Spinal fractures: Clinical sciences

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Introduction 0:00–0:43

Spinal fractures refer to breakage of the spinal vertebrae in the cervical, thoracic, or lumbar spinal columns. These fractures can occur from traumatic injuries such as blunt trauma like falls or sports injury, or rapid deceleration from motor vehicle collisions.
Sometimes, spinal fractures can be pathologic stemming from underlying conditions like osteoporosis or metastatic cancer.
Regardless of the cause, these fractures can cause neurological impairment, so timely diagnosis and treatment are important in preventing spinal cord injuries.
Alright, your first step when evaluating a patient with chief concern suggestive of a spinal fracture is to perform a primary survey by assessing their ABCDE.

Acute Management 0:43–2:39

Start by securing the airway as soon as possible. The big concern here is the injury of the phrenic nerve, which originates at C3 through C5 spinal nerve roots.
Any injury at this level or above prevents breathing due to diaphragm paralysis. For these reasons assume all trauma patients have a c-spine injury.
Stabilize the cervical spine in a neutral position during intubation. This means you can't do a head tilt to intubate like you normally would.
Use a jaw thrust instead! Keep in mind that patients with phrenic nerve injury might need a surgical airway like tracheostomy and mechanical ventilation.
Once the airway is secured and c-spine is stabilized, ensure adequate ventilation by providing supplemental oxygen. Next, obtain two large bore IVs or an intraosseous line if intravenous access cannot be obtained.
Continuously monitor vitals while starting appropriate resuscitative measures including blood transfusions. Then, assess for disability by performing a neurological assessment and calculating the Glasgow Coma Scale.
Ensure spine immobilization at all times by securing the patient in a supine position on the spine board. Make sure to assess for sensory or motor deficits in anyone with a suspected spine injury.
Finally, expose the patient by removing all clothing and bandages to ensure no injuries are missed. After examining the patient, place a warm blanket over them to avoid hypothermia.
Alright, if your patient is unstable, they will have signs of shock. If the shock is from other injuries, it is probably hemorrhagic shock, so you’ll find hypotension and tachycardia.

Unstable Patient 2:39–3:30

However, if it’s from a spinal cord injury, we are talking about neurogenic shock. In this case, they will have hypotension but with bradycardia.
This is because signals from the sympathetic nervous system cannot reach the heart, causing unopposed vagal parasympathetic innervation.
Either way, you should call the surgery team right away as these patients need to be moved to the operating room to manage their injuries and the cause of the shock.
In case of spinal shock, they would require emergent spinal cord decompression. Alright, now that unstable patients are taken care of, let’s talk about stable ones.

Stable Patient 3:30–4:17

Your next step is to perform a secondary survey, which includes a brief history and a full head-to-toe physical exam and trauma labs like CBC, CMP, and coagulation studies.
You also need to order imaging, including CT scan of the cervical, thoracic, and lumbar spine. Here’s a clinical pearl!
Even though plain lateral neck x-ray is no longer recommended due to low sensitivity, some places still do it, especially if CT is unavailable.
Keep in mind that a normal x-ray doesn’t completely rule out spinal fractures, so in this case you’ll need to get a CT as well.
Let’s first talk about patients with signs of spinal cord injury. History will often reveal recent trauma and/or underlying conditions like osteoporosis.

Unstable spinal fracture with spinal cord injury 4:17–6:29

On exam, concerning findings include posterior midline tenderness, neck spasms, bony step offs, limited range of motion, neurologic deficits like quadriplegia or paraplegia, paraspinal muscle spasms, loss of rectal tone, or urinary retention.
Any of these findings should lead you to consider spinal fracture with spinal cord injury. However, the CT will give you all the clues.
So, the CT might show a fracture involving two out of three adjacent spinal columns with or without bony fragments in the spinal canal.
You might also find other clues that the spinal cord is damaged like dislocation of vertebral body. With these findings, you can make the diagnosis of an unstable spinal fracture with spinal cord injury.
These patients need acute management right away, including CT scan of the head and CTA of the head and neck to evaluate for associated brain injury.
You should also consult the neurosurgery team for spinal cord decompression. Additionally, these patients require continuous vital sign monitoring with an arterial line, if possible, for accurate measurements.
Make sure to perform frequent neuro exams every hour to evaluate for any changes while maintaining spinal precautions. Furthermore, maintain mean arterial pressure goals and resuscitate if needed to avoid hypoxia and hypotension.
Lastly, consider obtaining additional imaging like an MRI. Time for a clinical pearl!
CT is not used to evaluate the spinal cord, but the spinal column, therefore the diagnosis of spinal cord injury is made based on the presence of severe neurological symptoms.
However, in some cases you might need to obtain an MRI which will help you visualize the spinal cord itself. Now, let’s go back to our CT of the spine and discuss another possibility.

