Initial Evaluation and Stabilization

All trauma patients are presumed to have a spinal injury until proven otherwise, and appropriate management of these patients requires the close cooperation of multiple disciplines, including general surgery, neurosurgery, orthopaedic surgery, and critical care specialists. Vigilant adherence to spinal precautions during the initial evaluation and resuscitation is crucial to preventing further neurologic damage. SCI, especially those associated with vehicular crashes, is commonly accompanied by other injuries, including loss of consciousness (43%), fractures of the trunk or long bones (40%), head injury (18%), and pneumothorax (17%). Because SCI is commonly associated with other severe and life-threatening injuries, proper protocols must be followed to ensure that the patient as a whole is cared for properly.

The initial evaluation and management of polytrauma patients starts in the field with first responders and continues en route and upon presentation to the hospital. Treatment priorities involve preserving life, then limb, and finally function. The American College of Surgeons has established Advanced Trauma Life Support (ATLS) protocols for the initial assessment, resuscitation, and stabilization of polytrauma patients. These protocols are designed to systematically evaluate and identify life-threatening injuries while maintaining precautions necessary to prevent further harm to the patient. It is precisely in this type of high-pressure environment where occult spinal injuries may not be immediately recognized because the initial focus needs to be on the airway, respiratory, and circulatory systems.

All polytrauma patients should be treated as though they have sustained an unstable spinal column injury until proper evaluation has excluded an injury. In fact, up to 25% of patients with traumatic spine injuries experience further neurologic deterioration after coming under the care of medical personnel. Thus, provisional stabilization and appropriate immobilization of the spine starting at the scene is crucial for preventing the onset of a neurologic injury or to avoid exacerbation of an existing neurologic injury. This entails returning the head and neck to a neutral alignment by aligning it with the long axis of the trunk and keeping the neck out of flexion or extension. The currently accepted practice is to apply a rigid cervical collar to help immobilize the cervical spine in the neutral position before extrication from the accident scene. It bears mentioning that even though the application of rigid cervical collars in trauma patients is still the standard of care, alone they may not sufficiently immobilize an unstable cervical spine and eliminate motion during transfers. In the past, the accepted method for moving a patient onto and off a spine board was using the logrolling maneuver. However, recent research has shown that this technique results in significantly more cervical, thoracic, and lumbar motion than other available techniques, such as the scoop stretcher, straddle lift and slide, and 6 + lift and slide methods. Thus, some authors recommend using one of these alternative techniques rather than logrolling when transferring trauma patients. The one exception is when a patient is found prone at the scene; he or she should be transferred directly onto a spine board using the logroll push technique. After the patient is positioned on a flat, rigid spine board, sandbags are placed on either side of the head and neck, and the head is taped to the board to adequately immobilize the spine. Of note, children have disproportionately larger heads; therefore, elevating the trunk on padding or using special pediatric spine boards with a recessed head section is needed to prevent potentially dangerous neck flexion and possible cord compression resulting from being placed directly onto a regular adult spine board.

Advanced Trauma Life Support

Early communication between first responders and the hospital emergency department (ED) is important to ensure that the proper personnel and resources are present as soon as the trauma patient arrives. Upon arrival, the first priority of the ATLS protocols involves initiation of the “primary survey” following the mnemonic “ABCDE,” which corresponds to airway, breathing, circulation, disability (i.e., neurologic status), and exposure (i.e., completely undress the patient).

The patency of the airway is first to be assessed. In a trauma patient, this can be obstructed by blood, teeth, the tongue, maxillofacial trauma, or laryngeal injury. If the patient is able to communicate verbally, the airway is patent and most likely not in immediate jeopardy. On the other hand, if there is an obstruction, then an airway must be quickly established by removing the obstruction, intubation, or performing a cricothyroidotomy. The prevalence of cervical spine fractures in the setting of head or facial injuries has been reported to be 7% to 24%. During the process of reestablishing a patent airway, it is important to maintain cervical spine precautions, especially if the cervical collar needs to be temporarily removed. This can be accomplished with in-line cervical stabilization, maintaining a neutral spinal position, and avoiding any flexion or extension.

