Trauma: Spinal Injury

Related Subjects: |Transverse myelitis |Acute Disseminated Encephalomyelitis |Cervical spondylosis |Spinal Cord Anatomy |Acute Disc Prolapse |Spinal Cord Compression |Spinal Cord Haematoma |Foix-Alajouanine syndrome |Cauda Equina |Conus Medullaris syndrome |Anterior Spinal Cord syndrome |Central Spinal Cord syndrome |Brown-Sequard Spinal Cord syndrome |Internal Decapitation

🚨 Trauma patients with head injury/coma may also have neck injury. 👉 If in doubt → apply a hard collar to stabilise the cervical spine. 📸 If scanning the head → image the C-spine to at least C7/T1 to avoid missed injuries.

📖 About

• ⏱ Early recognition & stabilisation are vital → delays cause irreversible deficits.
• 🧠 Spinal cord runs foramen magnum → L1; carries motor, sensory & autonomic tracts.
• 💨 C3–C5 innervate diaphragm → "C3, 4, 5 keeps the diaphragm alive".
• ✋ C5–T1 → arms/hands; injury here threatens independence.

🧩 Anatomy

• 31 pairs of spinal nerves:
  • 🦴 Cervical: 8 (C1–C8)
  • 🦴 Thoracic: 12 (T1–T12)
  • 🦴 Lumbar: 5 (L1–L5)
  • 🦴 Sacral: 5 (S1–S5)
  • 🦴 Coccygeal: 1 (Co1)

⚡ Aetiology

• Traumatic: fracture-dislocation, retropulsed bone fragments, haematoma.
• Non-traumatic: tumour, infection (TB, epidural abscess), degenerative stenosis.

🏗 Structure

• Three spinal columns:
  • Anterior: vertebral body front + anterior ligaments.
  • Middle: posterior body + posterior longitudinal ligament.
  • Posterior: laminae, pedicles, posterior ligaments.
• 💡 Instability = ≥2 columns damaged → surgical concern.

🚗 Causes

• Road traffic accidents (~50%).
• Falls (~25%, esp elderly).
• Violence (GSW/stab ~15%).
• Sports (~10% diving/rugby).
• Industrial/other (~5%).

⚠️ Risk Factors

• Ankylosing spondylitis (rigid fracture-prone spine).
• Cervical spondylosis, congenital/acquired stenosis.

🚨 Dangerous Mechanisms

• Falls >3 feet / >5 steps.
• Axial load (diving injury).
• High-speed RTA, rollover, ejection.
• Motorbike/ATV crashes.
• Bicycle vs vehicle collision.

🩺 Clinical Features

• ⚡ Spinal shock: flaccid paralysis, areflexia, atonic bladder (acute).
• ↗️ Later: hyperreflexia, spasticity, Babinski, autonomic overactivity.
• 📍 Midline pain, tenderness, sensory level on exam.
• 💨 Diaphragmatic breathing if C3–5 intact but intercostals lost.
• 🦽 Paraplegia (below T1), quadriplegia (cervical).
• 🍌 Priapism + hypotension/bradycardia → classic cord transection clue.

🔎 Incomplete Cord Syndromes

• Brown-Séquard: ipsilateral motor/proprioception loss + contralateral pain/temp loss.
• Anterior cord: bilateral motor + pain/temp loss, preserved vibration/proprioception.
• Central cord: arms > legs weakness, often post-hyperextension in cervical spondylosis.

🧪 Investigations

• 🩻 X-ray: AP, lateral, odontoid, ensure C7/T1 included.
• 💻 CT: gold standard for bone fractures/dislocation.
• 🖥 MRI: best for cord, discs, ligaments, haematoma.
• 🧠 Neuro exam: tone, reflexes, sensory level, Babinski.

🚑 Management

🛑 Treat all suspected spinal injuries as unstable until cleared.

• ABCDE trauma approach (manual in-line stabilisation).
• Immobilisation: hard collar, blocks, vacuum mattress.
• Airway/ventilation: high cervical injuries → early intubation.
• Steroids: methylprednisolone use is controversial; follow local/NICE policy.
• Surgery: urgent decompression + stabilisation if compression/instability.
• Supportive: catheterisation, VTE prophylaxis, pressure sore prevention.
• Rehabilitation: physio, OT, psychological/vocational support.

📊 Functional Outcome by Level

🌅 Prognosis

• Depends on level + completeness.
• ⏱ Early decompression (<24h) → better recovery.
• High cervical complete = poor survival, often ventilator-dependent.
• Incomplete injuries (esp. central cord) = best recovery chance.
• Long-term issues: UTIs, pressure sores, DVT/PE, depression.

🛡 Prevention

• Seatbelts, helmets, sports safety gear.
• Fall prevention in elderly.
• Posture and back-strengthening programmes.
• Manage predisposing spinal diseases (e.g., AS, spondylosis).