|SYMPOSIUM - POLYTRAUMA MANAGEMENT
|Year : 2013 | Volume
| Issue : 1 | Page : 28-33
Management of spinal injuries in a patient with polytrauma
Roop Bhushan Kalia, Alok Chandra Agrawal
Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||23-Sep-2013|
Roop Bhushan Kalia
402, Type V A, All India Institute of Medical Sciences Residential Complex, Kabir Nagar, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Acute spinal cord injury primarily affects young otherwise healthy people and is a major cause of patient morbidity and a source of significant health care expenditure. The priority in the management of spinal injury in a patient with polytrauma is to minimize secondary mechanical or physiological insults to the spinal cord. Identification of spinal injuries during initial trauma evaluation is challenging, as patients often have a reduced level of consciousness due to other injuries or are under the influence of sedative and/or analgesic medication. The management of suspected spinal cord injury in patients with polytrauma involves early immobilization of the whole spine and the institution of measures to prevent secondary injury from hypoxia, hypoperfusion or further mechanical disturbance. All spinal injuries should be considered unstable and incomplete until proven otherwise. Careful and informed neurological assessment, together with appropriate plain radiography, will identify the majority of spinal injuries. Early surgical decompression should be considered. Improvements in motor vehicle safety and traffic regulations can result in a marked reduction in spinal cord injury due to motor vehicle accidents with significant reduction in mortality attributable to spinal injury. A robust system of care is the best assurance of good health outcomes and reasonable health for people with spinal cord Injury.
Keywords: Polytrauma, spinal injuries, management
|How to cite this article:|
Kalia RB, Agrawal AC. Management of spinal injuries in a patient with polytrauma. J Orthop Traumatol Rehabil 2013;6:28-33
|How to cite this URL:|
Kalia RB, Agrawal AC. Management of spinal injuries in a patient with polytrauma. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2020 Feb 23];6:28-33. Available from: http://www.jotr.in/text.asp?2013/6/1/28/118746
| Introduction|| |
Acute spinal cord injury primarily affects young otherwise healthy people typically in their second and third decades with a male preponderance (a male to female ratio of 3:1)  and is a major cause of patient morbidity and a source of significant health-care expenditure. Civilian trauma accounts for 14% of years of life lost and 10% of death and is the leading cause of death in people aged 5-44 years. , Road traffic accidents and falls from height account for the majority of spinal injuries.
The priority in the management of spinal injury in a patient with polytrauma is to minimize the secondary mechanical or physiological insults to the spinal cord. This can be easily achieved by adequate immobilization of the spine in the multiply injured patient while the primary survey and resuscitation are ongoing. Early detection of spinal injuries is important in order to initiate further diagnostic testing and treatment and to avoid additional secondary neurological injuries, which can occur in a number of patients with catastrophic results especially in unconscious patients. The residual neurological deficit has profound effects on the health of the affected individual and has social and economic ramifications. Most patients with spinal injuries have injuries to other organ systems. Often in a patient with polytrauma, spinal injuries are easily overlooked in the presence of other more obvious injuries About half of severe spine injuries are reported not to be suspected in the pre-hospital setting.  Identification of spinal injuries during initial trauma evaluation is challenging as patients often have a reduced level of consciousness due to other injuries or are under the influence of sedative and/or analgesic medication.
| Management of Patients with Spinal Injury|| |
The possibility of spinal injury should be considered in all polytrauma patients. Significant spinal injuries can be missed easily in patients who are unconscious, intoxicated or due to failure examine patients adequately and errors in the interpretation of radiographs. Spinal cord injury without obvious radiological abnormality (SCIWORA) occurs in children who are less than 8 years old. The unique hyper mobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predisposes to SCIWORA.  It has been reported in 20-36% of children with traumatic myelopathy. Spinal trauma can be present in approximately 10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a Glasgow coma scale <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, Road traffic accidents and gunshot injury).  Diagnostic imaging of the whole spine and a diligent search for associated injuries are imperative.
| Primary Survey|| |
Airway and breathing with cervical spine control
During assessment of airway, breathing and circulation, efforts must be made to protect the spinal cord from potential secondary mechanical and physiological injury, which is achieved by early immobilization of the whole spine. This can be achieved by cervical traction by a head halter, which is universally available followed by a hard cervical collar and spinal board or head blocks and straps if available. This is sufficient until clearance of the spine is achieved. Cervical collars are contraindicated in patients with significant head injury due to concern regarding further rise in intracranial pressure with their use. Head blocks with straps are indicated for such patients. The adequacy of immobilization and the position of cervical collars, head blocks should be checked on arrival at the emergency department if they have been used in the pre-hospital care period.  Long spine boards should be removed as soon as possible, usually as part of the log-roll, decreasing the risk of pressure sore development with its prolonged use.
