Significant advancements have been made at every level of care for the spine injured patient, from transport methodology to improved imaging modalities to diagnose injury to less invasive, more precise operative interventions. Despite remarkable progress in the care of the spine trauma patient, these injuries, especially when associated with neurovascular injury, remain a debilitating source of burden for the patient, the health care system, and the economy.

Spine and associated spinal cord injuries assail 180,000 to 230,000 males while in the prime of their lives.¹ The spine injury patient is most often male (81% male preponderance) and half of the time is between 16 and 30 years of age.² The spine injury is most often incurred in motor vehicle crash (43%), followed by violence (18.9%), falls (18.8%), and sport injury (11.1%).²

Safety advancements in car manufacturing can be attributed for a plateau in motor vehicle-related injuries although violence-related injury has expanded at an alarming rate.³ Penetrating wounds, related to gunshot injury, are a common source of combined bone and cord injury. Substance abuse appears to have intimate connections to these violent, gun-induced, injuries.⁴

While ground was being lost to gun violence-related penetrating wounds during the 1990s, significant media attention was devoted to sports-related injury.⁵,⁶ It is unclear if media attention reduced injury rates. Even if injury rates where reduced, it was likely a fleeting moment in the history of sporting as newly invented sports become progressively faster, less regulated, and more “extreme.”

Ultimate solutions to the spine injury problem will not be found in our trauma bays but rather in political arenas where intervention can be directed at a point in the time line before the injury ever occurs. As patient care providers try to determine their role in the political process focused on improved safety for all, they must never lose sight of their role in the care of these patients late in the time line when rigorous attention to detail can reduce morbidity and mortality. Understanding spine anatomy is the first step toward understanding spine injury and improving care of the spine injured patient.

The human spine is composed of 31 segments including 8 cervical, 12 thoracic, 5 lumbar, and 6 sacrococcygeal segments (see Table 1). The adult spinal cord ends posterior to the L1-2 vertebral body. Neurologic examination should provide objective information related to lowest level of normal function and hence suggest anatomic site of injury.

Rapid, accurate neurologic assessment allows localization of possible fracture sites before any imaging. Spinal cord injury is often associated with head injury, which can complicate assessment and result in diminished reliance on physical examination with concomitant increase in reliance on imaging. Complete injury is often very clear and outcomes are well documented while incomplete injury results in a more complicated examination and a wider variety of outcomes. Effective care implemented at the first patient interface can significantly improve outcome in the incomplete injury.

In the cervical spine a few key findings allow localization and it is here that that one level of returned function from rapid effective care is most significant to outcome. Injuries to the level of C3 can often be clinically silent although cord injury here can result in diaphragm paralysis and ventilator dependence. With cord injury at the C4-5 level one may maintain some shoulder capability but wrist and hand function are eliminated. A functioning C6 level allows wrist function but no hand function. C7 permits arm straightening and hand use and is often regarded as the level that permits functional independence.

Thoracic fractures are rarely recognized before imaging. Cord injuries between T1 and T8 lead to lack of control of abdominal muscles making trunk control difficult whereas injury below T8 permits good sitting balance. Lumbar fractures are frequent but resultant neurologic injury is more difficult to predict than rostral levels given because nerve roots float freely and one may be injured while another escapes compression. Injury to lumbar nerve roots can lead to diminished control of the legs, hips, and anus. Neurologic examination and spine injury assessment should be assessed at each level of care, starting at the point of the patient’s injury and retrieval.

Patient evaluation and spine protection begins at the site of patient retrieval. Increased awareness of potential spine injury, and proper immobilization, can prevent unnecessary cord damage and can significantly reduce further functional decline.⁷ Unfortunately, all too often the Good Samaritan, unaware of spine injury, can make matters much worse before the arrival of emergency medical technicians (EMT).⁸,⁹ Airway, Breathing, and Circulation, as with all trauma evaluations, start the course of treatment. Full spine immobilization should be implemented immediately. All accident victims must be assumed to have an unstable spine. History and physical examination are good and, if present, pain along the spine is indicative of a spinal column injury.

