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The Initial Assessment and Management of the Multiple-Trauma Patient With an Associated Spine Injury

Harris, Mitchel B., MD*; Sethi, Rajiv K., MD

doi: 10.1097/01.brs.0000217924.56853.0d
Epidemiology of Spinal Cord Injury and Early Management
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Study Design. Review and summary of the relevant literature from multiple disciplines.

Objective. Provide the readership with evidence-based guidelines on the initial assessment and treatment of the multiple-trauma patient with an associated spinal column injury.

Summary of Background Data. Early operative stabilization of the isolated spinal column injury has decreased hospital and intensive care unit length of stay. Early intervention has not provided consistently improved neurologic outcomes. The timing of spinal column stabilization in the multiple-trauma patient continues to be a source of discussion.

Methods. Review of published English literature from 1990 to present using key words: spinal trauma, multiple-trauma with spinal injury; timing of spinal injury treatment; spinal fracture management; and Advanced Trauma Life Support.

Conclusions. The treatment of the poly-trauma patient with an associated spinal column injury requires strict adherence to Advanced Trauma Life Support principles. Once life and limb-threatening injuries have been identified and addressed, spinal column assessment and neurologic protection must be maintained at the highest priority. Early spinal stabilization can be performed safely in the multiple-trauma patient in medical centers, in which medical and ancillary staff is available on a 24-hour basis and is familiar with these procedures.

The evaluation and treatment priorities of the multi-trauma patient come into question when an associated spinal injury is suspected. Life-threatening conditions must be rapidly recognized and appropriately treated on presentation to the Trauma Unit. This process requires adherence to Advanced Trauma Life Support principles and a protocol driven evaluation plan. Early involvement of the spinal consultant can greatly improve the treatment plan of the multisystem trauma patient. Early spinal realignment and stabilization can be safely performed in trauma centers with experienced medical, surgical, and ancillary staff.

From the Department of Orthopaedic Surgery, *Brigham and Women's Hospital, and †MA General Hospital, Boston, MA.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Mitchel B. Harris, MD, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; E-mail: mbharris@partners.org.

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Epidemiology/Incidence of Spinal Injuries in the Poly-Trauma Patient

Spinal injuries are very common in the poly-trauma patient population. Therefore, a thorough evaluation of the spinal column should always be methodically performed when treating the trauma victim. Inadequate immobilization and unsupervised or unprotected movement of the spine may lead to (additional) neural injury and, ultimately, significantly worsen the outcome.

Hu et al1 reported that the overall incidence of spinal fractures was 64 per 100,000 within the Canadian province of Manitoba. Of incidence, 2 peaks were noted in this study, namely, young men and elderly women. Associated nonspinal injuries were documented in 38% of individuals. Overall mortality was noted to be 4%.1 In older patients with osteoporosis, spine fractures are often seen after minimal trauma. In the United States, it is estimated that spinal fractures occur with an incidence of >50,000/y.2

Because poly-trauma patients are initially seen in urgent circumstances, occult fractures may be easily overlooked. Anderson et al3 did a retrospective review of 181 trauma patients. They found that the patients in the delayed diagnosis group were often more hypotensive, critically injured, or had low Glasgow Coma Scale (GCS) scores. Occult spinal column injuries can also be overlooked because a large number of poly-trauma patients are unable to provide a medical history or assist in localizing pain because of altered consciousness secondary to head injury, intubation, or drugs. Sengupta4 has recently reported that missed spinal injuries are 4.5 times more frequent in the cervical spine (C-spine) when compared with the thoracolumbar spine. He also stated that most of these injuries are missed because of the failure to obtain correct or technically adequate radiographs.

The true incidence of spinal injuries in the poly-trauma patient is most likely higher than the (estimated) numbers referenced previously because of the number of missed or minor spinal injuries not included in most referred series. The most serious consequence of a missed spinal injury is a progressive neurologic deficit. Levi et al5 reviewed the experience of 8 spinal surgeon members of the Spine Trauma Study Group who had treated poly-trauma patients for a missed spinal injury resulting in a neurologic deficit. Their review supported the accepted concepts that missed spinal injuries are most often a result of either insufficient imaging studies performed, misinterpretation of “sufficient” imaging studies, or poor quality imaging studies. The most common etiology was insufficient imaging studies completed. The investigators estimated that the incidence of missed spinal injuries resulting in a neurologic injury relative to the population of trauma patients treated during that time was 0.0025%. In addition, the investigators highlighted the associated conditions of ankylosing spondylitis and closed head injuries as factors that increased the likelihood of a missed spinal injury. However, more frequently, missed spinal injuries result in progressive deformity, which can lead to persistent pain and an unfavorable outcome.

