Management of the spine in the polytrauma victim

Abstract

Major trauma is a common occurrence globally and a leading cause of death in younger patients. Its definition and epidemiology is described in depth elsewhere in the symposium. In the UK there are approximately 22,000 cases presenting per year. Overall management strategy dictates that major trauma is directed to centres experienced in its management. It is, however, important that all clinicians recognize and are aware of it, with implications for resource utilization. The spine can be injured through a variety of mechanisms but importantly in major trauma it is unusual for the spine to be injured in isolation, unless a direct impact is sustained. Conversely, it is critical to be aware of the possibility of vertebral and spinal cord injury which may be masked by distracting injury. Strategies and guidelines for the management of the spine in major trauma will be discussed, and some case examples will be shown in order to demonstrate key concepts and pitfalls.

Introduction

Major trauma accounts for approximately 22,000 cases per year in the UK. It is among the commonest causes of death in the younger age groups. It is difficult to extrapolate precise numbers for all trauma combined, but the World Health Organization (WHO) data for road traffic deaths specifically reveals that road traffic deaths are the leading cause among 15–29 year olds. Overall mortality is 15 per 100,000 per year globally, or 1.2 million people. An estimate of global trauma burden suggests approximately 6 million deaths per year, more than contagious diseases including HIV/AIDS, tuberculosis (TB), malaria and coronavirus disease (COVID-19) combined. There are some 40 million people permanently injured and up to 100 million temporarily injured per year.

Most common mechanisms of injury are road traffic collisions, falls (determined as ‘high’ falls or ‘low’ falls), interpersonal violence, and industrial machinery accidents. It is important to remember that in elderly patients with underlying co-morbidities and severe osteoporosis, comparatively small amounts of energy transfer can lead to significant fractures. In this group, a fall from standing height can lead to major trauma.

Within the UK reconfiguration of trauma services led to establishment of major trauma centres (MTC) and trauma units (TU), leading to improved outcomes in severely injured patients. ^, It is likely that all centres with an orthopaedic service will be either an MTC or TU, except for purely elective settings. Therefore, it is important to have a working knowledge of this system and early management of injuries that, for example, could be inadequately triaged to a TU, or their condition worsens after arrival.

With regards to the spine this forms the core of the axial skeleton. It is relatively well shielded, and one must consider the vector of force required to generate the injury observed. Combined with anatomical knowledge and cross-sectional imaging associated injuries can be estimated, and indeed the reverse whereby a spinal injury should be suspected in the presence of other clinical findings.

Similarly at junctional points, i.e. cranio-cervical, cervico-thoracic, thoraco-lumbar and lumbosacral spine it is important to exercise caution and have a low index of suspicion to consider advanced imaging, for example MRI scan to look for occult or undiagnosed injuries.

In this review we shall describe a systematic approach to managing the spine in the major trauma patient.

Assessment

In considering the major trauma patient it is essential to obtain as much information about the incident which caused the trauma. The key point in the initial assessment is an estimation of how much energy was exerted, either in ‘real’ terms, or relative if considering more frail patients.

The energy ‘input’ comes from the velocity the patient may have been travelling, and as an additional consideration the mass of the object the patient may have been struck by in the case of a pedestrian-vehicle collision.

In terms of falls, the height gives an idea of the potential energy that was applied, and this can be calculated as the patient’s mass multiplied by the gravitational acceleration and height. For a fall downstairs, for example, it is useful to know if the patient was able to slow themselves down on the railing, or whether they fell full height.

Energy dissipation is also a key consideration. If the patient came to a rapid stop the energy transfer (and therefore potential for damage) is much higher than a more controlled deceleration.

Key features in the history are summarized in Table 1 .

Table 1

Key features to consider in history-taking

Patient
Demographics	Medical history	Current state
Age Sex	Co-morbidities Antiplatelet/Anticoagulation therapy Osteoporosis	Intoxicated Obtunded
Mechanism
Road traffic collision	Fall	Violence
Speed Impact: rapid deceleration, i.e dead stop or gradual Self-extricated Ejected Prolonged extrication Other passengers in vehicle- any deaths?	Height Landed onto what surface: grass, concrete, water Any break of fall Able to mobilize	Any restricted movement Direct blow or stab injury

A standard Advanced Trauma Life Support (ATLS)-based approach is used to assess the patient and it is useful to use this as a framework for priorities and order in which spinal problems may become evident.

Airway

It is unusual for a spinal injury to cause a direct airway problem, but in the presence of facial injury or direct airway injury there should be a high suspicion of potential for cervical spinal injuries. This point brings us to one of the first key concepts. Airway management with C-spine precautions can be difficult, particularly in the face of upper airway/maxilla-facial bleeding. It is a reasonable assumption that in an emergency airway scenario the patient will be obtunded and, therefore, impossible to clear the neck. A key piece of information if possible is to ask the patient to move the hands and feet, so at least there is some evidence of distal movement prior to intubation.

In terms of airway manoeuvres head tilt and chin lift should be avoided. It is likely that a cervical collar will be in situ, or if not manual in line stabilization be applied. If an airway device is being placed then a jaw thrust is applied, keeping the neck in neutral position. Logistically this means having three people around the head and thus careful teamwork is required ( Figure 1 ).