Head to toe secondary survey permits isolation of motor and sensory deficits that can provide clues to level of injury. Scalp lacerations, cervical spine tenderness, and obvious deformity suggest presence of cervical fracture. Cervical collar should notbe considered to be complete immobilization as it permits significant translation especially in the high cervical spine where failed immobilization is most fatal.¹⁰,¹¹ The cervical soft collar, which permits neck movement in all directions, should never be considered for use in the trauma setting.¹² Securing the neck with parallel bilateral sand bags and silk tape is accepted as the most effective method of immobilization without airway obstruction and the addition of rigid collar eliminates the potential for hyperextension.¹³ When turning is necessary, as in the case of emesis, the patient should be log rolled by three members of the team with the neck held in neutral position. Flat firm backboard is the standard of care for most patients but is not always ideal. Young children whose heads are proportionately larger than their body should be placed on back board with a hole for the head as boards without this feature result in an unacceptable amount of cervical flexion.¹⁴ Rarely one is presented with an ankylosing spondilitis patient, who must be transported in the most comfortable position rather than risk inducing new fractures by forcing an abnormally fused spine into a “normal” position.¹⁵ Once secured, the spine injury patient is brought to the closest trauma facility for further care.

On arrival at the trauma center, the spine injury patient must be evaluated in the same detailed algorithm employed for all trauma patients. Evaluation must be repeated at multiple time points to catch progressive or ascending decline in neurologic function. All organ systems must be optimized to prevent secondary injury such as increase in spinal cord stroke from relative hypoxia. Subsequent to primary trauma survey, neurologic examination and external assessment for spinal deformity (e.g., spinous process step-off) radiologic evaluation should be initiated.

Physical examination in the trauma bay is critical to prioritization of care. Neurologic examination should include evaluation of lowest level of normal sensory and motor function. Neurologic motor examination is graded 1 to 5 in each major muscle group:

The examiner should evaluate the patient for obvious deformity of the spinous processes. Neurologic examination and deformity assessment will guide selection of imaging studies. Physical examination is the guide that will direct selection of imaging studies and is most crucial when time, due to hemodynamic instability, or lack of facilities, necessitates limited imaging evaluation. As examination and
evaluation progresses a member of the team should speak with emergency transport personal to determine the best examination in the field. A clear decline in neurologic function alters the course of further care and time line for interventions. In the stable patient, imaging studies immediately follow primary and secondary evaluation.

Radiologic evaluation should be determined based on capabilities of the facility at hand to optimize amount of data gained in minimal time. Set algorithms designed by a multidisciplinary team within each center based on accepted guidelines is a most effective standard of practice¹⁶,¹⁷,¹⁸,¹⁹ Trauma patients should undergo radiologic evaluation while still immobilized. Standard imaging modalities include computed tomography (CT), plain radiography, fluoroscopy, magnetic resonance imaging (MRI), and angiography. While CT has surpassed use of plain films in the evaluation of cervical spine injuries in many centers, plain films continue to serve as an excellent adjunct in the evaluation of this patient population, especially if CT is not immediately available.

The cervical spine series should include four views (i.e., lateral, open-mouth odontoid, anteroposterior, and oblique views).²⁰,²¹ Anterior, posterior, and lateral thoracic and lumbar films should also be attained. The plain films should be initially viewed for adequacy before evaluation for injury. If a patient is critically unstable, and time exists for only one film, one should acquire a lateral cervical spine film, which has a sensitivity of 70% to 80%.²¹,²²,²³,²⁴,²⁵ Patient hemodynamic stability permitting, addition of open mouth and anteroposterior views will significantly improve sensitivity to cervical injury.²²,²³,²⁶,²⁷ Insofar as the thoracic and lumbar spine is concerned, there are few clinically relevant fractures missed when standard trauma radiography protocols are followed.²⁸ CT has significantly enhanced the evaluation of spine injury in recent years.

When examination is limited by intubation and sedation or concomitant head injury, one must rely on available imaging and examination techniques until such time that a reasonable examination can be completed. The physical examination should include palpation of all spinous processes for clear step-off or fracture. Imaging studies that have shown promise for evaluation include helical CT. Helical CT offers nearly twice the sensitivity of plain films and rarely misses unstable fractures as opposed to plain radiography.²⁹ In situations where a patient is hemodynamically stable but without adequate neurologic examination, a combination of studies are commonly performed.