The purpose of this article is to provide the readership with a current perspective of the appropriate and necessary steps involved in the initial assessment of the poly-trauma patient with a suspected spinal column injury. Included in this review are the basic tenets of Advanced Trauma Life Support (ATLS) to emphasize the importance of identifying life and limb-threatening injuries during the initial evaluation and early treatment.

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Poly-Trauma Patient: Primary Clinical Assessment

Initial treatment of the poly-trauma patient begins with the primary clinical survey. The essential first steps of this evaluation include an assessment of airway, breathing, and circulation (A-B-Cs); followed by disability and environmental exposure. These guidelines have been set by the American College of Surgeons through their ATLS initiatives,6 which provide a systematic approach that will rapidly reveal life and limb-threatening injuries.7

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Airway and C Spine Treatment

Evaluation of the airway begins immediately on seeing the poly-trauma patient. Is the patient communicating verbally? Has the patient’s airway treatment been initiated in the field? If the patient has an altered level of consciousness, is there spontaneous chest motion associated with air passage?

If there is evidence of mechanical obstruction of the airway, either removing the source of obstruction or instituting intubation should address this. Foreign bodies and the tongue or teeth can lead to airway obstruction in the facial trauma victim. Additional facial, mandibular, or laryngeal injuries can result in potentially fatal upper airway obstruction. Once the oral cavity has been free of foreign material leading to the obstruction, a controlled chin lift or jaw thrust will provide potential airway clearance without threat to the cervical spine. Although the directed clinical evaluation of the C-spine falls to the secondary survey, immediate immobilization should be obtained at the scene of the accident. This procedure will ensure that the C-spine is being considered in the event intubation and controlled manipulation of the airway are necessary to maintain the airway.

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Breathing

Breathing is the second element of the primary survey and deals principally with life-threatening thoracic injuries. These conditions include tension pneumothorax, open pneumothorax, flail chest, and massive hemothorax. Tension pneumothorax develops when air enters the chest cavity through a 1-way valve and does not exit the cavity. The affected lung collapses as air continues to build up and the mediastinum is displaced to the contralateral side, thus impeding venous return. Absent breath sounds and hyperresonance on chest percussion are present. Immediate decompression by a large bore needle into the second intercostal space, midclavicular line is necessary to restore venous return.

Open pneumothorax results from large defects in the chest wall. This occurs because air follows the path of least resistance and enters the large defect. Immediate tube thoracostomy is indicated.

Flail chest occurs in the presence of multiple rib fractures and is usually associated with an underlying pulmonary contusion. The flail chest segment shows paradoxical chest motion and impairs ventilation. Pain results in restricted chest wall motion, while the pulmonary contusion results in hypoxia. Intubation and ventilation are often necessary.

Massive hemothorax, or the accumulation of 1–2 L of blood in the chest cavity, may be the result of blunt or penetrating trauma. The loss of blood may contribute to hypoxia or hemodynamic instability. Massive hemothorax often requires a thoracotomy to identify and control the source of hemorrhage, as well as restore adequate ventilation.

There can be difficulty differentiating upper airway compromise from ventilation problems. In the dyspneic patient, once intubation is performed, it is important to reassess the patient’s breathing and ventilation. In the setting of a tension pneumothorax, vigorous manual ventilation can exacerbate the respiratory compromise. In the trauma unit setting, once intubation occurs, a chest radiograph is mandatory.

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Circulation/Cord Hypoxia

Evaluation of circulation involves the assessment of blood pressure and heart rate. Hypotension in the trauma victim is most commonly a volume-related phenomenon. Therefore, fluid resuscitation is a vital first intervention. Heart rate, blood pressure, perfusion, and urine output monitor fluid resuscitation. For patients whose blood pressure is unresponsive to crystalloid, universal donor blood group (group O, Rh negative) is recommended. The early use of blood products is recommended in the poly-trauma victim with an associated spinal cord injury to maximize the oxygen carrying capacity and potentially minimize the secondary ischemic injury to the vulnerable spinal cord.