After an airway is secured, the next step is to assess the ability of the patient to ventilate, a process that requires adequate function of the lungs, chest wall, and diaphragm. Tension or open pneumothorax, massive hemothorax, and paralysis can all interfere with one’s respiratory function and can rapidly lead to death if not recognized and urgently addressed. The absence of respiratory effort can originate from a brainstem injury or a high cervical cord injury. The diaphragm is innervated by the phrenic nerve, which receives contributions from the third, fourth, and fifth cervical nerve roots. When evaluating the chest wall, it is important to keep in mind that the sternum–rib–costotransverse articulation acts as a physiologic buttress or “fourth column” ; thus, sternal fractures and multiple rib fractures in flail chest have been shown to further compromise the stability of thoracic spine fractures.

As the airway and respiratory status are being evaluated, the patient’s temperature, heart rate, blood pressure, and oxygen saturation should simultaneously be determined. Evaluation of the patient’s circulatory and hemodynamic status includes assessing the patient’s intravascular blood volume, cardiac output (via the heart rate, blood pressure, and urine output), and identifying sources of hemorrhage. In a trauma patient, hypotension (defined as a systolic blood pressure of <90 mm Hg) is presumed to be hypovolemic in origin until proven otherwise. External sources of bleeding should be controlled with direct manual pressure whenever possible, and appropriate intravenous (IV) access should be obtained. In the setting of hemodynamic instability and shock, IV access should involve at least two large-bore (minimum of 16-gauge) peripheral IV lines, preferably in the upper extremities. Initial resuscitation is with crystalloid, but if there is no improvement in end-organ perfusion (i.e., level of consciousness, urinary output, peripheral perfusion) after 2 L, packed red blood cells (universal donor blood—group O, Rh negative, if necessary), platelets, and fresh-frozen plasma should be given in a 1 : 1 : 1 ratio. Of note, the finding of hypotension without tachycardia on presentation should raise clinical suspicion for neurogenic shock from a SCI above T6. Disruption of the sympathetic innervation results in unopposed vagal tone, resulting in vasodilation, decreased systemic vascular resistance, and decreased cardiac output. This form of shock, referred to as neurogenic shock, is often treated with vasopressors when the fluid challenge proves ineffective and, in severe circumstances, cardiac pacing.

Patients can lose large amounts of blood internally in the thorax, peritoneum, retroperitoneum, and thighs, so these areas demand careful examination in a hypotensive trauma patient. A hemothorax should be identifiable during the assessment of the patient’s respiratory status. Peritoneal blood is commonly identified by a Focused Assessment with Sonography Test (FAST) or diagnostic peritoneal lavage (DPL). Pelvic injuries can also result in substantial blood loss into the retroperitoneal space, which may not be picked up by FAST or DPL. Physical examination findings suggestive of pelvic injury include scrotal or labial swelling and ecchymosis, blood at the urethral meatus, or perineal or genital lacerations. Provocative maneuvers to assess pelvic stability, such as compressing the iliac wings medially or applying an anterior to posterior stress against the anterior superior iliac spine, should only be performed once because these maneuvers can lead to disruption of the initial blood clot. A retrospective review of 18,644 trauma patients showed that the presence of a pelvic fracture was an independent risk factor for cervical spine injury, increasing the risk ninefold. The thigh is another potential space and is capable of containing up to 4 units of blood when there is a femur fracture. Femur fractures are usually the results of high-energy trauma and thus are often associated with other injuries. In fact, a multicenter retrospective review of 201 patients with femoral shaft fractures showed that 3.5% of them were also found to have concurrent thoracic or lumbar spine fractures. Missing a spine injury in a patient with a femoral shaft fracture can be dangerous because the process of positioning and the traction required to place a femoral intramedullary rod could exacerbate an unstable spine injury.

As part of the initial trauma evaluation, a rapid neurologic evaluation should be performed to determine the patient’s level of responsiveness (Glasgow Coma Scale [GCS] score). This is based on the patient’s best eye response, verbal response, and motor response to verbal commands or painful stimuli. Scores range from 3 to 15, with a GCS score of 15 corresponding to a patient that is awake, alert, appropriate, and following commands. A GCS score of 13 or 14 represents mild brain injury, a score of 9 to 12 corresponds to moderate injury, and a score of 8 or less is indicative of severe brain injury.

