Spinal fractures: Clinical sciences

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.

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. 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. 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.

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.