Hypoxemia will further worsen the prognosis of an already injured spinal cord. High spinal cord injury (above C6) with its associated disruption of the sympathetic chain will generally present with hypotension and bradycardia. This condition, referred to as neurogenic shock, leads to further problems of spinal cord perfusion in the setting of an already coexisting injury.8 The early use of vasopressors such as dopamine is recommended to maintain the systolic blood pressure >100 mm Hg. As the circulatory compromise is corrected and spinal cord perfusion is restored, free radical mechanisms and cell transduction pathways can be altered to prevent further white matter injury.9

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Poly-Trauma Patient: Secondary Clinical Assessment

GCS

The GCS is used as a measure of neurologic status and should be performed on all trauma patients at presentation. It has prognostic value with regard to future neurologic function. Appendicular reflexes should also be monitored because these not only can be used to monitor intracranial pathology but also the status of an injured spinal cord.7 The minimum GCS score is 3 and is represented in patients who are unable to open their eyes spontaneously, speak, or show a motor response to pain. Patients who spontaneously open their eyes, obey verbal commands, and are oriented, score the maximum number of points allowed, 15. A GCS score of ≤8 signifies coma.

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Axial Skeleton

Injuries to the axial skeleton include those to the pelvis and spine. Injuries to the pelvis can result in massive hemorrhage. Hypotension caused specifically by a pelvic injury is invariably associated with a mechanically unstable pelvis and may require emergent pelvic stabilization or angiographic embolization. Early control of hemorrhage can control persistent hypotension, which is well known to worsen pulmonary and neurologic injury, as well as renal and cardiac function.

Physical examination findings of pelvic injury include scrotal and labial swelling, open lacerations in the perineum, vagina, or rectum, and excessive internal or external rotation of the lower extremity. Provocative maneuvers to test the stability of the pelvis should only be performed once because further manipulation might dislodge clots that control extensive venous bleeding. Special attention should be paid to open pelvic injuries. Rectal and vaginal examinations must be performed to exclude lacerations. Clinical findings might include blood at the urethral meatus, high riding prostate, or inability to pass a Foley catheter. Such patients might require a retrograde urethrogram to identify the location of a bladder or urethral injury. Occult open pelvic injuries have a high mortality rate associated with sepsis.

During inspection and examination of the chest and abdomen, it is important to keep in mind some of the external appearances associated with significant visceral and axial skeletal injuries. The presence of a laceration or contusion about the level of the lap belt should alert the examining physician of the possibility of a flexion-distraction mechanism of injury. These injuries commonly have both spinal implications and the potential for retroperitoneal injuries to the pancreas or duodenum. The presence of a calcaneal fracture may imply a significant deceleration or fall from height mechanism of injury, both noted to have associated spinal injuries to the thoracolumbar or low lumbar spine. The presence of a shoulder strap contusion/abrasion should heighten the suspicion of a cervical-thoracic junction injury. In addition, many of these spinal injuries may have a benign or innocuous appearance while the patient is kept in the supine (unloaded) position. These injuries should not be underestimated. Once identified, vigilance is important, and an entire evaluation of the spine is required.

The goal of the spinal secondary assessment is to identify and provide initial treatment of potentially unstable spinal fractures from both a mechanical and neurologic basis. All clinical examinations of the spine should follow a consistent and repeated pattern. This pattern allows for comparison of neurologic status on a longitudinal basis, thus avoiding potential confusion about a progressive neurologic deficit.

Logrolling the patient to evaluate the spine is essential. Once the anterior cervical soft tissue has been examined and the cervical collar applied, the posterior paraspinal soft tissues should be inspected for evidence of swelling, bogginess, malalignment, or bruising. Systematic palpation of the spinous processes of the entire spinal column, from the occipital cervical junction to the sacrum, can help to identify and localize any injury. After palpating the entire posterior spine, the patient is again logrolled onto his/her back. Generally, the patient is maintained on the immobilization board until the computerized axial tomography has been obtained because this provides further assistance in controlled patient transfer. However, in the insensate patient, it is important to limit the time on a spine board (optimally less than 2 hours) to avoid the development of soft tissue breakdown and decubiti. Once the initial radiographic studies have been obtained, it is important to remove the rigid backboard on which the trauma victim was transported. A complete neurologic examination, including motor, sensory, and reflexes should be performed, as well as perianal sensation, rectal sphincter tone, and sacral reflexes, such as the bulbocavernosus reflex.

