 5 minutes after injury, which initiates
spinal cord swelling. Cells that line the still-intact blood
vessels in the spinal cord also begin to swell, and this further
reduces blood flow to the injured area. The combination of
leaking, swelling, and sluggish blood flow prevents the normal
delivery of oxygen and nutrients to neurons, causing many of
them to die.“
28. True or False: Spinal cord injury sets off apoptosis, a
normal process of cell death that helps the body get rid of
old and unhealthy cells, because these injuries interrupt
oxygen and nutrients to the spinal cord.
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88
b. False
p. 13: “For reasons that are still unclear, spinal cord injury
sets off apoptosis—a normal process of cell death that helps
the body get rid of old and unhealthy cells. Apoptosis kills
oligodendrocytes in damaged areas of the spinal cord days to
weeks after the injury. Apoptosis can strip myelin from intact
axons in adjacent ascending and descending pathways,
causing the axons to become dysfunctional and disrupting the
spinal cord’s ability to communicate with the brain.”
29. Microdisectomy involves minimally invasive surgery on a
ruptured disc in
b. the neck or back.
p. 65: “Microdisectomy involves minimally invasive surgery
on a ruptured disc in the neck or back. This procedure aims at
removing a small part of the ruptured disc in order to
alleviate pain while avoiding any possible instability in the
spine.”
30. A patient with _________________ loses movement and
sensation below the level of the injury on the side where
the injury occurred, while opposite the side of the injury
temperature and pain sensation are lost.
c. Brown-Sequard syndrome
p. 19: “Brown-Sequard syndrome: Results from injury to the
right or left side of the spinal cord. On the side of the body
where the injury occurred, movement and sensation are lost
below the level of the injury. On the side opposite the injury,
temperature and pain sensation are lost due to the crossing
of these pathways in the spinal cord.”
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