Patients who are agitated and moving around should not have their cervical spine immobilized in isolation. Further evaluation of the spine can be safely deferred until immediate life-threatening conditions have been assessed and resuscitation is under way.
The priority in trauma patients is to maintain oxygenation through a patent airway, which may necessitate airway opening maneuvers such as a jaw thrust, use of suction or basic adjuncts and can involve an endotracheal intubation. High flow oxygen can be administered to patients with cervical spine injury with neurological deficits safely by a mask. In conscious patients with quadriplegia due to upper cervical spine injury and diaphragmatic breathing having CO 2 retention and poor respiratory effort, early intubation and ventilation should be considered. The ideal technique is fiber-optic intubation with cervical spine control. However, there is little evidence that a properly performed orotracheal intubation with cervical traction will cause further cervical cord injury provided adequate care is taken. ,
During this initial phase, the whole spine must be maintained in neutral alignment after gentle controlled movement to a neutral position if this is necessary. Attempts to bring the head into neutral alignment against palpable resistance or if the patient complains of pain should be abandoned and the head immobilized as it is found.
Signs of shock with the systolic blood pressure (BP) <90 mm should not be attributed to the spinal cord injury and neurogenic shock until internal hemorrhage has been excluded. Approximately 80% of patients with spinal cord injury have multiple injuries.  The most common sources of occult internal hemorrhage are chest injuries (often associated with thoracic spine fractures), intra-abdominal hemorrhage, retroperitoneal hemorrhage, pelvic fractures and multiple or open long-bone fractures. Clinical signs of intra-abdominal hemorrhage may be difficult to detect in a patient with spinal injuries. Referred shoulder tip pain may be the only indication of intra-abdominal injury and further investigation with ultrasonography, diagnostic peritoneal lavage or computed tomography (CT) are essential to exclude intra-abdominal bleeding in a hemodynamically unstable patient. Urgent control of continuing hemorrhage is required to reduce the risks of hypoperfusion and secondary neurological injury.
After excluding occult sources of hemorrhage initial treatment of neurogenic shock involves cautious fluid resuscitation. The therapeutic goals for neurogenic shock are adequate perfusion with a systolic BP of 90-100 mmHg (acceptable for patients with complete cord lesions), a heart rate of 60-100 beats/min, urine output above 30 mL/h and normothermia.
| Secondary Survey|| |
The secondary survey involves a head-to-toe examination. In conscious patients, this includes a focused history to establish pre-existing medical conditions, the mechanism of injury and the presence of back or neck pain, limb weakness and sensory disturbance. The patient should then be asked to move each limb in turn, provided that there is no pain or discomfort in the limb or spinal column. In addition, direct questions should be asked regarding absent or abnormal sensation in the limbs or trunk. At this stage, a more thorough neurological examination should be carried out. The goal of the neurological examination is to determine the level of the lesion, document the deficit and identify the need for emergency treatment. Injuries above C5 cause quadriplegia and respiratory failure due to Phrenic nerve involvement and may require ventilatory support.
A log-roll should be performed as part of the secondary survey. This allows assessment of the back and vertebral column and the removal of the long spine board if one is present. Before the log-roll is commenced, cervical traction should be instituted. The collar can also be removed at this stage to check the neck for any deformity, tenderness, bogginess or spasm. This technique requires at least five people. One person, the team leader, is responsible for maintaining the in-line stabilization of the head and neck and coordination of the log-roll. A second person holds the patient's shoulder with one hand and places the other hand on the pelvis. The third person holds the pelvis with one hand and places the other hand under the patient's opposite thigh. The fourth person places both arms under the opposite lower leg and support it during the roll. The fifth person is responsible for examining the back, conducting a rectal and perineal examination, observing pressure areas and clearing debris such as blood, splinters and foreign material on the back.
The examination of the back includes looking for evidence of bruising or swelling, palpation over the spinous processes for deformity, swelling, wounds or increased tenderness down the whole length of the spine. Local tenderness at any point should be used to guide radiographic examination. Examination of the perineum should identify sacral sparing, assess anal tone by digital rectal examination. Once the log-roll is completed, the patient can be rolled back to the supine position using similar instructions as before. Patients with an altered level of consciousness or other distracting injuries may not have any features on examination of the back to suggest spinal injury and may be unable to cooperate with neurological examination.  Other signs, which suggest spinal injury in these patients are listed in [Table 1]. These patients will require spinal immobilization until they regain full consciousness, at which time further neurological assessment should be performed.
