MINI-SYMPOSIUM: THE SPINE

The initial management of spinal injuries

Nick A Aresti Ishvinder S Grewal Alexander S Montgomery

Abstract
Spinal injuries are common and are often associated with other injuries, therefore should always be suspected in the polytrauma victim. Spinal cord injury resulting from trauma can be compounded by errors in handling, therefore the safe handling of the potentially spinal cord injured patient is of paramount importance at all stages preceding and during hospital care. The early detection of spinal injury is possible using a combination of clinical and radiological criteria, whilst safe initial management before transfer to a designated spinal injury unit consists of spinal immobilisation using recommended protocols.

The detection of spinal injuries can be difcult, particularly in the multiply injured patient. The literature suggests that fractures are missed, or a diagnosis delayed, in 0.5%e24% of cases. The incidence of missed thoracolumbar trauma resulting in neurological injury has been shown to be around 0.21% (or 0.025% of trauma patients evaluated).5 An important point to consider when evaluating any trauma patient is the high propensity for non-spinal injuries to be associated with spinal trauma. 25% of patients with spinal fractures will have a concomitant brain, chest or major extremity injury. In the presence of a spinal fracture, a second fracture in a different region of the spine is present in 5%e20% of cases. The risk of missing a second injury is greater in the head injured, polytraumatised or intoxicated patient.6

Pre-hospital management of spinal trauma

The importance of the early management of spinal trauma should not be underestimated. Up to a quarter of spinal cord injuries occur after the initial traumatic incident has occurred, either during transfer or in the initial hospital management phase. Current recommendations are to immobilise patients with a collar, blocks and tape, along with a hard spinal backboard.7 Despite clear benets, the use of such devices are not without drawbacks. Patients can experience discomfort, as well as delays in transfer because of the time taken to apply these protective devices. Once immobilised, an expedited transfer to a named centre is important, as delays in transferring patients to specialist centres has been showed to lead to poorer outcomes, longer hospital stay, and greater costs.8

Keywords cervical spine clearance; spinal cord injury; spinal injuries

Introduction
Spinal injuries are common, affecting approximately 19.5 per 1000 trauma patients. Broadly speaking, fractures can be categorised as those affecting old, osteoporotic bone following low energy injuries and those affecting the young and healthy following high energy trauma. The severity of injuries varies signicantly. They may be isolated, stable, single level fractures, multilevel fracture dislocations with a spinal cord injury or anything in between. Given the epidemiological variation and differences in severity, the burden of spinal injuries is difcult to quantify. When associated with spinal cord injuries the total economic burden may rise to 1.7 m per person affected, calculated to be 1.5 bn annually for a country the size of Canada (assuming 1389 fractures per year).1 The male sex is affected by approximately 2/3 of fractures, with 31e40 year olds being the most aficted. The most common causes of traumatic spine injuries are accidental falls and road trafc accidents. Falls typically lead to thoracolumbar fractures in slightly older patients, whereas cervical spine injuries typically follow motor vehicle accidents in a slightly younger age group.2 A signicant, if not greater proportion of patients sustaining spinal fractures are pedestrians involved in road trafc accidents (RTAs) rather than occupants of the car.3 Furthermore, motorcycle accidents are associated with more severe, and more commonly multilevel, injuries than other vehicle accident types.4

Immobilisation of the cervical spine e Triple immobilisation

Patients who have sustained a signicant traumatic injury should have their cervical spine injury immobilised as quickly as possible. International consensus dictates the use of a semi-rigid collar, blocks and tape.7 A variety of collars are available for use, and several studies have compared their efcacy. Types of cervical orthoses Several different types of cervical orthoses are available for use. They can be divided into cervical orthoses (CO) or cervicothoracic orthoses (CTO).9 COs may either be soft or hard, the latter being able to x the head to an extent. Soft collars provide minimal motion restriction (exion/extension limited by 5%, lateral exion by 5e10% and rotation by 10e17%), so their role in acute trauma being is negligible. They do provide minimal pain relief. Hard collars further restrict exion/extension, by 20e25%. They must incorporate the chin, occiput or forehead for a signicant effect (approx. 60% in all planes with the head and occiput incorporated). NecLoc cervical orthoses have been shown to be superior in restricting cervical movement in all planes when compared to other devices, followed by the Miami-J collar.10 CTOs further restrict movement by incorporating the trunk, chin and occiput. Flexion and extension are restricted by 70 e80%, lateral exion by 60%, and rotation by 60e70%. Unfortunately their perceived benet is offset by their increased discomfort.

