Traumatic Spine Injury

Charlotte S. Myers and Laurie Baker

Keywords: autonomic dysreflexia, cauda equina syndrome, central cord syndrome, spinal cord injury, spinal fractures, spinal shock

12.1 Traumatic Spine Injury

A traumatic spine injury involves damage to the spinal cord, spinal nerves, supporting ligaments, vertebral bodies, blood vessels, or a combination of these. Many cases of traumatic spine injury result in serious implications for patients, both initially and long term. Long-term outcomes are influenced by the type, level, and severity of the injury. Of all traumatic spine injuries, an injury to the spinal cord is the most calamitous.

12.2 Spinal Cord Injury

Spinal cord injury (SCI) is a devastating, life-changing event that may result from trauma, neoplasm, hemorrhage, infection, or a degenerative spine condition. Bony fracture or dislocation is frequently associated with SCI (Video 12.1). It results in major morbidity and is costly for the health care system (▶ Table 12.1). SCI does not take only a physical toll; it also results in significant psychological stress and can bring about major lifestyle changes. Injury to the spinal cord will alter the patient’s independence, economic security, body image, lifestyle, and overall quality of life.

Patients with SCI pose a unique set of challenges for the bedside nurse. The many emotional and physiologic responses associated with this type of injury may affect different systems in the body. The ability to recover from SCI depends on a host of variables, including the level of injury; the patient’s personal characteristics; the receipt of timely, evidenced-based medical care; and access to neurorehabilitation. Some patients may have no identifiable neurologic impairment, whereas, sadly, others experience severe and permanent disability.

12.2.1 Etiology of Spinal Cord Injury

Spinal cord injury can be caused by accidents, diseases, or developmental anomalies (Box 12.1 Etiology of Spinal Cord Injury). Following are some common causes:

• 
  

  Motor vehicle accidents

  
  
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  Falls

  
  
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  Acts of violence (e.g., gunshot wounds)

  
  
• 
  

  Sports injuries

  
  
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  Tumors

  
  
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  Hemorrhage

  
  
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  Infection

Epidemiology of Spinal Cord Injury

• 
  

  About 12,500 new cases of SCI occur annually in the United States alone (Box 12.2 Risk Factors for Spinal Cord Injury)

  
  
• 
  

  In 2014, over 275,000 people in the United States had an SCI

  
  
• 
  

  About 80% of patients with SCI are men

  
  
• 
  

  Most are white, followed by African American, then Hispanic

12.2.2 Types of Spinal Cord Injury

Concussion

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  Caused by a blow to the spinal column that jars or shakes the spinal cord

  
  
• 
  

  Results in temporary loss of neurologic function; this impairment can last for just a few hours or many days

Contusion

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  Bruising of the spinal cord caused by fracture, dislocation, or direct trauma

  
  
• 
  

  Necrosis of spinal cord tissue may result from initial trauma or from later compression caused by bleeding or edema

  
  
• 
  

  Resulting dysfunction depends on the severity of the contusion

Compression

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  Caused by constriction or pressure on the spinal cord

  
  
• 
  

  Pressure may be brief (e.g., hyperextension injury) or prolonged (e.g., mass effect from bone fragments, neoplasm, hemorrhage, or disk herniation)

  
  
• 
  

  Compression may cause contusion, concussion, laceration, or transection of the spinal cord

Laceration

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  Partial tear or cut into the spinal cord

  
  
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  Deficits are permanent and irreversible

Transection

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  Complete tear or cut through the spinal cord, severing it

  
  
• 
  

  Permanent loss of neurologic function below the level of injury

Hemorrhage

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  Bleeding within the spinal cord or its surrounding tissues

  
  
• 
  

  Compression of the spinal cord, causing irritation to spinal nerves

Infarction

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  Ischemia of the spinal cord due to interrupted blood flow

  
  
• 
  

  Results from compression of the spinal cord or injury to the blood vessels that perfuse it

12.2.3 Mechanisms of Spinal Cord Injury

Hyperflexion

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  Occurs when the head and neck are violently forced forward

  
  
• 
  

  Deceleration injury. Occurs when a person in motion is abruptly stopped, as in a head-on motor vehicle collision or diving accident

  
  
• 
  

  C5 and C6 typically experience the greatest amount of stress

  
  
• 
  

  Compression fracture and wedge fractures are the most common fractures associated with hyperflexion (discussed in greater detail later)

