Spinal Injuries

Spinal Injury Prevalence and Clinical Urgency

Spinal injuries in the emergency setting range from minor ligamentous strains to catastrophic fractures with spinal cord compromise. The emergency nurse must rapidly identify potential spinal injury, prevent secondary cord damage, and coordinate definitive care.^[1] Approximately 3% of blunt trauma patients have a spinal injury; missed injuries can lead to permanent paralysis.^[2] This topic is high-yield for the CEN exam and clinically critical for safe trauma resuscitation.

Spinal Shock, Neurogenic Shock, and Incomplete Cord Syndromes

• Spinal shock: Temporary loss of spinal cord function below the level of injury – flaccid paralysis, areflexia, absent sensation. May persist hours to days.^[3]
• Neurogenic shock: Result of sympathetic interruption (usually above T6) – bradycardia, hypotension, warm/dry skin. Distinct from hypovolemic shock.^[3]
• Primary injury: Mechanical damage from initial trauma (fracture, dislocation, cord transection).^[1]
• Secondary injury: Ongoing ischemic, inflammatory, and excitotoxic damage after the initial insult – the primary target of emergency interventions.^[1]
• Spinal cord injury (SCI) without radiographic abnormality (SCIWORA): Seen in children and elderly – cord injury with normal plain films and CT; requires MRI for detection.^[4]
• Central cord syndrome: Most common incomplete SCI – upper extremity weakness > lower (sacro-lumbar fibers preserved). Geriatric hyperextension injuries.^[3]
• Anterior cord syndrome: Loss of motor and pain/temperature sensation below injury; dorsal columns (proprioception/vibration) spared. Poor prognosis.^[3]
• Brown-Séquard syndrome: Hemicord lesion – ipsilateral motor loss and proprioceptive loss, contralateral pain/temperature loss below injury. Best prognosis of incomplete syndromes.^[3]

Injury Kinematics and Standard Immobilization Protocol

Mechanisms of Injury

• Flexion-compression: Burst fractures (e.g., diving accidents).
• Flexion-distraction: Chance fractures (e.g., lap belt in MVA).
• Extension: Often cervical; common in elderly with falls or MVA – can cause central cord syndrome.
• Rotation: Facet dislocations, often unstable.
• Penetrating: Gunshot or stab wounds; usually do not require spinal immobilization unless hemodynamically unstable with neurologic deficit?^[2]

Immobilization Principles

1. Maintain manual inline stabilization immediately upon arrival.
2. Apply rigid cervical collar (correct size; avoid hyperextension/rotation).
3. Secure patient to full backboard with head blocks and tape.
4. Minimize movement during transfers – logroll technique.
5. Remove backboard as soon as feasible (within 1-2 hours) to prevent pressure injury.^[1][2]

Clinical Presentation and Neurologic Findings in Spinal Injury

• Pain: Localized midline spinal tenderness on palpation.
• Deformity: Step-off, ecchymosis, swelling.
• Neurologic deficits: Weakness, numbness, paresthesias, priapism (cord injury).
• Respiratory compromise: High cervical (C3-5) injuries may cause diaphragmatic paralysis – paradoxical breathing, inability to cough, respiratory arrest.^[3]
• Hypotension with bradycardia: Neurogenic shock (warm dry skin with low SVR) vs. hypovolemic shock (cool clammy skin). Distinguish carefully.^[3]
• Loss of bladder/bowel control (sacral cord damage).
• Horner syndrome: In cervicothoracic injury (ptosis, miosis, anhidrosis).

NEXUS Criteria, Canadian Rule, and Imaging Modalities

Prehospital/ED Screening

• NEXUS criteria (National Emergency X-Radiography Utilization Study) – cervical spine imaging not required if all are met:
  • No posterior midline cervical tenderness
  • No evidence of intoxication
  • Normal level of consciousness
  • No focal neurologic deficit
  • No distracting painful injury^[5]
• Canadian C-Spine Rule: For alert, stable trauma patients – age ≥65, dangerous mechanism, or paresthesias in extremities require imaging.^[6]

Diagnostic Imaging

• CT scan: Gold standard for acute spinal trauma – detects fracture/dislocation with high sensitivity.^[1]
• Plain X-rays: Still used in some low-resource settings (three-view cervical series).
• MRI: Indicated for neurologic deficits with negative CT, suspected ligamentous injury, or to assess cord edema/compression.^[1]
• Neurologic exam: Motor strength (0–5), sensation to light touch and pinprick, reflexes, anal tone, sacral sparing – document serial exams.

Additional Assessment

• Spinal shock: Bulbocavernosus reflex returns marks resolution (usually 24–72 h).^[3]
• Neurogenic shock: Suspect when hypotension + bradycardia persists despite adequate volume resuscitation and no other cause.