Nick A Aresti MBchB MRCS Trauma Orthopaedic StR, Percivall Pott Rotation, NE Thames, UK. Ishvinder S Grewal MBchB MRCS Trauma Orthopaedic StR, Royal London Rotation, NE Thames, UK. Alexander S Montgomery MBchB MRCS Dipl Orth Eng FRCS Consultant Spine & Orthopaedic Surgeon, Barts Health, Barts and The Royal London Hospital, UK.

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2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Aresti NA, et al., The initial management of spinal injuries, Orthopaedics and Trauma (2014), http://dx.doi.org/ 10.1016/j.mporth.2014.02.004

MINI-SYMPOSIUM: THE SPINE

The ability of a cervical orthosis to stabilise the cervical spine in the trauma setting has been studied in some detail. Podolsky demonstrated that the addition of sandbags and tape to a collar signicantly increases stability, hence the current ATLS recommendations of triple immobilisation.11

Immobilisation of the thoracolumbar spine

Immobilisation of the spine following trauma has been the standard care for almost 30 years.12 The decision to immobilise a patient is traditionally based on the mechanism of injury and whether a spinal injury is suspected. Although limited evidence exists for spinal immobilisation, several cases of poor outcome following mishandling of injuries have been described in the literature. Immobilisation has been shown to cause back and head pain, increasing the number of false positive examination ndings, which in turn necessitates an increased number of investigations to rule out injury.13 The use of selective immobilisation has therefore been endorsed by several studies.14,15 Patient comfort is increased by discontinuing spinal board immobilisation after transfer but this must be carried out safely. Two main techniques for removing patients from spinal boards are currently employed. The lift and slide technique has been shown to be superior to removing a board during a log roll.16

Manual in-line stabilisation during intubation has been shown to minimise the risk of cervical subluxation and yet allow better vocal cord visualisation. The choice of laryngoscope blade inuences the degree of axial distraction; the Miller blade has been shown to be superior to other techniques.18 The use of indirect intubation has been shown, albeit it in an elective setting, to lead to less cervical motion than direct laryngoscopy.19

Spinal cord injuries

A complete spinal cord injury is dened as the absence of motor and sensory function below an anatomic level of injury, in the absence of spinal shock. An incomplete injury is dened as an injury whereby residual cord or nerve root function remains below the anatomic level of injury. Incomplete lesions can be further classied into one of several syndromes, which help to determine prognosis. The initial clinical assessment is a key factor in deciding on subsequent treatment. The reproducibility of examination ndings and the classication systems for recording this assessment must be consistent. Several classication systems exist for spinal cord injuries, however the revised 1996 ASIA/IMSOP scale is considered the most appropriate.20 This includes the AIS (ASIA impairment scale), which scores spinal cord injuries as grades A (complete) to E (normal) (see Table 1).

Management of patients the Emergency Department

For all suspected spinal trauma, ATLS guidelines must be systematically adhered to. Each part of the ABCDE algorithm has points pertinent to managing spinal fractures and cord injuries and many of these topics are revisited later in this article. The rst part of the algorithm involves Airway control and Cervical Spine immobilisation. Immobilisation of the cervical spine comes hand in hand with airway management and difculties are often encountered when managing the two together (see below). Assessment and management of breathing and ventilation (B) and circulation with haemorrhage control (C) are of signicance in spinal trauma patients. Aggressive uid resuscitation to maintain end organ perfusion has been shown to correlate with a better outcome following spinal cord injury. Identication of trunk injuries may raise the suspicion of concomitant spinal injuries. Often in the multiply injured patient the neurological examination (D-disability) can be difcult and often the detail of the examination is suboptimal. One must bear in mind that a normal examination does not preclude a cord injury and that the initial ASIA (see later) score for spinal cord injury correlates with outcome. Exposure (E) involves a log roll, which allows for a systematic physical assessment of the entire spine. In the patient who is not under the inuence of alcohol or drugs (including pre-hospital analgesia) a log roll examination can successfully exclude lumbar (but not thoracic) fractures.17