As highlighted by Hu,10 there are several key points in the secondary spinal assessment. An alert, conscious patient who is able to provide a history is the best spinal cord monitor. Patients with spinal cord injury above C5 often will have respiratory insufficiency and will show paradoxical abdominal movement with respirations. Spinal cord shock is present when the bulbocavernosus reflex is absent. In the presence of spinal shock, the neurologic prognosis is uncertain. Finally, the unconscious or uncooperative patient should be assumed to have a spinal injury until proven otherwise.

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Appendicular Skeleton

The appendicular skeleton and major injuries to the long bones can be a significant source of morbidity and mortality in the trauma victim. Femoral shaft fractures are high-energy injuries. Early treatment of these injuries is important. An unsplinted closed femur fracture can lose up to 4 units of blood into the thigh.7 Tibial fractures with severe soft tissue or neurovascular trauma can render an extremity nonviable if proper care is not instituted.

Initial evaluation includes palpation of the entire extremity and a thorough neurovascular examination. Assessment of soft tissue injury should be performed to exclude an open fracture. These fundamental examination procedures should be performed with the utmost concern for the possibility of an associated unstable spinal column injury. Therefore, the trauma victim is always assumed to have an unstable spinal column until proven otherwise.

The surgeon should reduce dislocations as soon as possible, taking care to dress open fractures and wounds with gauze, followed by the application of a splint. Vascular injury must be excluded. Pulses and perfusion must be checked, and if a pulse deficit is present, all correctable causes should be reevaluated (i.e., fracture alignment should be corrected, traction released, compartments checked, and hypotension corrected). Ankle-brachial index may provide information about limb perfusion. An ankle-brachial index of ≥0.9 will exclude arterial injury. One must remember that angiography remains the gold standard for excluding arterial injury.11

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Poly-Trauma Patient: Radiologic Assessment

Plain radiographs begin the assessment of the trauma victim once the A-B-Cs are completed and the patient is deemed hemodynamically stable. The anteroposterior radiograph of the pelvis is used to determine the stability of the pelvis. The sacrum can also be scrutinized for irregularity. Pelvic ring injuries can be classified based on anatomic location, mechanism, or stability. Thus, the anteroposterior radiograph can help to predict blood loss and anticipate correct treatment.12 Initial radiographs of the chest can also be performed once the primary clinical assessment is complete, which can assist to elaborate further on problems identified in the primary survey: pneumothoraces, flail chest, hemothorax, etc.

Plain radiographs of the cervical spine have largely been replaced by the direct images and reconstructions obtained with multi-detector computerized tomography (CT). However, the lateral view of the C-spine is still commonly obtained in the setting of a poly-trauma victim, particularly those with hemodynamic instability. A well-performed lateral cervical spine radiograph with visualization of the cervical thoracic junction can provide sufficient information to the emergency room and trauma surgeons to allow the trauma victim to proceed to the operating room, without additional intervention aside from the maintenance of a collar.13

Brown et al14 have recently shown that helical CT in their institution identified 99.3% of all fractures of the cervical, thoracic, and lumbar spine, and those missed by helical CT required minimal or no treatment. Newer studies are showing that helical CT is cost effective. A study from Vanderbilt Medical Center showed that C-spine evaluation with helical CT has an expected cost of 554 US dollars per patient compared with 2142 US dollars for plain films.15 These investigators state that helical CT is the preferred initial screening test for detection of cervical spine fractures among moderate-to-high risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are considered. Similarly, more recent studies confirm the benefits of whole body CT for detection of visceral injuries of the abdomen, as well as bony injuries of the pelvis and spine.16–19

Once a spinal injury is suspected or localized, dedicated CT studies of that area may be beneficial for long-term treatment and, particularly, preoperative planning. Coronal and sagittal plane reconstructions can assist the surgeon in appreciating the degree of deformity and severity of injury. CT reconstructions can also help to identify subtle or rotational or translational planes across fracture sites. It is imperative to remember the dictum that once a spinal fracture or spinal column injury is identified, the entire spinal column needs to be imaged. With the emergence of “pan scanning” of the axial skeleton, the concept of noncontiguous fractures has been further reinforced.

