Injuries to the spine are most commonly secondary to high-energy trauma in the young but secondary to low energy forces, with minimal or even no trauma, in the elderly. In the cervical spine, injuries occur in 2–3 % of all patients who sustain blunt trauma [3]. Injuries are more common at the upper cervical region compared to the subaxial cervical spine with injuries most commonly secondary to high-energy trauma such as motor vehicle accidents or falls from height in the young as opposed to low-velocity falls in the elderly [4–7]. At the thoracic and lumbar spine, most isolated fractures are related to osteoporosis and involve minimal trauma. Osteoporosis leads to approximately 750,000 vertebral fractures each year in the United States [8]. Conversely, only about 15,000 thoracic or lumbar fractures related to trauma are reported annually [9].

Most spine fractures occur at the thoracic and lumbar regions, accounting for more than half of all spinal injuries in trauma victims with 60 % of those fractures occurring between the T11 and L2 vertebral levels [10–12]. Although spinal cord injury is exceptionally rare with osteoporotic fractures, neurologic injury occurs in one-fourth of traumatic thoracic and lumbar fractures [12]. Overall, neurologic injury following thoracic or lumbar trauma is 3 % [12]. This rate is significantly lower than the rate of spinal cord injury after cervical spine fractures as spinal cord injury after cervical trauma accounts for 65 % of all traumatic spinal cord injuries [13].

The presence of a spinal cord injury dramatically affects a patient’s mortality risk and his ultimate function and quality of life. For patients with a spinal cord injury, the overall mortality during the initial hospitalization was 17 % based on a study in the early 1980s, but more recently, the National Spinal Cord Injury Statistical Center estimates the mortality of traumatic spinal cord injury to be 2.6 % [1, 14]. However, some have suggested that the number is actually closer to 5–10 % [15].

The goal of any intervention following spine trauma is to achieve spinal stability. White and Panjabi describe clinical spinal stability as the “ability of the spine under physiologic loads to limit patterns of displacement so as not to damage or irritate the spinal cord or nerve roots and, in addition, to prevent incapacitating deformity or pain caused by structural changes” [16].

Any patient who has sustained a high-energy trauma should be assumed to have a spine injury until proven otherwise. In fact, at least 6 % of all trauma patients sustain a spine injury [1]. As a general rule, all trauma patients need to be fully investigated for spinal injury. Before proceeding with any intervention in the trauma setting, establishing the ABCs (airway, breathing, circulation) and applying the Advanced Trauma Life Support protocols are paramount. Field management of trauma victims requires vigilance for the possibility of an unstable spinal injury until spinal injury is definitively excluded or treated. Proper extrication of the patient and immobilization of the cervical spine at the accident scene are critical to avoid further neurologic injury [17]. The head and the neck need to be aligned with the long axis of the trunk and immobilized in this position with the use of a cervical collar, sandbags, tape, and spine board. Cervical extension should be avoided because it narrows the spinal canal more than flexion [18]. Logrolling precautions must be maintained, although logrolling has been shown to allow some degree of motion at the spinal injury site [19].

As part of the initial evaluation of ABCs, assessment of vital signs including blood pressure and heart rate may reveal abnormalities that must be accurately diagnosed to prevent potential catastrophe. Unlike other trauma patients who are more likely to suffer from hemorrhagic shock, patients with spine trauma may instead be in a state of neurogenic shock, which must be distinguished for safe resuscitation (Table 9.1) [20, 21]. Neurogenic shock results from a loss of sympathetic outflow leading to hypotension with simultaneous bradycardia in the face of warm extremities and a normal urine output. It is generally treated with administration of vasopressors (e.g., dopamine), whereas treatment with fluid resuscitation, if confused with hemorrhagic shock, can actually precipitate pulmonary edema. A more favorable neurologic recovery has been found in those whose mean arterial pressure is maintained above 85 mmHg, allowing for adequate perfusion of the cord [22].

After acute stabilization, other injuries must be assessed. While a primary lesion may be suspected at a particular spinal level, injuries at noncontiguous levels have been reported to occur in as many as 15–20 % of patients [23]. Although cervical spine fractures are unlikely to be associated with an abdominal injury, with a reported rate of 2.6 % of cases, chest and abdominal injuries are commonly identified in patients with thoracic and lumbar fractures [24].