In the event of intubation a proprietary video laryngoscopy device is advisable; this allows visualization of the vocal cords and some allow for the tube to be passed via the device itself

Breathing

This may be the first point a spinal injury becomes apparent in an obtunded patient. A high cervical injury can mean damage to the spinal cord, with injuries between C2 and C5 most critical as the phrenic nerve supply to the diaphragm arises from the phrenic motor nucleus in the ventral portion of the cord at C3, C4 and C5, with the C4 root being the predominant supply.

An awake patient will be likely quadriplegic with difficulty breathing. In an unconscious or intubated patient, it may only become apparent if the patient’s own respiratory effort can be judged. As many emergency intubation protocols include the use of paralysing agents to enable intubation and ventilation, assessing the patient’s own respiratory effort can be challenging.

Figure 2 shows a case example of significant high cervical injury.

Circulation

Assessment of circulation can give clues regarding the status of the spinal cord, along with assessment of the patient’s general status. It is vital to differentiate between spinal shock, which will be discussed in further detail later, and neurogenic shock.

Neurogenic shock is a distributive shock caused by dysfunction of the autonomic nervous system occurring with injuries above T6. Neurogenic shock is rare, only apparent in approximately 20% of patients at presentation. However, even if the heart rate is observed to be reduced (less than 70), suggesting neurogenic shock evolving then this can be a negative indicator of future neurological function.

Key features of neurogenic shock are neurological dysfunction, fluid resistant hypotension and warm peripheries, due to massive peripheral vasodilation. If the injury is as high as T2, the other hallmark is bradycardia, due to unopposed vagal action as the cardiac sympathetic outflow at T2-5 is lost. It is vital to recognize and support neurogenic shock with vasopressor support in a high-dependency unit environment.

It is also important to take a global overview. Haemodynamic compromise in the trauma patient can arise due to multiple causes. The most obvious of these are fractures but also consider solid organ contained bleeds, especially affecting the spleen. Often scanning sequences for polytrauma will include angiography but lower pressure bleeds, such as from a venous plexus can be difficult to identify.

Another confounding feature could be an underlying medical problem. This may even be the cause of the trauma itself, for example an arrhythmia leading to a road traffic collision, or ‘collapse, query cause’ leading to a fall from standing height in an older patient. Other pitfalls include β-blockade or pacemakers, which can affect observed heart rate due to pharmacological or electrical modulation.

Figure 3 shows a case requiring significant awareness and interpretation of clinical findings.

Disability

This stage of the assessment is when the role of the orthopaedic resident becomes most challenging. There is invariably a pressure to ‘clear the spine’ as this takes significant pressure off resources; a dependent spinal patient must be log rolled routinely and this means a team of several people must be involved each time.

The two most common scenarios are suspected spinal injury without neurological deficit and suspected spinal injury with neurological deficit. The advent of the major trauma system has superseded regional spinal cord injury (SCI) protocols – historically patients with suspected cord injuries would be diverted straight to an SCI Centre. Now, as the patients may have significant other injuries, they may be sent to an MTC. Whilst an MTC will have spinal surgeons available, the availability of SCIs is not as widespread. For UK practice the National Institute for Health and Care Excellence (NICE) sets out guidelines for the initial assessment and management of spinal injury (NICE clinical guideline 41, see Further reading).

Neurological deficit

In addressing the patient with suspected spinal injury and neurological deficit a prompt assessment is necessary. Suboptimal pressure area care can lead to pressure sores which can affect the patient for a long time going forwards. The British Orthopaedic Association Standards for Trauma (BOAST; The Management of Traumatic Spinal Cord Injury, see Further reading) outline the responsibilities of the initial assessing team in a stepwise manner.

Ideally the patient should be on a vacuum mattress in a spilt scoop. This allows more time for assessment and facilitates the transfer of the patient for imaging. Imaging should include CT sequences appropriate to the situation-potentially including brain, whole spine and chest/abdomen/pelvis. Even in the absence of fracture or an unstable injury observed on CT, an MRI should be performed. Patients can have neurological deficit due to acute disc prolapse, haematoma, and cord syndromes, which would not be evident on CT scan. Note also a significant soft tissue injury involving the disc and ligaments, may only show subtle signs on the CT scan. Plain films have little role in modern practice in the immediate stage.

Once imaging is performed the split scoop can be removed and the patient placed on an appropriately supportive mattress.

In terms of imaging results in patients with neurological deficit, the imaging should be transferred to the local spinal surgical centre and specialist referral made via local protocols.

Spinal shock: at this point it is pertinent to discuss the concept of spinal shock. This is a misnomer, in the sense that it is not a condition of inadequate tissue perfusion or haemodynamic instability. However, please note that neurogenic shock can co-exist. Spinal shock has been described since the 18th century and the specific term first used in the literature by Hall in 1840. It defines motor paralysis (flaccid paralysis), loss of sensation and abolition but gradual restoration of reflexes following an SCI. Priapism is also observed. Ditunno defined the phases of spinal shock observed in clinical practice (see Table 2 ).

Table 2

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