ATLS Module 7 - Spine & Spinal Cord
Trauma
35 yo man ejected for MVC. vitals are BP 80/40, HR 11, RR 24, GCS 15. airway and
breathing are intact. He complains of severe back pain, has no sensation below umbilicus,
lower thoracic tenderness, unable to move lower extremities. chest and pelvic x-rays are
normal. along with administration of IV fluids, which of the following is most appropriate tx for
pt's hypotension?
a. vasopressor
b. ct scan
c. apply pelvic binder
d. perform FAST or DPL - ANS-d
although pt likely has spinal cord injury, tachycardia & hypotension should lead you to
hemorrhage as etiology of hemodynamic abnormality
\40 yo in MVC is evaluated in rural hospitals w/o surgical capacity. pt has clear cervical spine
fx at C4 with inability to move any extremities and sensation is limited to supraclavicular
region. He is having difficulty breathing w RR of 30. BP is 80/40 and HR 50. What should be
performed prior to transfer? - ANS-crystalloid bolus, initiate pressors, intubate, and then
transfer pt once hemodynamically stable
\are C1 Jefferson fractures usually associated with spinal cord injury? - ANS-no... but they
are unstable and initially tx'd with rigid cervical collar
\are penetrating spinal injuries stable? - ANS-usually stable unless missile destroys a
significant portion of vertebra
\blunt trauma to neck can result in carotid and vertebral artery injuries... what are spinal
indications to screen for this? - ANS--C1-C3 fx
-c spine fx with subluxation
-fx involving foramen transversarium
\cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional
injuries are commonly a/w cervical fractures? - ANS-brain injury and additional spinal
fractures
*25% of all spine injuries have at least mild form of brain injury & 10% of patients with a
cervical fx will have another noncontiguous spine fx
\during the initial treatment, what do you consider in all pts with radiographic evidence of
injury and with neurological deficits? - ANS-unstable spinal injury
\elderly female falls & sustains hyperextension injury to neck. exam demonstrates decreased
strength in upper extremities compared with lower extremities. What is the cause of unusual
neuro findings? - ANS-central cord syndrome
\facet joints of thoracic and lumbar region make fx dislocations relatively uncommon... unless
extreme flexion or sever blunt trauma occurs... however, when they occur, what is common?
- ANS-fracture subluxations in thoracic spine commonly result in complete neurological
deficits bc the spinal canal is narrow in relation to spinal cord (red text)
, \how can spine injuries effect the ability to perceive pain? - ANS-inability to perceive pain
can mask a potentially serious injury elsewhere in the body, such as the usual signs of acute
abdominal or pelvic pain a/w pelvic fx
\how can you exclude spinal injury in patients without neurological deficit, pain or tenderness
along the spine, evidence of intoxication, or additional painful injuries? - ANS-absence of
pain or tenderness along spine virtually excludes presence of significant spinal injury
\how do you test C5 myotome? - ANS-biceps... elbow flexors
\how do you test C6 myotome? - ANS-wrist extension
\how do you test C7 myotome? - ANS-triceps... elbow extension
\how do you test C8 myotome? - ANS-finger flexors
\how do you test L2 myotome? - ANS-hip flexion
\how do you test L3 myotome? - ANS-knee extension
\how do you test L4 myotome? - ANS-ankle dorsiflexion
\how do you test L5 myotome? - ANS-long toe extensors
\how do you test S1 myotome? - ANS-ankle plantar flexors
\how do you test T1 myotome? - ANS-finger abduction
\how does a pt with C1 rotary subluxation present? - ANS-persistent rotation of head
(torticollis)
*the odontoid is no equidistant from the 2 lateral masses of C1
*restrict motion with head in rotated position and refer for further specialized tx
\how is a child's cervical spine markedly different from that of an adults until ~8-12 years old?
- ANS-more flexible joint capsules & interspinous ligaments, flat facet joints, and vertebral
bodies are wedged anteriorly and tend to slide forward with flexion
\how is the C1 jefferson fracture best seen on imaging? - ANS-open mouth view of C1-C2
region and axial CT scans
\if pt has neck pain and normal radiograph, whats next? - ANS-MRI... it is possible for pt to
have isolated ligamentous spine injury that results in instability w/o fx/subluxation
\most thoracic spine fxs are wedge compression fxs, not associated with spinal cord injury...
however, what happens when a fracture dislocation does occur? - ANS-almost always
results in complete spinal cord injury bc of the relatively narrow thoracic canal
\neurogenic shock is associated with what level of spinal cord injury and causes systemic
hypotension via what mechanism? - ANS-T6 and higher
*via distributive shock from lack of vasomotor response
*due do injury to descending sympathetic fibers from upper thoracic spinal cord that help
maintain tone of vasculature and heart rate
*pt may have relative bradycardia a/w distributive shock from dilation of peripheral
vasculature
\physiologic effects of neurogenic shock are not reversed with fluid resuscitation alone... and
massive resuscitation can result in fluid overload and/or pulmonary edema... what may be
required after moderate volume replacement? - ANS-vasopressors
*atropine may be used to counteract hemodynamically significant bradycardia
\pt cannot move legs
can move fingers & wrists bilaterally
weak tricep extension on left
cannot move elbow on right
can feel digits on both hands
no sensation to medial aspect of arm
*where do you suspect the lesion is? - ANS-C6 or C7
Trauma
35 yo man ejected for MVC. vitals are BP 80/40, HR 11, RR 24, GCS 15. airway and
breathing are intact. He complains of severe back pain, has no sensation below umbilicus,
lower thoracic tenderness, unable to move lower extremities. chest and pelvic x-rays are
normal. along with administration of IV fluids, which of the following is most appropriate tx for
pt's hypotension?