The grading of spinal cord injury

A Complete: No motor or sensory function (for denitions, see text) is preserved in the sacral segments S4eS5 B Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4eS5 C Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3 D Incomplete: Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more E Normal: Motor and sensory function are normal. Table 1

The prognosis of spinal cord injury can be predicted by the initial neurological state. Patients with an initial AIS score of A have only a 2e3% chance of recovering to an AIS score of D by 1 year. Similarly the level of incomplete lesions and age are major determinants of long term outcome. Patients with an AIS score of B, with preservation of perianal pinprick sensation, have a 70% chance of regaining limb function. Likewise, over 90% of patients younger than 50 with an AIS score of C or D on presentation can be expected to ambulate at 1 year.

Radiographic assessment and C-spine clearance

In the USA and Canada alone, over 13 million people annually sustain signicant trauma and are at risk of cervical spine injuries.21 Variation between clinicians and research ndings has led to discrepancies in practice and the overuse of plain radiographs. Although plain radiographs of the cervical spine are cheap, overuse has led to a signicant nancial burden.22,23

Intubation of the patient with spinal injuries

Spinal injuries make airway control and intubation technically more challenging, particularly in the pre-hospital setting. Despite this, intubation in patients where cervical immobilisation is maintained does not lead to a worsening neurological status.

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2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Aresti NA, et al., The initial management of spinal injuries, Orthopaedics and Trauma (2014), http://dx.doi.org/ 10.1016/j.mporth.2014.02.004

MINI-SYMPOSIUM: THE SPINE

Patients can be broadly categorised into the alert cooperative patient and the obtunded or intubated patient: The alert, cooperative patient Two large trials have been conducted assessing the use of clinical parameters in clearing cervical spines, thus avoiding the use of radiography. The National Emergency X-Radiography Utilization Study (NEXUS) conducted a trial across 21 centres in the USA, using ve low-risk criteria (Table 2). When applied prior to radiography the criteria yielded a sensitivity of 99.6% and a specicity of 12.9% for cervical spine injury.24 A Canadian group devised the Canadian Cervical-spine Rule (CCR), which incorporated three high-risk criteria, ve low-risk criteria and considered the ability of patient to rotate their neck (Figure 1). Application of the CCR prior to radiography in 10 Canadian units yielded a sensitivity of 100% and specicity of 42.5% for the detection of cervical spine injuries. A prospective validation among 8283 patients has further demonstrated that the CCR is more sensitive than the NLC for detecting injuries (99.4% vs 90.7%).25 The obtunded or intubated patient These patients previously posed a medical conundrum. Often patients would have multiple imaging studies of various types and would have to wait till they were alert enough for NEXUS or CCR rules to be applied prior to the cervical spine being cleared. This often meant long periods of time immobilised, resulting in signicant morbidity. The use of CT alone is safe when clearing a cervical spine; its superiority over plain radiographs has also been demonstrated.26 A large meta-analysis of 14,327 patients assessed the use of modern helical CT alone in the clearance of cervical spines. The study demonstrated a sensitivity and specicity of >99.9% in the use of CT alone in detecting injuries. If CT scans were used to clear spines alone, this would equate to a typical trauma centre missing one unstable injury every 14 years. Furthermore, the signicance of missing an unstable injury is not necessarily associated with an adverse outcome. Keeping a patient immobilised until they can be clinically examined is not necessarily a superior option as a 6.8e67% complication rate is associated with cervical immobilisation.27

 Local signs of injury;  Abnormal neurological signs;  Cervical spine fracture;  GCS <15;  A major distracting injury;  Alcohol/drug intoxication. Multi-detector CT (MDCT) has been shown to be by far the most superior imaging modality for spinal trauma. It is more accurate and quicker than other modalities.29 It has also been shown to be more cost effective and its use improves outcomes.30