Hemodynamic Goals, Pharmacotherapy, and Surgical Timing

Initial Stabilization

1. Maintain ABCs: Airway – cervical spine immobilization during intubation (manual inline). Ventilation – assist if respiratory compromise. Circulation – treat hypotension aggressively.
2. Hemodynamic management: Goal MAP ≥85 mmHg for first 7 days to optimize spinal cord perfusion (neurogenic shock may require vasopressors – phenylephrine or norepinephrine).^[1][7]
3. Spinal immobilization: Continue until injury cleared clinically or by imaging.
4. Neuroprotective measures: Avoid hypoxia, hypotension, hyperthermia.

Pharmacologic Interventions

• Methylprednisolone: No longer standard of care. Current guidelines (2018 AANS/CNS) recommend against its routine high-dose use.^[7]
• Pain management: Judicious use of opioids to avoid masking neurologic progression; consider ketamine for procedural sedation.
• Deep vein thrombosis prophylaxis: LMWH or unfractionated heparin within 24-72 hours once bleeding risk is acceptable.^[7]

Surgical Management

• Decompression +/- fusion for unstable fractures, subluxations, or compressive lesions (e.g., epidural hematoma).^[1]
• Timing: Urgent for progressive neurologic deficit or incomplete SCI; early (<24 h) may improve outcomes.^[7]

Nursing Interventions

• Frequent neurologic checks (q1h) – motor strength, sensation, level changes.
• Prevent pressure ulcers: Regular repositioning, specialty mattress, skin inspection.
• Bowel/bladder program: Indwelling catheter initially, intermittent catheterization later.
• Respiratory care: Incentive spirometry, cough assist, suctioning – atelectasis and pneumonia are leading causes of mortality.^[3]
• Emotional support and spinal cord injury education for patient/family.

Critical Safety Actions and Common Complication Management

Critical Safety Actions

• Never remove immobilization until injury is cleared – can convert unstable fracture to cord injury.
• Beware of missed injury: Altered mental status, distracting pain, or intoxication increase risk. Maintain immobilization in all high-risk patients.^[5]
• Logroll – do not twist or bend the spine during transfers.
• Monitor for respiratory deterioration: Ascending edema in cervical injuries may require early intubation.

Common Complications

Test-Focused Clinical Distinctions for Spinal Injuries

• Know NEXUS vs. Canadian C-Spine Rule: Both high yield. NEXUS is more sensitive for the very young; Canadian is more specific in older patients.
• Distinguish spinal shock vs. neurogenic shock: Spinal = temporary cord dysfunction (flaccid paralysis, absent reflexes). Neurogenic = hypotension + bradycardia from sympathetic loss.
• Memorize incomplete cord syndromes: Central (arms > legs), anterior (motor + pain loss), Brown-Séquard (ipsi motor/contra pain loss), cauda equina (lower extremity weakness, saddle anesthesia, bladder/bowel).
• Autonomic dysreflexia: Classic exam scenario – SCI patient above T6 presents with severe hypertension, headache, bradycardia, sweating. Immediate action: sit patient up, check for bladder distention or fecal impaction.
• Steroids: Not recommended – high-dose methylprednisolone no longer part of standard protocols.
• MAP goal: ≥85 mmHg for first 7 days to prevent secondary injury.
• Cervical collar sizing: Too large allows flexion; too small causes hyperextension. Measure from chin to sternal notch.
• ABCs first: Airway may need fiberoptic or video laryngoscopy with manual inline stabilization.

References & Sources

1. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries: 2022 Update. Neurosurgery. 2022;90(2):e1-e14. doi:10.1227/NEU.0000000000001777
2. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2012;73(4):S416-S428. doi:10.1097/TA.0b013e31826ab3d7
3. Fehlings MG, Tetreault LA, Aarabi B, et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Rehabilitation. Global Spine J. 2019;9(1 suppl):101S-118S. doi:10.1177/2192568219833770
4. Pahys JM, Mulcahey MJ, Betz RR. SCIWORA in children: a review. Eur Spine J. 2012;21(8):1413-1422. doi:10.1007/s00586-012-2294-0
5. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. doi:10.1056/NEJM200007203430204
6. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. Lancet. 2001;358(9291):1088-1093. doi:10.1016/S0140-6736(01)05616-9
7. Hawryluk GWJ, Rowland JW, Kwon BK, et al. Guidelines for the Management of Acute Spinal Cord Injury 2022: Part 1 – Prehospital and Emergency Department Care. J Trauma Acute Care Surg. 2022;92(2):e31-e48. doi:10.1097/TA.0000000000003040