The patients at this stage of the resuscitation need a nasogastric tube and urinary catheter. These help to prevent the bladder and gastrointestinal distension developing after spinal injury. Urinary catheterization must be performed under strictly aseptic conditions in order to reduce the incidence of urinary tract infection.
| Radiography|| |
Patients with symptoms or signs of cervical injuries, altered consciousness, intoxication or polytrauma require three cervical spine radiographs: A lateral view to include the top of the T1 vertebral body; a long anteroposterior (AP) view; and an open-mouth AP view to show the C1/C2 articulation. The combination of these three views has a high sensitivity for spinal injury.  The careful interpretation of the three standard cervical spine views can provide adequate information regarding the integrity of the vertebral column in most patients. Combinations of cervical and thoracic fractures or thoracic and lumbar fractures are most common and additional films typically including AP and lateral thoracic or lumbar spine Radiographs Adequate. care needs to be taken during radiography with instructions to the radiographer regarding precautions during the procedures and adequacy of the radiographs.
| Concept of Stability|| |
Stability is the ability of the vertebral column to withstand stress under physiological loads without further deformity or neurological damage. The vertebral column is provided stability by the ligaments and intervertebral discs binding vertebrae together and acting as strong tethers. Stability can be determined by considering the integrity of all bony and ligamentous elements of the spinal column in three vertical columns as proposed by Dennis. The stability of the spine is dependent upon the integrity of the anterior, middle and posterior columns. If two of these or the middle column is injured, then the spine is potentially unstable and any movement can damage the spinal cord.
Roentgenographically, cervical spine instability is indicated by the horizontal translation of one vertebra relative to an adjacent vertebra in excess of 3.5 mm on the lateral flexion-extension view. Instability is also indicated by more than 11° of angulation of one vertebra relative to another [Figure 1].
|Figure 1: Radiologically cervical spine instability is defined as translation of more than 3.5 mm or angulation between adjacent vertebrae >11°|
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Conscious patients who have well-localized, severe central neck pain may have an unstable ligamentous injury but no neurological or radiographic abnormalities. Such injuries are much more common in the cervical spine. Flexion views of the cervical spine may be useful in demonstrating any instability; these are achieved by asking the patient to flex his or her neck voluntarily during exposure, after which the film should be examined for evidence of subluxation.
CT scanning has become the mainstay for definitive imaging of the vertebral column injuries. Middle and posterior column fractures can be clearly visualized.  There is evidence that routine imaging of the upper cervical spine in patients undergoing CT for head injury will reveal abnormalities not detected on the plain film and CT of the cervical spine is standard in patients who are intubated and ventilated prior to CT of the head. ,
Magnetic resonance imaging (MRI)
MRI is ideal for imaging the contents of the spinal canal and detecting ligamentous and intervertebral disc damage, as well as vascular injury. It will also identify extradural spinal hematomas and spinal cord hemorrhage, contusion and edema. Sagittal T2-weighted images are regarded as most useful in defining ligamentous injury [Figure 2] and [Figure 3]. However, MRI scanning is currently suitable only for hemodynamically stable patients and is therefore unlikely to be of use in the resuscitation phase of dealing with a patient with multiple injuries. There is a potential role of a second MRI scan 3-4 days later to delineate intramedullary lesion expansion especially in patients with complete motor cervical spine injury. 
|Figure 2: Radiographs of a patient with traumatic paraplegia showing fracture L1 with involvement of anterior and middle column and subluxation of T12 over L1|
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|Figure 3 (a, b): T1, T2-weighted magnetic resonance imaging of the same patient as in Figure 2 delineates the soft tissue component of the injury. Notice the disruption of the disc, posterior elements and transection of the cord with edema of the cord proximally|
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| Emergency Treatment|| |
The goal of emergency treatment in spinal injury is to reduce the secondary injury, improve motor function and sensation and reduce the extent of permanent paralysis. This should concentrate on minimizing secondary physiological and mechanical injury by optimizing oxygenation, ventilation and perfusion, maintaining spinal immobilization and in some cases surgical decompression. Measures to avoid decubitus, which can develop rapidly need to be instated such as air mattresses, frequent change of position and avoidance of soiling of skin by urine and feces.
One of the most controversial areas in the management of spinal cord injury is the use of steroids. There has been much debate over the last two decades as a result of limited evidence from the three US National Acute Spinal Cord Injury studies, which investigated the use of methylprednisolone in acute spinal cord injury.  Further studies have provided no evidence of benefit.  Indeed, there is mounting evidence that adverse event rates are higher with the use of steroids, including sepsis, incidence of pulmonary embolism, pancreatitis and gastrointestinal hemorrhage. Currently, there is no role for the use of steroids in the management of acute spinal cord injury.