Management of cervical fracture dislocations

Patients with fracture dislocations of the cervical spine, in particular those with canal compromise or abnormal neurology, should have their injury reduced in a timely manner. Several controversies exist as to the method of reduction and whether pre-procedure MRI is necessary. In the awake and alert patient, closed reduction has been shown to be a safe technique.31 The two modalities employed for closed reduction are traction-reduction (TR) and manipulation under anaesthesia (MUA). TR is generally used as a means of directly achieving reduction, with one study showing it to have a lower complication rate than MUA. The latter is normally reserved for a failed TR, although it is occasionally used primarily.32 A success rate of approximately 80% for closed reduction has been quoted by the American Academy of Neurological Surgeons, with an overall permanent neurological complication rate of 1%, and a risk of transient injury of 2e4% (reversible with reduction in weights or open reduction).33 Whether an MRI is required prior to reduction remains a controversial topic, as highlighted by the Spine Trauma Study Group.34 Although an MRI will demonstrate a herniated disc in up to half of patients, the signicance of the disc is questionable. Several authors have attempted to describe what constitutes a potentially dangerous lesion, which would necessitate an open decompression/reduction. Vaccaro suggested a protruded vertebral disc, behind the cephalad disc, constitutes a dangerous lesion35 but this has since been refuted elsewhere, with several studies demonstrating disc retraction following reduction, and no correlation between MRI ndings and neurological deterioration.36 Indications for an MRI scan in a cervical dislocation include: patients who are un-examinable, in an attempt to ascertain the status of the spinal cord, and irreducible dislocations. Treatment following such an MRI is again a controversial topic. If a herniated disc is considered a dangerous lesion, anterior cervical discectomy and fusion is indicated. What constitutes a dangerous lesion still remains unclear.

Radiographic evaluation of thoracolumbar fractures

Far fewer studies have been conducted regarding the detection of thoracolumbar fractures. Indications for imaging of the thoracolumbar spine should include:28  Back pain/midline tenderness;

Nexus low-risk criteria for assessing neck pain

Early management decisions for thoracolumbar fractures
The NEXUS low-risk criteria. Cervical-spine radiography is indicated for patients with trauma unless they meet all of the following criteria: C No posterior midline cervical-spine tenderness C No evidence of intoxication C A normal level of alertness C No focal neurologic decit C No painful, distracting injury Table 2

Most spinal fractures occur in the thoracolumbar (TL) spine. The transition between the relatively immobile thoracic spine and the mobile lumbar spine, and the change in disc morphology, provides a weak point. The thoracolumbar junction (T11-L1) is therefore the most injured region of the thoracolumbar spine.37 Neurological decits are reported in around 15%e20% of patients following TL fractures. Fractures above L2 are more likely to be associated with neurological injury, as the conus medullaris and cord occupy the canal up to L1 and are more susceptible to injury.

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2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Aresti NA, et al., The initial management of spinal injuries, Orthopaedics and Trauma (2014), http://dx.doi.org/ 10.1016/j.mporth.2014.02.004

MINI-SYMPOSIUM: THE SPINE

Figure 1

Classication of thoracolumbar fractures

Perhaps the most recognised classication system for TL fractures is Deniss 3 column classication, in which the spine is considered as three columns:38

 The anterior column, which contains the anterior longitudinal ligament (ALL) and the anterior half of the vertebral body and disc.  The middle column, which contains the posterior half of the body and disc and the posterior longitudinal ligament.

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MINI-SYMPOSIUM: THE SPINE

 The posterior column, which includes the neural arch (pedicles, laminae, facet joints) and the PLC. The Denis system has withstood the test of time and remains useful as a general descriptor, although questions remain over its inter-observer reproducibility39 and its ability to predict neurological recovery.40 McAfee expanded on Deniss system and provided a comprehensive descriptive classication, based on the forces that disrupt the middle column (Table 3): TLICS classication The most recent classication system to have gained popularity is the Thoracolumbar Injury Classication and Severity Score (TLICS). Unlike other classication systems it takes into account the morphology of fractures, the state of the posterior ligamentous complex (PLC) and neurology.41 It has been successfully validated42 and shown to be reliable.43 This acts as a useful guide to the initial management of TL spine trauma (Table 4).