a. vasopressor
b. ct scan
c. apply pelvic binder
d. perform FAST or DPL - ANS-d
although pt likely has spinal cord injury, tachycardia & hypotension should lead you to
hemorrhage as etiology of hemodynamic abnormality
\40 yo in MVC is evaluated in rural hospitals w/o surgical capacity. pt has clear cervical spine
fx at C4 with inability to move any extremities and sensation is limited to supraclavicular
region. He is having difficulty breathing w RR of 30. BP is 80/40 and HR 50. What should be
performed prior to transfer? - ANS-crystalloid bolus, initiate pressors, intubate, and then
transfer pt once hemodynamically stable
\are C1 Jefferson fractures usually associated with spinal cord injury? - ANS-no... but they
are unstable and initially tx'd with rigid cervical collar
\are penetrating spinal injuries stable? - ANS-usually stable unless missile destroys a
significant portion of vertebra
\blunt trauma to neck can result in carotid and vertebral artery injuries... what are spinal
indications to screen for this? - ANS--C1-C3 fx
-c spine fx with subluxation
-fx involving foramen transversarium
\cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional
injuries are commonly a/w cervical fractures? - ANS-brain injury and additional spinal
fractures
*25% of all spine injuries have at least mild form of brain injury & 10% of patients with a
cervical fx will have another noncontiguous spine fx
\during the initial treatment, what do you consider in all pts with radiographic evidence of
injury and with neurological deficits? - ANS-unstable spinal injury
\elderly female falls & sustains hyperextension injury to neck. exam demonstrates decreased
strength in upper extremities compared with lower extremities. What is the cause of unusual
neuro findings? - ANS-central cord syndrome
\facet joints of thoracic and lumbar region make fx dislocations relatively uncommon... unless
extreme flexion or sever blunt trauma occurs... however, when they occur, what is common?
- ANS-fracture subluxations in thoracic spine commonly result in complete neurological
deficits bc the spinal canal is narrow in relation to spinal cord (red text)
, \how can spine injuries effect the ability to perceive pain? - ANS-inability to perceive pain
can mask a potentially serious injury elsewhere in the body, such as the usual signs of acute
abdominal or pelvic pain a/w pelvic fx
\how can you exclude spinal injury in patients without neurological deficit, pain or tenderness
along the spine, evidence of intoxication, or additional painful injuries? - ANS-absence of
pain or tenderness along spine virtually excludes presence of significant spinal injury
\how do you test C5 myotome? - ANS-biceps... elbow flexors
\how do you test C6 myotome? - ANS-wrist extension
\how do you test C7 myotome? - ANS-triceps... elbow extension
\how do you test C8 myotome? - ANS-finger flexors
\how do you test L2 myotome? - ANS-hip flexion
\how do you test L3 myotome? - ANS-knee extension
\how do you test L4 myotome? - ANS-ankle dorsiflexion
\how do you test L5 myotome? - ANS-long toe extensors
\how do you test S1 myotome? - ANS-ankle plantar flexors
\how do you test T1 myotome? - ANS-finger abduction
\how does a pt with C1 rotary subluxation present? - ANS-persistent rotation of head
(torticollis)
*the odontoid is no equidistant from the 2 lateral masses of C1
*restrict motion with head in rotated position and refer for further specialized tx
\how is a child's cervical spine markedly different from that of an adults until ~8-12 years old?
- ANS-more flexible joint capsules & interspinous ligaments, flat facet joints, and vertebral
bodies are wedged anteriorly and tend to slide forward with flexion
\how is the C1 jefferson fracture best seen on imaging? - ANS-open mouth view of C1-C2
region and axial CT scans
\if pt has neck pain and normal radiograph, whats next? - ANS-MRI... it is possible for pt to
have isolated ligamentous spine injury that results in instability w/o fx/subluxation
\most thoracic spine fxs are wedge compression fxs, not associated with spinal cord injury...
however, what happens when a fracture dislocation does occur? - ANS-almost always
results in complete spinal cord injury bc of the relatively narrow thoracic canal
\neurogenic shock is associated with what level of spinal cord injury and causes systemic
hypotension via what mechanism? - ANS-T6 and higher
*via distributive shock from lack of vasomotor response
*due do injury to descending sympathetic fibers from upper thoracic spinal cord that help
maintain tone of vasculature and heart rate
*pt may have relative bradycardia a/w distributive shock from dilation of peripheral
vasculature
\physiologic effects of neurogenic shock are not reversed with fluid resuscitation alone... and
massive resuscitation can result in fluid overload and/or pulmonary edema... what may be
required after moderate volume replacement? - ANS-vasopressors
*atropine may be used to counteract hemodynamically significant bradycardia
\pt cannot move legs
can move fingers & wrists bilaterally
weak tricep extension on left
cannot move elbow on right
can feel digits on both hands
no sensation to medial aspect of arm
*where do you suspect the lesion is? - ANS-C6 or C7