  
  
• 
  

  Neurologic deficits are expected only if the posterior ligament is torn and facets are dislocated (fracture or dislocation)

Hyperextension

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  Occurs when the head and neck are suddenly forced backward

  
  
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  Acceleration injury. Occurs when a person is suddenly pushed into motion from a stopped state, as in a rear-end motor vehicle collision or forward fall onto the face, with the chin forced backward (common in the elderly population)

  
  
• 
  

  C4 and C5 experience the most stress

  
  
• 
  

  Soft-tissue strain (i.e., whiplash) is common; contusion or ischemia of the spinal cord from stretching is less likely but possible

  
  
• 
  

  Neurologic deficits may result if the spinal cord is damaged

  
  
• 
  

  Plain radiographs are nondiagnostic because ligaments usually remain intact and neither fractures nor dislocations occur with this type of injury

Compression

• 
  

  Injury results from axial loading, or force applied straight down on the vertebrae (▶ Fig. 12.1)

  
  
• 
  

  Can result from a fall from a height, with the person landing on her feet or buttocks

  
  
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  Compression injuries usually result in a burst fracture or wedge fracture in the thoracic or lumbar spine

  
  
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  Usually no associated neurologic deficits.

  
  
  
  

  

  
  

  Fig. 12.1 Compression fracture.

Rotation

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  Occurs when there is extreme twisting of the head or neck

  
  
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  Posterior ligaments may tear or rupture, resulting in dislocation of one or more facet joints

  
  
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  No neurologic deficit is expected if only one facet joint is involved; however, neurologic deficit is expected if two or more facets are locked

Penetration

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  Results when a foreign object (e.g., a bullet or knife) pierces the spinal column

  
  
• 
  

  Damages soft tissue and may involve vertebrae or spinal cord transection

  
  
• 
  

  Neurologic deficits are expected if the spinal cord is involved

12.2.4 Classification of Spinal Cord Injury

Complete Spinal Cord Injury

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  Complete loss of voluntary motor and sensory functions below the level of injury

  
  
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  Irreversible, permanent damage to the spinal cord

  
  
• 
  

  Tetraplegia (also called quadriplegia) (▶ Fig. 12.2)

  
  
  
  
  • 
    

    Caused by injury to the cervical spinal cord

    
    
  • 
    

    Results in loss of motor and sensory function of both upper extremities, both lower extremities, and bladder and bowel function

  
  
• 
  

  Paraplegia

  
  
  
  
  • 
    

    Results from injury to the thoracic or lumbar spinal cord

    
    
  • 
    

    Results in loss of motor and sensory function in both lower extremities and bladder/bowel function (▶ Fig. 12.3).

    
    
    
    

    

    
    

    Fig. 12.2 Complete spinal cord injury at cervical spine level.

    
    
    
    

    

    
    

    Fig. 12.3 Complete spinal cord injury at lumbar spine level.

Incomplete Spinal Cord Injury

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  Some sensory or motor function is preserved below the level of injury

  
  
• 
  

  Spared spinal cord tracts allow some neurotransmission

  
  
• 
  

  The SCI syndromes below are descriptive classifications of different types of incomplete SCI (▶ Table 12.2)

  
  
  
  
  • 
    

    Central cord syndrome

    
    
    
    
    • 
      

      Most common subset of incomplete SCI (▶ Fig. 12.4)

      
      
    • 
      

      Can occur at any age, but it is most common in older patients with cervical bony degeneration and cervical stenosis; see also Chapter 11: Spinal Disorders

      
      
    • 
      

      Often caused by hyperextension injury, with damage to the center of the spinal cord where the nerve fibers that lead to the upper extremities are located

      
      
    • 
      

      Loss of motor and sensory function is more severe in the upper extremities than in the lower extremities (e.g., the patient can walk to the door, but cannot open it); bladder dysfunction may or may not result

      
      
    • 
      

      Function is usually restored in the lower extremities first, then bladder function is restored

      
      
    • 
      

      Recovery of hand intrinsic function is variable and is often the last function to return

    
    
  • 
    

    Anterior cord syndrome

    
    
    
    
    • 
      

      Caused by direct injury to the anterior portion of the spinal cord or by disruption of the anterior spinal artery, anterior cord syndrome results in ischemia and infarction of the anterior two-thirds of the spinal cord (▶ Fig. 12.5)

      
      
