Spine Injuries

Abstract

You arrived in the theater of operations several weeks ago, and injured patients from your first mass casualty event are streaming into the ER. With the exception of the uniforms and the fact that your ER is a tent, it looks a lot like a civilian trauma event. Multiple patients arrive bleeding and moaning, almost all of them on spine boards and with cervical collars in place. One patient has multiple fragment wounds to his chest, neck, and face and is having a hard time breathing. He is bleeding around his cervical collar, but no one wants to remove it or move the patient for fear of violating “spinal precautions.” Suddenly, the experienced triage physician arrives and wastes no time in removing the collar, sitting the patient upright, and assessing his neck wounds. Miraculously the patient survives with an intact spinal cord and neurologic function.

Civilian Translation of the Military Experience and Lessons Learned

• John G. DeVine 

Evolution

Modern trauma care has evolved over the last century utilizing many of the lessons learned after each major conflict in which wartime casualties are treated. Interestingly, the types of injuries have changed as the weapons of combat and the combatant’s armor have evolved. The most recent conflict is no exception. It is difficult to determine if the incidence of spinal column injuries has changed over the last hundred years because many patients sustaining thoracic or abdominal trauma in previous conflicts did not survive. Body armor has significantly changed the landscape of combatant’s injuries, and extremity injuries have become more prevalent. In addition, the use of improvised explosive devices (IEDs) utilized as “roadside bombs” has increased the incidence of blunt trauma. With this in mind, the combatant surviving the initial injury and cared for in the combat setting can be viewed as a “multi-trauma” patient, including potential spinal column and spinal cord injuries.

ATLS

As pointed out in the preceding chapter, the primary assessment never changes: airway, breathing, and circulation. Resuscitation guidelines as recommended by the American College of Surgeons and ATLS are well described. The potential spine injury is of little significance if the primary assessment and the actions taken while addressing these are not successful. However, the importance of spinal immobilization during the resuscitation cannot be overstated. Historically, spine immobilization was one of the most frequent prehospital procedures in the USA. However, recent literature has questioned the efficacy and safety of spinal immobilization in all trauma patients. Historically, spinal immobilization was implemented based on mechanism of injury. However, current practice is to use clinical findings to determine whether continued immobilization is required. This is critical because prolonged use of c-collars and/or spine boards is associated with complications such as skin necrosis and compartment syndromes. In an environment in which a patient may be in transport for a prolonged period, such as evacuation from combat hospital, this must be taken into account.

Clear the Spine

The decision can be made in theater on “clearing” a spine and removing spinal precautions provided the patient has no evidence of the following: altered level of consciousness or mental status, intoxication, neurologic symptoms or signs of a distracting injury, and midline spinal pain or tenderness. If the patient has any of the above, then precautions must be used. C-collars used in transport can be removed while the head is held in-line with mild traction for examination, for intubation, or to obtain a surgical airway. Patients should be removed from the backboard as soon as feasible and logrolling implemented as the primary form of thoracolumbar spine precautions. The backboard should be utilized only for transport from one bed to another.

Spine Surgery Emergencies: The Rural Hospital and the Combat Hospital

There are very few spine surgery emergencies in the civilian trauma center. The most serious is the progressive neurologic deficit – either a cauda equina syndrome or progressive spinal cord injury (incomplete). The progressive neurologic deficit requires emergent management in the civilian setting. However, emergent management is not feasible in many rural settings in the USA. This is not unlike the combat hospital environment. With limited spine surgery resources and imaging modalities, these scenarios are unfortunate – and definitive care must await resuscitation efforts and eventual transport to a higher and appropriate level of care. Being able to recognize the neurologic deficit becomes the most important variable in this setting – because it sets in motion the planned eventual evacuation plan. Documenting a thorough neurologic examination will localize the injury. Maintaining appropriate spinal precautions will avoid continued neural trauma. Avoiding hypotension and hypoxia during the resuscitation and transport will limit secondary injury to the neural elements.