Finally, during the evaluation of a trauma patient, it is important to remove all clothing to perform a thorough assessment. However, it is equally important to cover up the patient again with blankets to prevent hypothermia after the assessment is completed. Even though ATLS outlines the ABCDEs of the primary survey, this is not a linear process. Rather, it is usually carried out in parallel, with the patient being undressed and vital signs and IV access being obtained while the airway, respiratory, and cardiovascular systems are being evaluated.

After the primary survey is completed and resuscitative efforts are underway, the secondary survey begins. This involves a head-to-toe examination of the head, neck, chest, abdomen, perineum, and musculoskeletal system and a complete spine and neurologic examination. With the patient still supine on the spine board, the scalp and head should be examined for any lacerations, contusions, and fractures. The eyes are assessed for pupillary size and reactivity, hemorrhage, and ocular muscle entrapment, as well as for midface stability. The anterior neck is evaluated for swelling, tracheal deviation, and subcutaneous emphysema. The entire chest is inspected for wounds and bruising, the chest cage is palpated for tenderness and flail segments, and the lungs are auscultated to confirm proper air movement and to identify a pneumothorax or hemothorax. The abdomen is examined for tenderness and peritoneal signs, but normal initial examination findings do not exclude significant intraabdominal injury. Patients with unexplained hypotension, neurologic injury, impaired sensorium, or equivocal abdominal findings are candidates for FAST, DPL, or, if hemodynamically stable, an abdomen and pelvis computed tomography (CT) scan. The perineum is examined next for lacerations, ecchymosis, and urethral bleeding. A vaginal examination should be performed in patients at risk for vaginal injury. The extremities and pelvis are then evaluated for any wounds (e.g., open fractures), deformities, and pain or tenderness with palpation or range of motion. Peripheral pulses should be assessed to identify accompanying vascular injuries and to confirm sufficient resuscitation and restoration of appropriate blood pressure.

Classification of Neurologic Injury

The spinal examination is an essential part of the comprehensive musculoskeletal examination. It is essential to replace the field collar with an appropriate rigid cervical collar. With the appropriate personnel present, the patient should be rolled onto his or her side for direct visualization, palpation, and examination of the back and spine. One assistant stabilizes the head and neck while two or three additional assistants support the patient’s trunk and legs ( Fig. 10-1 ). The examiner then inspects the back, looking for abrasions, ecchymosis, and the rare open spinal fracture. The midline spinous processes should be carefully palpated from the cervical through the lumbar spine to identify areas of tenderness, stepoffs, malalignment, and abnormal diastasis between adjacent-level spinous processes. One must also examine the perineum for sensation, rectal tone, and the presence of any gross or occult blood in the rectal vault. The bulbocavernosus reflex can also be examined to evaluate for spinal shock. The backboard is then slid out and the patient carefully rolled back onto the stretcher. After this, a complete neurologic examination should be performed.

Clinical photograph showing a patient being logrolled. One assistant stabilizes the head and neck while two or three additional assistants support the patient’s trunk and legs.

The American Spinal Injury Association (ASIA) neurologic classification of SCI and the ASIA impairment scale (modified from the Frankel classification ) are useful tools for precisely mapping motor and sensory deficits to a specific spinal cord level ( Fig. 10-2 and Table 10-1 ). Motor strength is tested bilaterally in each of five upper extremity muscle groups ( Fig. 10-3 ) and five lower extremity muscle groups ( Fig. 10-4 ) and graded on a scale from 0 to 5. Sensation to light touch and pinprick is tested bilaterally in each of 28 sensory dermatomes. According to ASIA definitions, the neurologic injury level in SCI is the most distal level of the spinal cord with normal motor and sensory function bilaterally. A “complete injury” (ASIA A) is one in which there is complete absence of motor and sensory function below the neurologic injury level, including the lowest sacral segment (S4–S5) (see Table 10-1 ). Sensation at these levels involves sensation at the anal mucocutaneous junction ( Fig. 10-5 ) and deep anal sensation; sacral motor function requires the voluntary contraction of the external anal sphincter. “Incomplete injuries” (ASIA B–D) have partial preservation of sensory or motor function in the lower sacral segments and are associated with a greater potential for some neurologic recovery (see Table 10-1 ).