Magnetic resonance imaging (MRI) is the most sensitive imaging method for evaluation of soft tissues. Thus, MRI of the spine provides the best imaging of neurologic structures, ligaments, and discs. MRI is not routinely used in the evaluation of the poly-trauma patient because of the time required to perform a technically adequate scan in an environment that might not allow all the necessary monitoring equipment. MRI is most useful in patients whose plain radiographs or CT results fall short of explaining their full clinical picture. This result is most common in the neurologically impaired victim with “normal” appearing plain films.

Vaccaro et al20 reported that 25% of patients with cervical thoracic injuries and a neurologic deficit on presentation had their preliminary treatment plan altered after obtaining MRI. In the same study cohort, the investigators revealed that routine MRI did not alter the treatment plan in the neurologically intact patients. MRI can provide valuable information about the status of the ligamentous structures, without the additional risk to the spinal cord often associated with physician directed flexion-extension evaluations.21 In patients with cervical facet subluxations or dislocations, or thoracolumbar and lumbar flexion distraction injuries, MRI should be used to exclude the presence of an associated extruded disc before or after the reduction maneuver, depending on the clinical situation.

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Emergent Care

The primary and secondary surveys provide the trauma team the opportunity to recognize life-threatening head, chest, abdomen, and pelvic injuries, and, thus, institute life and limb-saving interventions. Although adequate imaging may not be possible before taking the exsanguinating trauma patient to the operating room, all efforts must be taken to immobilize these patients safely, as though they had an associated injury to their spinal column. Significant intracranial bleeds require immediate evacuation. Once a hemothorax is diagnosed, chest tube thoracostomy should be performed to improve ventilation parameters. Hemorrhage into the peritoneal cavity requires emergent laparotomy. If a severe pelvic ring injury is identified, deemed unstable, and associated with significant ongoing hemorrhage, external immobilization is often performed. Initial pelvic immobilization can consist of a sheet wrapped around the pelvis, extending to the greater trochanters of both hips, or of a binding corset. External fixation can be applied in the emergency room but is more commonly applied in the operating room in conjunction with other procedures, such as exploratory laparotomy or evacuation of intracranial hemorrhage.

Limb-preserving treatment comes after life-threatening conditions have been identified and treated. Vascular injury must be recognized immediately in injured extremities. Although arterial repair may be necessary, bony stability via external fixation often needs to be achieved before vascular repair to ensure safety of the vascular repair as the limb is brought out to its proper length.

Compartment syndrome should be recognized and treated urgently with fasciotomy. In the obtunded poly-trauma patient, clinical examination may not be possible. Therefore, any patient with severe crush injury or prolonged warm ischemia (>4 hours) should undergo compartment pressure monitoring. Compartment pressures within 30 mm Hg of diastolic pressure should lead to emergent fasciotomy.

Open fractures require urgent surgical debridement and stabilization. Temporizing measures to gain stability of the fractured limb are recommended if definitive procedures cannot be tolerated. Wounds that are heavily soiled should not be closed primarily. Poly-trauma patients with multiple fractures benefit from early stabilization. However, in the setting of an unstable spine fracture, or one that has not been fully evaluated before the onset of life preserving measures, care must be taken to immobilize the spine until proper stabilization and/or a comprehensive evaluation can occur. Intubation should be performed with either in-line head traction, a cervical collar in place, or fiberoptic assistance.22 The spine is at risk during transfer from stretcher to operating table. Therefore, one must use strict logrolling precautions. It is noteworthy that fractures as common as a femur fracture have had an association with spinal column injuries of up to 3.5%.23 Therefore, it is essential to avoid awkward positioning and excessive traction in the incompletely evaluated trauma patient.

There remains considerable debate as to the priority of long bone fracture treatment referable to spinal stabilization. Trauma centers in which the spinal consultants and trauma surgeons communicate effectively generally decide on a case-by-case basis the safest order of injury treatment. In the instance in which a thoracotomy or laparotomy is necessary for hemorrhage control or visceral injury, the positioning of the patient for the life-saving procedure also will influence the order of injury treatment.