Although open wounds require surgical exploration, the timing of surgery in patients who have sustained a closed acute spinal cord injury remains controversial.  Surgically remediable and potentially reversible cord compression owing to dislocation of a vertebral body or displaced bone fragments must be treated urgently. Spinal cord injury in humans is characterized by lesion expansion during the hours following trauma. Lesion expansion has a positive relationship with spinal cord compression and may be mitigated by early surgical decompression. Decompression within 2 h may allow some recovery of spinal cord function. However, even stable injuries can be associated with a significant cord compression and may benefit from decompression. Early decompression is also advocated for incomplete lesions, especially if the limbs are becoming progressively weaker. Detailed clinical and radiological evaluation will usually be required in order to make informed treatment decisions.
| Definitive Care|| |
Although some fractures heal with immobilization and time (usually 2-3 months), many patients with complex vertebral fractures will require closed or open reduction and internal fixation for stability of the spine when conditions permit. Typically a week's time may be required after laparotomy for abdominal injury to safely undertake definitive spinal fixation. In the cervical spine injury and polytrauma, skull traction may be required in the interim or may be used as definitive treatment. Manipulative reduction in experienced hands can result in dramatic improvement.
| Summary|| |
The management of suspected spinal cord injury in patients with polytrauma involves early immobilization of the whole spine and the institution of measures to prevent secondary injury from hypoxia, hypoperfusion or further mechanical disturbance. All spinal injuries should be considered unstable and incomplete until proven otherwise. Careful and informed neurological assessment, together with appropriate plain radiography, will identify the majority of spinal injuries. Early surgical decompression should be considered. Close consultation with other members of the trauma team will be required to safely undertake the definitive fixation at the opportune time and has to be individualized. Improvements in motor vehicle safety and traffic regulations can result in a marked reduction in spinal cord injury due to motor vehicle accidents with a significant reduction in mortality attributable to spinal injury.  A robust system of care is the best assurance of good health outcomes and reasonable health for people with spinal cord injury. 
| References|| |
|1.||Parsons KC, Lammertse DP. Rehabilitation in spinal cord disorders. 1. Epidemiology, prevention, and system of care of spinal cord disorders. Arch Phys Med Rehabil 1991;72:S293-4. |
|2.||World Health Organization. World Health Report 2009; 2009. Available from: http://www.who.int/whosis/whostat/EN_WHS09Table2.pdf 2009. [Accessed on 2010 Dec 06]. |
|3.||Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523-6. |
|4.||Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G, AG Polytrauma der DGU. Spinal fractures in multiply injured patients: An analysis of the German trauma society's trauma register. Unfallchirurg 2007;110:946-52. |
|5.||Kriss VM, Kriss TC. SCIWORA spinal cord injury without radiographic abnormality in infants and children. Clin Pediatr (Phila) 1996;35:119-24. |
|6.||Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study. Eur Spine J 2011;20:2174-80. |
|7.||Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh and Joint Royal Colleges Ambulance Service Liaison Committee. Joint position statement on spinal immobilization and extrication. Prehosp Immediate Care 1998;2:168-72. |
|8.||Majernick TG, Bieniek R, Houston JB, Hughes HG. Cervical spine movement during orotracheal intubation. Ann Emerg Med 1986;15:417-20. |
|9.||McLeod AD, Calder I. Spinal cord injury and direct laryngoscopy - The legend lives on. Br J Anaesth 2000;84:705-9. |
|10.||Burney RE, Maio RF, Maynard F, Karunas R. Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch Surg 1993;128:596-9. |
|11.||Ross SE, O'Malley KF, DeLong WG, Born CT, Schwab CW. Clinical predictors of unstable cervical spinal injury in multiply injured patients. Injury 1992;23:317-9. |
|12.||Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma. Ann Emerg Med 1988;17:792-6. |
|13.||Borock EC, Gabram SG, Jacobs LM, Murphy MA. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001-5. |
|14.||Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: Role of CT. J Emerg Med 1990;8:183-98. |
|15.||Aarabi B, Simard JM, Kufera JA, Alexander M, Zacherl KM, Mirvis SE, et al. Intramedullary lesion expansion on magnetic resonance imaging in patients with motor complete cervical spinal cord injury. J Neurosurg Spine 2012;17:243-50. |
|16.||Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second national acute spinal cord injury study. J Neurosurg 1992;76:23-31. |
|17.||Pointillart V, Petitjean ME, Wiart L, Vital JM, Lassié P, Thicoipé M, et al. Pharmacological therapy of spinal cord injury during the acute phase. Spinal Cord 2000;38:71-6. |
|18.||Tator CH, Fehlings MG, Thorpe K, Taylor W. Current use and timing of spinal surgery for management of acute spinal surgery for management of acute spinal cord injury in North America: Results of a retrospective multicenter study. J Neurosurg 1999;91:12-8. |
|19.||Oliver M, Inaba K, Tang A, Branco BC, Barmparas G, Schnüriger B, et al. The changing epidemiology of spinal trauma: A 13-year review from a level I trauma centre. Injury 2012;43:1296-300. |
|20.||McColl MA, Aiken A, McColl A, Sakakibara B, Smith K. Primary care of people with spinal cord injury: Scoping review. Can Fam Physician 2012;58:1207-16, e626. |
[Figure 1], [Figure 2], [Figure 3]