SCIWORA 6:29–7:39

If there are no vertebral fractures or prevertebral soft tissue swelling, you should consider a spinal cord injury without radiologic abnormality, or SCIWORA for short.
This type of injury is more common in children, and is usually associated with sport injuries, motor vehicle crashes, and abusive trauma.
In SCIWORA, the damage to the spinal cord doesn’t come from fractures, but from hyperextension of the spine, soft tissue edema, or vascular injury.
Even though there might not be radiologic evidence of a fracture, any patient with signs of spinal cord injury requires acute management.
As before, you should get additional imaging like CT of the head and CTA of the head and neck; consult the neurosurgery team; monitor vitals; perform frequent neuro exams; maintain spinal precautions; maintain mean arterial pressure goals; resuscitate if needed; and consider additional imaging like MRI.
Alright, let’s go back to history and physical exam and talk about patients without signs of spinal cord injury. History might reveal recent trauma or underlying conditions like osteoporosis.

Spinal fracture 7:39–8:17

On examination, you might find point tenderness over the affected spinal region with or without bony step offs, and possibly a milder neurological deficit than with spinal cord injury like pain or paresthesia.
If the CT reveals a transverse process fracture or a compression fracture of the vertebral body, diagnose a spinal fracture.
Now, if one vertebral column is involved, you are dealing with a stable spinal fracture. This injury's management includes neurosurgery and trauma surgery consultation to assess for and treat other injuries.

Stable spinal fracture 8:17–9:56

In addition, implement spinal precautions, appropriate pain management, and physical therapy or occupational therapy evaluation.
Overnight observation is appropriate in these patients to further evaluate their injuries and monitor for the development of delayed neurologic deficits.
Here’s a high-yield fact! There are two major types of vertebral fractures: compression fractures which are most common and burst fractures.
Vertebral compression fractures are often due to osteoporosis but can also be due to bony metastases or direct vertebral trauma.
They are typically stable but can cause point tenderness and acute back pain. Without proper treatment, they can lead to decrease in height and progressive kyphotic deformity known as a “dowager hump”.
This shouldn’t be confused with a burst fracture, which is an injury football players get from tackling headfirst, known as spearing.
A burst fracture is vertebral body fracture of multiple locations typically secondary to severe axial loading injury. On imaging, it looks like the vertebrae “burst” into many pieces, as the name suggests.
These fractures often have displacement of bony fragments into the spinal canal, which can raise concern for spinal cord injury.
Alright, back to our CT findings. If there is a spinal fracture involving two or more vertebral columns, you are dealing with a spinal fracture with unstable ligamentous injury.

Spinal fracture with unstable ligamentous injury 9:56–10:46

This means that the spinal ligament that connects and stabilizes the vertebrae is injured in a way that poses an increased risk of spinal cord injury.
Your management in this case should include neurosurgery consult while maintaining spinal precautions. You should also obtain additional imaging to evaluate for concurrent injuries as the force causing this trauma can result in injuries of other structures.
Lastly, these patients will likely require pain medication, but try to minimize sedating agents to allow for frequent accurate neurological exams.
Finally, if no vertebral fractures, osteoarthritic changes, loss of vertebral height, or vertebral body retropulsion are seen on CT, consider an alternative diagnosis.

Alternative diagnosis 10:46–12:13

Your management should include an MRI of the spine, and a primary care physician referral for additional workup. Here’s a clinical pearl!
In any patient with a suspected spinal fracture, a detailed workup to determine the etiology should be performed. This includes asking about old traumatic injuries, history of osteoporosis, kidney disease, or prior malignancies.
In some cases, you can also obtain PTH, serum vitamin D, calcium, and renal function tests to assess for any underlying metabolic or renal conditions.
If the fracture was a sequela of an underlying condition, treatment includes optimization of the medical condition. Okay, let’s wrap up with a high-yield fact!
Even if you think your patient doesn’t have a spinal fracture or spinal cord injury, don’t be quick to remove their C-collar.
To clear the patient for C-collar removal they must be neurologically asymptomatic, with normal physical exam, awake, not under the influence of any substances, and with negative imaging.
Alright, as a quick recap… When a patient presents with signs of spinal fracture, first perform a primary survey to determine if they are stable or unstable.

Review 12:13–12:59

Unstable patients might have neurogenic shock and need spinal cord decompression. On the flip side, stable patients with signs of spinal cord injury and positive CT findings might have an unstable spinal fracture with spinal cord injury, but if CT is negative, consider SCIWORA instead.
However, if the patient doesn’t have signs of spinal cord injury and their CT shows spinal fracture in 1 vertebral column, think stable spinal fracture, but if 2 or more vertebral columns are involved, that’s a spinal fracture with unstable