Evaluation of the spine trauma patient

1

How many traumatic spinal column and spinal cord injuries occur in the united states each year?

It is estimated that over 50,000 traumatic spinal column fractures occur per year in the United States. (1) According to the National Spinal Cord Injury Statistical Center, 17,730 new cases of spinal cord injury occur each year in the United States. This equates to approximately 54 cases per million population annually. Neurologic injury occurs in approximately 25% of all spine fractures but in up to 40% of cervical fractures. There are two peaks of injury with a first peak occurring in young men aged between 15 and 29, and a second peak occurring in adults over age 65 years. The average age of spinal cord injury in the United States during 2015–2018 was 42.9 years, which is consistent with a slow steady increase in the average age of patients sustaining spinal cord injuries.

2

What is the distribution of spinal injuries according to spinal region?

It is estimated that 20% of spinal injuries occur in the cervical region, 30% in the thoracic region, and 50% in the lumbar and sacral region. More than 15% of patients with traumatic spines fracture have a second, noncontiguous vertebral column fracture. (2, 3)

3

What are the most common causes of spinal cord injury?

The leading causes of spinal cord injury are:

• Vehicular accidents (39.3%)

• Falls (31.8%)

• Acts of violence, including gunshot wounds and stabbings (13.5%)

• Sport-related injuries (8%)

• Medical/surgical causes (4.3%)

• Miscellaneous causes (3.1%)

4

What is the distribution of spinal cord injuries according to neurologic level and extent of neurologic involvement?

The distribution of spinal cord injuries by neurologic level and extent of involvement is:

• Incomplete tetraplegia: 47.2%

• Incomplete paraplegia: 20.4%

• Complete paraplegic: 20.2%

• Complete tetraplegic: 11.5%

Less than 1% of persons with an initial spinal cord injury experience complete neurologic recovery by the time of hospital discharge.

5

Summarize the key principles that guide the initial evaluation and management of a trauma patient with a potential spine injury.

• Patients are triaged according to treatment needs and available resources. Initial assessment includes a rapid primary survey, resuscitation, detailed secondary survey, and initiation of definitive care in accordance with Advanced Trauma Life Support (ATLS) principles (American College of Surgeons, The Committee on Trauma).

• All trauma patients are assumed to have a spine injury until proven otherwise

• The injured patient should be immobilized at the accident scene with a rigid cervical collar supplemented with lateral bolsters and straps secured to a long spine board to immobilize the entire spine. Pediatric patients less than 8 years of age require immobilization on a backboard with an occipital recess or placement of a pad underneath the torso to maintain neutral neck position and avoid neck flexion due to their larger head to body ratio. Special precautions are necessary in patients with ankylosed spines such as those with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH) as they are at risk of neurologic deterioration with supine positioning on a rigid spine board or placement of a cervical collar and should be splinted in the position of injury with pillows.

• The cervical spine should remain immobilized and the spine protected by maintaining strict log-roll precautions until spinal injury is ruled out.

• Long backboards should be used only during patient transportation, and should be removed promptly following arrival at the hospital.

6

What are the components of the primary survey?

The primary survey is performed simultaneously with resuscitation and includes the “A, B, C, D, Es” of trauma care:

• A : Airway maintenance while taking care to protect the cervical spine

• B : Breathing and ventilation

• C : Circulation and control of hemorrhage

• D : Disability assessment including a brief evaluation of neurologic status and Glasgow Coma Scale (GCS)

• E : Exposure and environmental control, which includes fully exposing the patient and measures to prevent hypothermia.

7

What are the components of the glasgow coma scale?

The GCS is a 15-point scale to assess traumatic brain injury and impaired consciousness. It is comprised of three components that rate the stimulus intensity required for an eye-opening response (E), verbal response (V), and motor response (M). A final score results from the sum of each of the three components and the injury is categorized based on this score as mild (13–15), moderate (9–12), or severe (3–8) ( Table 54.1 ).