Cervical spine injuries often can be initially treated with traction. Acute stabilization of the cervical spine with a halo ring has been advocated as one method, which facilitates further necessary diagnostic evaluation and emergent surgical treatment of associated injuries in the poly-trauma patient.24 Once the emergent surgical care has been completed, the definitive treatment of the cervical injury can be determined with the use of the halo vest as an alternative. Of the 78 patients in this study, 46 had undergone surgical procedures performed after halo ring application, and none of the patients had any neurologic deterioration. This result illustrates the importance of effective communication among the many services involved in the treatment of the poly-trauma patient as the spinal consultant provides safety in treatment of the spinal injury while the trauma surgeon can successfully address the life-threatening abdominal or thoracic injury.

The principles of halo ring application have been well described.25,26 Adherence to established application guidelines is critical to minimize morbidity. Safe zones for pin placement have been described.

To attempt to address the question of timing of spinal stabilization in the poly-trauma patient, McLain and Benson27 analyzed their results of urgent surgical stabilization of thoracolumbar spinal fractures in the poly-trauma patient. They hypothesized that the benefits of early spinal stabilization would parallel those seen with early long-bone stabilization, and NOT endanger the overall well being of the poly-trauma victim. They compared the results of urgent spinal stabilization (± decompression within 24 hours) to early treatment (between 24 and 72 hours). Their indications for urgent spinal stabilization included the presence of a progressive neurologic deficit, extensive poly-trauma that predisposed to severe pulmonary and/or metabolic derangements if not mobilized, associated injuries that dictated emergent surgical treatment, and chest trauma and pulmonary contusions that would predictably result in pulmonary deterioration.

There were 14 patients in the urgent group and 13 in the early group. No statistical differences were noted in the operative characteristics recorded, including blood loss and operating time. Similarly, there were no statistically significant differences in the outcome measures, including operative complications (infections, instrumentation- related mishaps) mortality, or neurologic improvement/deterioration. Although the urgent group showed a slighter better average improvement in their neurologic recovery, because of the small sample size, it did not reach statistical significance. The investigators concluded that urgent spinal stabilization could be beneficial in the “total management” of the poly-trauma patient.27 They emphasize that if the ancillary staff, anesthesia and general surgical staff who are experts in treating these patients can be mobilized at all hours, safe and effective spinal stabilization can be performed on an urgent basis with predictable results.

Kerwin et al28 reported contrasting outcome results in their subset of poly-trauma patients with spinal injuries. In the poly-trauma group, as has been consistently shown in the isolated spinal column injured patient, early stabilization (<3 days) shortened the hospital length of stay and the intensive care unit length of stay. However, in the poly-trauma group that underwent early spinal stabilization, the number of perioperative deaths and pneumonias was higher than in their “late” stabilization group. Because of relatively small patient numbers (early = 84; late = 45), statistical significance could not be shown. The comparison groups showed similar injury severities, age, and presenting GCSs. One explanation proposed by the investigators was that the spinal stabilization procedure represented the critical “second hit,” popularized by Pape et al.29

Spinal cord compression with neurologic involvement as a result of spinal malalignment should be remedied as soon as possible in the trauma victim. Facet subluxations or dislocations can drastically reduce the dimensions of the spinal canal. In these cases, reduction can be immediately initiated in the alert cooperative patient after placement of the halo ring. In the obtunded or intubated patient, MRI is generally recommended to exclude an associated disc. However, the option of anterior discectomy and spinal cord decompression followed by indirect reduction, grafting, and plating should be considered if MRI proves to be too cumbersome or not readily available. One caveat to be considered if this strategy is undertaken is that the surgeon may not be able to identify an additional source of neural compression from a posterior epidural bleed or an additional disc herniation.

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Controversies Surrounding Operative Treatment of Spinal Injuries

Several recent studies suggest that patients with spinal cord injury, who undergo “early surgery,” have significant benefits in terms of more rapid rehabilitation, decreased intensive care unit days, and decreased hospital costs. The effect of early surgery on neurologic outcomes remains a topic of much debate. Gaebler et al30 found that patients who underwent decompression and stabilization procedures for thoracolumbar fractures within 8 hours of injury had a significantly higher rate of neurologic recovery compared with those who had surgery after 8 hours. Mirza et al31 have reported that stabilization within 72 hours of injury in cervical spine injured patients is sufficient to improve neurologic outcomes. Other studies confirm the findings of improved neurologic outcome after early surgery in patients with both thoracolumbar and cervical injury.32,33