TLICS classication
TLICS classication Type Morphology Compression Burst Translational/Rotational Distraction PLC integrity Intact Suspected/indeterminate Injured Neurology Intact Nerve root Cord/conus, complete Cord/conus, incomplete Cauda equina Table 4 Point

1 2 3 4

0 2 3

The management of spinal cord injury

Spinal cord injuries may be obvious at the time of presentation. In the polytraumatised patient, subtle signs are difcult to pick up, so a high index of suspicion is always required. Spinal cord injured patients, particularly those with cervical injuries, are also commonly at risk of cardiac or respiratory compromise either related directly to spinal cord injury or to other systemic injuries. Evidence suggests that hypotension and hypoxia after spinal cord injury results in a worse neurological outcome, due to reduced spinal blood ow and hypoperfusion. Aggressive resuscitation of blood pressure in such patients has been shown not to effect outcome.44 It is therefore recommended that the mean arterial pressure (MAP) is maintained between 85 and 90 mmHg for 7 days following spinal cord injury.44

0 2 2 3 3

The use of steroids in spinal cord injury

The neurologic decit related to spinal cord injuries develops as a result of primary and secondary injury processes. The initial (primary) injury results from local deformation and energy dissipation at the time of injury. Compression, distraction or cord transection leads to cell death, axonal disruption, as well as vascular and metabolic changes causing hypoxia and ischaemia. Grey matter is irreversibly damaged within the rst hour (due to its softer consistency and greater vascularity). White matter is irreversibly damaged within 72 h of injury.45 The secondary

injury ensues and involves tissues adjacent to those already damaged. Various pathological processes have been acknowledged, including free radical formation, reperfusion injury, calcium-mediated insult, immunological injury and disturbances in mitochondrial function. The NASCIS (National Acute Spinal Cord Injury Study) trials looked at steroid use in an attempt to reduce the effect of the secondary insult, preserving neurological function. Several studies have been performed to date, the results of which have sparked much controversy. Results demonstrated a trend towards improved motor recovery (particularly those treated within 3e8 h), though the statistical signicance has been questioned. In fact, despite 4 prospective blinded RCTs, no class I evidence exists demonstrating any benecial effect.46 The trials did show trends towards higher rates of sepsis and pneumonia with steroid treatment, however. The American Association of Neurological Surgeons now does not recommend the use of steroids in spinal cord injured patients. Current trials are instead looking at the use of Riluzole, a glutamate receptor blocker.47

McAfee and Denis system

Type Compression Stable Burst Unstable Burst FlexioneDistraction Chance Translational Table 3 Anterior Compression Compression Compression Compression Tension Shear Middle None Compression Compression Tension Tension Shear Columns Posterior None None Comp, Lat Flex, Rot Tension Tension Shear Mechanism Forward exion Axial compression Comp, Lat Flex, Rot Anterior fulcrum Anterior fulcrum Shear

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MINI-SYMPOSIUM: THE SPINE

Relative hypothermia in spinal cord injuries

Inducing hypothermia has been shown, in several studies, to have potential metabolic benets: reduction of glutamate in CSF, reduction of vasogenic oedema, reduction in neutrophil inltration and an improvement in cerebral and spinal cord blood ow. Conversely hyperthermia leads to a worse outcome.48e50 Although systemic hypothermia has itself adverse effects, such as possible respiratory complications, infections, thrombosis, and metabolic derangement, systemic cooling to a modest 33  C via endovascular methods has been shown to be safe, with complication rates similar to those seen in normothermic patients.50,51 Several experimental and clinical trials have recently emerged with promising results, prompting the demand for larger prospective studies.49

Transferring the patient safely on to the operating table

If a decision has been made to operate, transferring a patient with an unstable spine using a Jackson table has been shown to reduce both cervical and thoracolumbar movement in all planes compared to log rolling. The patient slides across on to the Jackson table in a supine position and is appropriately secured to allow a 180 degree ip in to the prone position (if that is the approach being used). Jackson tables should therefore be used where available in unstable injuries in the operating theatre.52,53

Summary
All patients with potential spinal injury should be treated as if such exists and steps should be taken to conrm or refute the diagnosis. If spinal injury is conrmed the initial management consists of immobilisation using recognised methods. Unstable injuries may need surgical management. Early, accurate classication of the injury can help guide treatment and indicate the prognosis. It is vital that patients subject to trauma that could potentially cause spinal injury are treated as if spinal injury exists, as to do otherwise risks causing additional neurological injury that may prove permanent. A
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Please cite this article in press as: Aresti NA, et al., The initial management of spinal injuries, Orthopaedics and Trauma (2014), http://dx.doi.org/ 10.1016/j.mporth.2014.02.004