Rosen & Barkin's 5-Minute Emergency Medicine Consult (663 page)

• Detailed neurologic exam, focused on determining if any deficit exists and attempting to define the level of injury
  
• A neurosurgical consultation if deficit exists is recommended in most cases
  

• Basic preoperative lab studies are indicated.
  
• Consider sedimentation rate and C-reactive protein to risk-stratify other potential diagnoses.
  

All areas of clinical suspicion should be imaged with plain radiographs.

Cases in which plain radiographs may be difficult to interpret due to severe DJD, the use of CT may be more appropriate.

• CT of the spine when plain films are normal or ambiguous:
  
  • CT allows assessment of the spinal canal and any impingement by bone fragments.
    
• MRI is the imaging modality of choice for detection of spinal cord damage; in the acute setting, the indications for MRI are:
  
  • Neurologic deficits not explained by plain films or CT
    
  • Clinical progression of a spinal cord lesion
    
  • Determination of acute surgical candidacy
    
  • Disadvantages of MRI include:
    
    • The inability to adequately monitor the patient while undergoing the study
      
    • The incompatibility with certain metal devices
      
    • The time to complete the exam
      

• Myelography is used with CT when MRI is not available or cannot be performed.
  
• A lumbar puncture may be required if considering Guillain–Barré, multiple sclerosis, or transverse myelitis.
  

• Dorsal root injury
  
• Peripheral nerve injury
  
• Guillain–Barré syndrome
  
• Multiple sclerosis
  
• Transverse myelitis
  
• Epidural abscess
  
• Cerebral vascular accident
  

TREATMENT

• Full spinal immobilization
  
• IV access should be established for fluid resuscitation in the setting of neurogenic shock.
  
• Patients should be transported to the nearest trauma center:
  
  • Prompt evaluation and neurosurgical intervention may lead to a better outcome.
    

Cervical collars must be the appropriate size for the child; splinting the head and body with towels and tape is a reasonable alternative.

• Spinal immobilization must be maintained at all times.
  
• Intubation must proceed with in-line spinal immobilization.
  
• IV fluids should be administered at maintenance levels unless shock is present:
  
  • Spinal trauma may cause hypotension due to loss of sympathetic tone; fluid administration is 1st-line treatment.
    
  • Other causes of hypotension (e.g., hemorrhage) should be sought before being attributed to spinal cord injury (SCI).
    
  • Generally, hypovolemic shock causes tachycardia, whereas neurogenic shock results in bradycardia.
    
  • If BP does not improve after a fluid challenge and no other cause for hypotension can be found, vasopressor use may be necessary; α-agonist is preferred.
    

• Other injuries must be treated as indicated.
  
• Level of SCI should be determined as a baseline to follow for improvement or deterioration.
  
• A neurosurgeon must be consulted once an SCI is suspected, even when plain films are normal; early surgical decompression or immobilization may reduce morbidity.
  
• The patient with an SCI should be managed at an appropriate regional trauma or spinal center:
  
  • If necessary, transfer should occur as soon as management of other injuries allow.
    
• IV antibiotics and tetanus prophylaxis are given to patients with a penetrating injury.
  
• IV vasopressor support may be required to treat neurogenic shock.
  

• Phenylephrine: 0.5–2 μg/kg bolus then 50–100 μg/min drip
  
• Ancef: 1,000 mg q8h
  

FOLLOW-UP

All patients with spinal cord syndrome must be admitted to an ICU setting.

No patient with symptoms suggestive of SCI should be discharged.

• A detailed neurologic exam and attempt to document the spinal level of neurologic symptoms is critical.
  
• Involve neurosurgical consultants early, as outcome is time-dependent in many cases.
  
• EM physicians should not start methylprednisolone treatment for acute SCI.
  

• Bracken MB, Shepard MJ, Collins WF, et al. A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. Results of the Second National Acute Spinal Cord Injury Study.
  N Engl J Med
  . 1990;322(20):1405–1411.
  
• Schouten R, Albert T, Kwon BK. The spine-injured patient: Initial assessment and emergency treatment.
  J Am Acad Orthop Surg
  . 2012;20(6):336–346.
  
• Theodore N, Aarabi B,Dhall SS, et al. Transportation of patients with acute traumatic cervical spine injuries.
  Neurosurgery
  . 2013;72(suppl2):35–39.
  

CODES

• 344.89 Other specified paralytic syndrome
  
• 952.02 C1-C4 level with anterior cord syndrome
  
• 952.03 C1-C4 level with central cord syndrome
  

BASICS

• Injury to the neck that results in injury to the spinal cord, cervical spine, or ligaments supporting the cervical spine
  
• May have more than 1 mechanism concurrently
  
• Flexion injuries:
  
  • Simple wedge fracture: Usually a stable fracture
    
  • Anterior subluxation: Disruption of the posterior ligament complex without bony injury; potentially unstable injury
    
  • Clay shoveler’s fracture: Avulsion fracture of the spinous process of C7, C6, or T1; stable fracture
    
  • Flexion teardrop fracture: Extremely unstable fracture; may be associated with acute anterior cervical cord syndrome
    
  • Atlanto-occipital dislocation: Unstable injury
    
  • Bilateral facet dislocation: Can occur from C2–C7; unstable injury
    
• Flexion/rotation injuries:
  
  • Unilateral facet dislocation “locked” vertebra: Stable injury
    
  • Rotary atlantoaxial dislocation: Unstable injury
    
• Extension injuries:
  
  • Extension teardrop fracture: An avulsion fracture of the anteroinferior corner of the involved vertebral body; unstable in extension and stable in flexion
    
  • Posterior arch of C1 fracture: Arch is compressed between the occiput and the spinous process of the axis during hyperextension; unstable fracture
    
  • Avulsion fracture of the anterior arch of the atlas: Horizontal fracture of C1 and prevertebral soft tissue swelling on the lateral C-spine
    
  • Hangman fracture: Traumatic spondylolisthesis of the axis involving the pedicles of C2; unstable fracture
    
  • Hyperextension dislocation: Described as the syndrome of the paralyzed patient with a radiographically normal-appearing C-spine
    
• Extension–rotation injury:
  
  • Pillar fracture: Generally stable fracture
    
• Vertical compression (axial loading) injuries:
  
  • Jefferson fracture: Burst fracture of both the anterior and posterior arches of C1; extremely unstable fracture
    
  • Burst fracture: A comminuted fracture of the vertebral body with variable retropulsion of the posterior body fragments into the spinal canal
    

• Blunt trauma is the major cause of neck injuries:
  
  • Automobile accidents account for >50%.
    
  • Falls account for ∼20%.
    
  • Sporting accidents account for 15%.
    
  • Minor trauma in patients with severe arthritis may result in cervical injuries.
    
• Penetrating trauma
  

DIAGNOSIS