The major criticism with the aforementioned studies is that they are not prospective, randomized, or controlled. The definitive answer with respect to the appropriate indications and timing for surgery must come from a well-designed prospective randomized and controlled clinical series.34 To our knowledge, Vaccaro et al35 have performed the only prospective, randomized, controlled study designed to determine whether functional outcome is improved in patients with spinal cord injury who undergo surgery. The study was conducted to determine whether neurologic and functional outcome is improved in patients with traumatic cervical spinal cord injury, who underwent early surgery (<72 hours after spinal cord injury) compared with those patients who underwent late surgery (>5 days after spinal cord injury). The results of this study revealed no significant neurologic benefit when cervical spinal cord decompression after trauma is performed less than 72 hours after injury (mean 1.8 days), as opposed to waiting longer than 5 days (mean 16.8).

Currently, there are no defined standards regarding the timing of decompression and stabilization in acute spinal cord injury. Fehlings et al36 recently conducted a metaanalysis and provided the following guidelines. They recommend urgent decompression of bilateral locked facets in patients with incomplete tetraplegia or in patients with spinal cord injury, having neurologic deterioration. Urgent decompression in any acute cervical spinal cord injury remains a reasonable practice option and can be performed safely. Currently, a prospective study attempting to define further the benefits of urgent/early decompression and stabilization is underway. It is under the supervision and direction of The Spine Trauma Study Group, an international association of spinal surgeons.

An additional controversy in the assessment and treatment of the spine in the poly-trauma patient is the issue of “cervical spine clearance.” This topic evokes emotional responses from the multiple disciplines involved in the care of the poly-trauma victim and the patient with a closed head injury as clearance guidelines continue to evolve. Both these patient populations illustrate our dependence on imaging studies because there can be no reliable feedback during an examination from the patient. CT has clearly become a necessary primary study with coronal and sagittal reformats eliminating the need for plain radiographs. However, the definitive evaluation of the soft tissue structures requires either MRI or some form of physiologic loading with static films. Multiple algorithms have been proposed21 with no consensus.

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Summary

A thorough evaluation of the spinal column should always be methodically performed when treating the trauma victim. Every trauma victim should be presumed to have a spinal injury until proven otherwise. The incidence of spinal injuries in the poly-trauma patient is most likely higher than the estimated numbers because of the number of missed and minor injuries not accounted for in most published series.

Initial treatment of the poly-trauma patient begins with the primary clinical survey. The essential first steps of this evaluation include an assessment of airway, breathing, and circulation (A-B-Cs), life-preserving measures. The goal of the spinal secondary assessment is to identify and provide initial treatment of potentially unstable spinal fractures from both a mechanical and neurologic basis.

Plain radiographs of the cervical spine have largely been replaced by the direct images and reconstructions obtained with multi-detector CT. MRI is the most sensitive imaging method for evaluation of soft tissues. A well-performed lateral radiograph of the C-spine can often provide enough information to proceed to the operating room in unstable situations.

Diagnosed cervical spine injuries often can be initially treated with traction. Acute stabilization of the cervical spine with a halo ring has been advocated as a method that facilitates diagnostic evaluation and surgical treatment of associated injuries in the poly-trauma patient. However, spinal cord compression as a result of spinal malalignment should be remedied as soon as possible in the trauma victim. Currently, there are no standards regarding the timing of decompression and stabilization in acute spinal cord injury. The definitive answer with respect to the appropriate indications and timing for surgery must come from well-designed prospective randomized and controlled clinical series.

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Key Points

  • The initial treatment of the multi-trauma patient requires strict adherence to the ATLS principles of A-B-Cs.
  • Early and consistent appreciation for the possibility of a spinal column injury will facilitate the safe and effective treatment of the multi-trauma patient.
  • A comprehensive physical examination, including neurologic evaluation, followed by an efficient radiographic evaluation algorithm optimize the treatment of the multisystem injury patient.
  • Open communication between the spinal consultant and trauma surgeon will allow for treatment priorities to be most appropriate and patient specific.
  • The current literature does not mandate urgent spinal stabilization but does infer spinal cord decompression in the face of a neurologic deficit to be a primary treatment issue.
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References

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Keywords:

spinal fracture management; poly-trauma and spinal fracture; timing of spinal fracture stabilization

© 2006 Lippincott Williams & Wilkins, Inc.