A thorough physical examination, identifying any potential neurologic deficits, is critical for guiding management. A methodical evaluation of motor and sensory groups for each spine level must be performed (Table 9.2). Based on this examination, an American Spinal Injury Association (ASIA) score may be assigned. The ASIA classification is graded from A, complete motor and sensory deficit, to E, completely intact neurologic exam. Distal motor function and sacral sparing are important for prognosis [25]. In fact, even in those who are initially found to have a motor complete lesion, the return of sacral pinprick sensation by 4 weeks post-injury carries an improved prognosis of regaining ambulatory potential [26, 27]. Similarly, pinprick preservation in more than 50 % of the lower extremity dermatomes L2–S1 in the first 72 h of injury is associated with improved prognosis for ambulation [28].

Although an ASIA score is given on admission, it is reassessed and rescored with each successive exam. The score may also be lower secondary to spinal shock [28]. Spinal shock occurs when the physical energy of the inciting trauma causes immediate depolarization of axonal membranes in the neural tissue, resulting in a functional neurologic deficit that exceeds the actual tissue disruption. Spinal shock may be related to depolarization of the entire cord. Spinal reflexes caudal to the injury are depressed. Typically, the effects of spinal shock resolve within 24 h, but some effects, such as return of deep tendon reflexes, may take weeks or even months [28]. Unfortunately, the delayed plantar reflex, the first sign of emergence from spinal shock, is present only transiently and can easily be missed. The return of other reflexes, such as the bulbocavernosus, cremasteric, or anal wink, may take several more days to return.

Spinal cord injuries may be either complete or incomplete. Complete injuries affect motor and sensation below the level of the injury such that no function exists. Incomplete injuries are more varied (Table 9.3). The most common site of spinal cord injury is the cervical region, accounting for 50–64 % of traumatic spinal cord injuries, with incomplete injuries outnumbering complete ones by nearly a 2:1 ratio [13, 14]. Approximately 41 % of the patients with an acute spinal cord injury have a complete injury on initial evaluation [13].

Acute management of spinal cord injury is controversial. The results of the third National Acute Spinal Cord Injury Randomized Controlled Trial (NASCIS III) showed that steroid administration begun within 8 h of injury is beneficial. From that trial, the guidelines established are as follows: for injuries within three hours, an initial bolus of 30 mg/kg of methylprednisolone is given followed by 5.4 mg/kg/h infusion over the next 24 h, and if steroids are begun 3–8 h after the injury, the infusion is continued for 48 h [29–31]. Some have abandoned steroid administration claiming no benefit and increased pulmonary complications and infections. The decision to administer steroids has largely become a medicolegal one.

Plain radiographs may be limited by soft tissue shadows and preexisting spondylosis, while computed tomography (CT) displays high-resolution imaging of the spinal column that provides more information about the extent of a thoracolumbar injury than radiographs alone. One study found that for thoracolumbar trauma, plain radiographs alone may yield an incorrect diagnosis in as many as 25 % of individuals with burst fractures and underestimate their amount of canal compromise by 20 % [33, 34]. CT allows for more accurate assessment of comminution and perhaps, more importantly, the ability to detect retropulsed bony fragments which may influence treatment options. Because of its greater sensitivity and efficiency, a single helical CT scan has been shown to be preferable to a series of plain radiographs for screening polytrauma patients who may have spinal injuries [35].

To reduce routine cervical spine imaging in trauma patients, two competing prediction rules have been developed and validated: the National Emergency X-ray Utilization Study (NEXUS) criteria (Fig. 9.6b) and the Canadian C-spine Rule (Fig. 9.6a) [37, 38]. The Canadian C-spine injury prediction rules have better sensitivity and specificity and reduce unnecessary imaging to a greater extent, but they are more complex to apply routinely [37–39]. Applying the Canadian C-spine Rules in the field may prevent 38 % of out-of-hospital spine immobilizations [40]. Many centers use these guidelines to help clear the cervical spine, and if the patient meets the NEXUS criteria or Canadian rules, then the cervical collar is removed.