Assessment of Spinal Injury

Stephen Schutts, Master Sergeant, WA ANG

National Registry Emergency Medical Technician - Paramedic
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 Objectives
 Identify the anatomical levels of the spine.
 Understand the function of the spinal
cord/column.
 View Types and Mechanisms of injury that
can cause spine injury.
 Discuss the difference between Spinal
Column Injury vs Spinal Cord Injury.

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 Objectives
 Overview of Spinal Regions and Injuries
 Step by step view of the EMS Spinal
Immobilization Assessment Protocol
 Discuss Common
Treatment/Management Mistakes

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 Introduction
 Spinal injuries are devastating
 Improper management can have horrible
and permanent results
 Appropriate use of spinal immobilization
can mean the difference between a patient
who fully recovers and one who must
spent the rest of his/her life paralyzed

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 Mechanism based assessment
(the current method)
 Low-speed fender bender Are all 8 patients assumed
 An elderly man trips over to have spinal injuries?
a lamp cord and falls Does this man have a
spinal injury? Do all
 When in doubt back such falls cause spinal
board ‘em injuries?
Not necessarily, apply
EMS Spinal
Immobilization.

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 Anatomy & Physiology-
General Structure & Function
Spinal Column
 Made up of 26
vertebrae stacked on
top of one another
 Divided into 5 areas;
cervical, thoracic,
lumbar, sacral, and
coccyx

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 Anatomy &
Physiology-“Long Bone”
Think of the Spinal
Column as on “Long
Bone” with “Joints”
at each end
– The Cervical spine
makes up one “joint”
– The Hip makes up
the other

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 Anatomy & Physiology-
Cervical Spine (7)
 “Joint” at the superior end
of the spinal “Long Bone”
 Very flexible
– Allows flexion, extension,
and rotation of the head
 The head acts as a weighted
lever during acceleration/
deceleration
 Common site of spinal injuries

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 C-1 “Atlas” C-2 “Axis”

•C-1 supports the full weight of the head

•C-1 and C-2 allow head rotation and fine flexion and
extension
 Anatomy & Physiology-
Thoracic Spine (12)
 Much less flexible than C-Spine
– Stabilized by rib cage (especially down to T-10)
 Spinal canal narrow through T-Spine
– Spinal cord tightly fitted into narrow space
– Spinal cord ends about T-12 or L-1

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 Anatomy & Physiology-
Lumbosacral Spine
 5 Lumbar vertebrae plus sacrum and coccyx
 More flexible than T-spine
 More room in spinal canal
 Spinal cord ends about T-12 or L-1
– flexible nerve roots (Cauda equina) flow through LS
spine

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 Anatomy & Physiology-
Spinal Cord
 Bundles of nerve fibers originating in the
brain
 Bundles or tracts travel in right and left pairs
 Spinal Tract pairs crossover midline at
various specific levels
– always in specific anatomical areas
– understanding of the structure of these tracts
helps in assessing spinal cord injuries
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 Mechanism of Injury
 Physical manner and forces involved in producing
injuries or potential injuries
 Valuable tool in determining if the a particular set
of circumstances could have caused a spinal injury
 Mechanisms likely to produce spinal injuries occur
in MVAs, falls, violence, and sports (including
diving accidents)

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Hyperflexion
Hyperextension
Hyperotation
Axial Loading
Axial Distraction
 Sudden/Extreme Lateral
Bending
 Excessive/abnormal lateral movement of the spine
 Can affect any portion of the spine
 Example: T-bone MVAs

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 Spinal Column Injury
 Bony spinal injuries may or may not be associated with
spinal cord injury
 These bony injuries include:
– Compression fractures of the vertebrae
– Comminuted fractures of the vertebrae
– Subluxation (partial dislocation) of the vertebrae
 Other injuries may include:
– Sprains- over-stretching or tearing of ligaments
– Strains- over-stretching or tearing of the muscles

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 Spinal Cord Injury
 Cutting, compression, or stretching of the spinal
cord
 Causing loss of distal function, sensation, or motion
 Caused by:
– Unstable or sharp bony fragments pushing on the cord, or
– Pressure from bone fragments or swelling that interrupts
the blood supply to the cord causing ischemia

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 Primary Spinal Cord Injury
 Immediate and irreversible loss of sensation and
motion
 Cutting, compression, or stretching of the spinal
cord
 Occurs at the time of impact/injury

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 Secondary Spinal Cord
Injury
 Injury Delayed
 Occurs later due to swelling, ischemia, or
movement of sharp or unstable bone fragments
 May be avoided if spine immobilized during
extrication, packaging, treatment, and
transport

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 Incomplete Spinal Cord
Injury
 Complete injury to specific spinal tracts with
reduced function distally
 Other tracts continue to function normally with
distal function intact

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 Spinal Region Overview
 Cervical Spine Injuries
 Thoracic Spine Injuries
 Lumbosacral Spine Injuries
 Spinal Injury Summary

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 Cervical Spine Injuries
 C-spine very flexible
 Most frequently injured area of spine
 Most injuries at C-5/C-6 level

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 Thoracic Spine Injuries
 T-spine less flexible
 Narrow spinal canal
 Cord injury occurs with minimal displacement
 Common mechanisms
 Any cord damage usually complete at this level
 Most T-spine injuries occur at T-9/T-10

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 Lumbosacral Spine Injuries
 LS spine flexible nerve roots in roomy spinal canal
 May have bony injury w/o cord or nerve root
damage
 Secondary injury still possible
 Neurological injury rare w/ isolated sacral
injuries

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 Assessment Overview
 Decision to apply spinal immobilization in
past based was solely on mechanism of injury
 Utilize EMS Spinal Immobilization
Algorithm to determine when spinal
immobilization is NOT needed

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 Spinal Immobilization Algorithm
Patient Mentation:
Decreased Level of Consciousness?
No Yes ----------------------------Immobilize
ETOH/Drug Impairment?
No Yes ----------------------------Immobilize
Subjective Assessment:
Cervical/Thoracic/Lumbar Spinal pain?
No Yes ----------------------------Immobilize
Numbness/Tingling/Burning/Weakness?
No Yes -----------------------------Immobilize
Objective Assessment:
Cervical/Thoracic/Lumbar Deformity or Tenderness?
No Yes -----------------------------Immobilize
Other Severe Injury?
No Yes -----------------------------Immobilize
Other Severe Injury?
No Yes -----------------------------Immobilize
Pain w/Cervical Range of Motion?
No Yes -----------------------------Immobilize
MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS
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 Principles of Treatment
 Protect spinal cord from secondary injury
 We have little or no effect on primary injury
 Focus on prevention of secondary injury

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 Complete Spinal
Immobilization
 Must act as if whole spine unstable
 Immobilize entire spine
 To do this we must immobilize the head, neck,
shoulders/chest, and pelvis /hips

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 Common
Treatment/Management
Mistakes
 Improperly sized C-Collar
 Spine not supported due to improper positioning on backboard
 Inadequate strapping allows excessive movement
 Movement possible due to little or no padding to shim the body
 C-spine movement by inadequate or improperly applied head
immobilization device
 C-spine hyperextension due to improperly applied C-collar or
head immobilization device

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 Common
Treatment/Management
Mistakes (cont.)
 Readjusting torso straps after immobilization of the head,
causing misalignment of the spine
 Securing head to backboard prior to securing shoulders, torso,
hips, and legs

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Any Questions???