The American Spinal Injury Association (ASIA) neurologic classification of spinal cord injury and the ASIA impairment scale are useful tools for precisely mapping motor and sensory deficits to a specific spinal cord level.

Examination of muscle groups innervated by nerve roots in the upper extremity should include elbow flexion (C5), wrist extension (C6), wrist flexion (C7), finger flexion (C8), and finger abduction (T1).

Examination of muscle groups innervated by nerve roots in the lower extremity should include leg abduction (L2), knee extension (L3), ankle dorsiflexion (L4), great toe extension (L5), and great toe flexion (S1).

Test sensation in the lower sacral dermatomes to evaluate for sacral sparing.

The examination is considered unreliable if the patient is intoxicated, obtunded, or in spinal shock. If the patient is intoxicated or unresponsive, the initial neurologic assessment involves gathering information from the first responders regarding neurologic function (i.e., witnessed voluntary extremity motion) at the scene and in transport. Careful observation of spontaneous movements and response to noxious stimuli, reflexes, and rectal tone can give some information about spinal cord function in these patients. In a patient with no voluntary movement or response to noxious stimuli, the presence of reflex arcs indicates an upper motor neuron injury; their absence implies a lower motor neuron injury. Figure 10-6 illustrates the locations of the upper and lower extremity stretch reflexes and the responsible nerve roots. Other important reflexes include the plantar reflex and anal wink. The plantar reflex is tested by firmly stroking the plantar aspect of the foot with a pointed object and observing toe movement. Flexion of the toes is normal, but extension of the great toe with splaying of the lesser toes is abnormal (“Babinski sign”) and indicates an upper motor neuron lesion. The anal wink reflex is mediated by the S2 to S4 nerve roots and is elicited by stroking the skin around the anal sphincter and watching for its contraction. This reflex is abnormal if no sphincter contraction is observed.

Upper and lower extremity muscle stretch reflexes and the responsible nerve roots.

Patients may also present in spinal shock, which is the transient physiologic depression in spinal cord function caudal to the level of injury. This usually results in 24 to 72 hours of paralysis, diminished tone, loss of sensation, and the absence of reflexes caudal to the injury level. The end of spinal shock is marked by return of the bulbocavernosus reflex mediated by the S1, S2, and S3 nerve roots. This reflex arc is tested by squeezing the glans penis or tugging on an indwelling Foley catheter and looking for contraction of the external anal sphincter ( Fig. 10-7 ). Any significant neurologic deficits that persist after this resolution often are slow to recover if they recover at all. It should be emphasized that the neurologic assessment should be systematically repeated and updated over time as the patient’s level of consciousness improves.

The bulbocavernosus reflex is tested by squeezing the glans penis or tugging on an indwelling Foley catheter and looking for contraction of the external anal sphincter. This reflex is mediated by the S1, S2, and S3 nerve roots.

If the patient is alert, cooperative, and sober and there are no “distracting injuries,” areas of tenderness on examination can help guide further radiographic evaluation. Otherwise, one needs to maintain a high suspicion for spinal injury, and knowledge of associated injuries can help. Head, facial, or neck trauma should raise suspicion for cervical spine injury. Additionally, the presence of a pelvic fracture increases the risk of the presence of a concomitant spine injury. The presence of a “seatbelt sign,” ecchymosis on the trunk from shoulder or lap belts, is associated with abdominal and thoracolumbar spine (TLS) injury, especially if only lap belts are used. In fact, there is a significant correlation between flexion–distraction injuries of the TLS and intraabdominal and retroperitoneal injuries. Importantly, if one finds an injury at one vertebral level, the entire spine needs to be imaged to evaluate for noncontiguous spinal injuries. Keenen and colleagues reported a 6.4% incidence of noncontiguous spine fractures based on retrospective review of 941 patients with spine fractures. Similarly, a series of 137 pediatric patients with spine injuries at a single trauma center revealed that 7% of patients had multilevel noncontiguous spine fractures.