    • 
      

      Direct injury may result from an acute disk herniation or hyperextension injury with fracture dislocation of the vertebrae

      
      
    • 
      

      Paralysis and loss of pain and temperature sensation are evident below the level of injury

      
      
    • 
      

      Light touch, vibration, and proprioception are preserved, because these nerve tracts are located in the dorsal columns of the spinal cord, which are perfused by the posterior spinal arteries

      
      
    • 
      

      Prognosis for recovery varies, but it is generally unfavorable

    
    
  • 
    

    Cauda equina syndrome

    
    
    
    
    • 
      

      A neurosurgical emergency requiring urgent intervention, cauda equina syndrome is caused by compression of the lumbar nerve roots below L1 (Box 12.3 Clinical Alert: Cauda Equina Syndrome)

      
      
    • 
      

      Most commonly occurs when large disk herniations at L4/L5 exert mass effect on the lumbar nerve roots descending through the spinal canal

      
      
    • 
      

      Deficits vary depending on the specific nerve roots involved, but may include loss of motor and sensory functions of the pelvic organs (i.e., bladder, bowel, and sexual dysfunction) and the lower extremities

      
      
    • 
      

      Recovery is variable, but early diagnosis and prompt surgical treatment are associated with improved outcomes

    
    
  • 
    

    Conus medullaris syndrome

    
    
    
    
    • 
      

      Caused by pressure on the conus medullaris. Tumor growth, spinal trauma, infection or abscess, degenerative arthritis, or another element may be responsible for pressure exerted on the conus medullaris

      
      
    • 
      

      Symptoms include low back pain, numbness of the groin or inner thigh, numbness or weakness of the leg or foot, urinary incontinence, difficulty walking, and impotence

      
      
    • 
      

      Treatment depends on the underlying cause and may include corticosteroids to reduce swelling, decompressive surgery, or radiotherapy for spinal tumor

    
    
  • 
    

    Brown-Séquard syndrome

    
    
    
    
    • 
      

      Accounts for less than 4% of all SCIs and rarely occurs alone

      
      
    • 
      

      Results from an inflammatory SCI or from a penetrating injury with transverse hemisection of the spinal cord (▶ Fig. 12.6)

      
      
    • 
      

      Paralysis and loss of proprioception occur on the side of injury (the spinal tracts responsible for motor function and proprioception do not cross the spinal cord as they travel to the brain)

      
      
    • 
      

      Pain and temperature sensation is lost on the contralateral side (the spinal tracts responsible for conveying pain and temperature cross to the opposite side of the spinal cord as they travel to the brain)

      
      
    • 
      

      Functional recovery varies but is often favorable

    
    
  • 
    

    SCI without radiographic abnormality

    
    
    
    
    • 
      

      Includes SCI following a traumatic event without signs of fracture, dislocation, or ligamentous injury on plain radiography, computed tomography (CT), or myelography

      
      
    • 
      

      Magnetic resonance imaging (MRI) will reveal soft tissue or spinal cord abnormalities not evident on standard radiography

      
      
    • 
      

      Common in elderly patients who have stenosis of the spinal canal.

      
      
      
      

      

      
      

      Fig. 12.4 Central cord syndrome.

      
      
      
      

      

      
      

      Fig. 12.5 Anterior cord syndrome.

      
      
      
      

      

      
      

      Fig. 12.6 Brown-Séquard syndrome.

      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      

      Table 12.2 Spinal cord injury: clinical syndromes

      Syndrome	Area of injury	Clinical symptoms	Prognosis
      Central cord	Center of spinal cord	Upper extremity weakness	Variable
      Anterior cord	Anterior spinal cord	Paralysis, loss of pain and temperature sensation below level of injury Vibration, light touch, and proprioception are preserved	Variable, but generally poor
      Brown-Séquard	Transverse hemisection of spinal cord	Ipsilateral paralysis and loss of proprioception below level of injury Contralateral loss of pain and temperature sensation	Variable, but generally favorable
      Cauda equina	Nerve roots below L1	Lower extremity weakness and/or sensory loss Loss of bowel/bladder/sexual function Saddle anesthesia Symptoms may vary depending on specific nerve roots involved	Can be excellent, early surgical intervention is critical
      Conus medullaris	Conus medullaris	Lower extremity weakness and/or sensory loss Loss of bladder/sexual function	Variable with treatment

12.3 Conditions Associated with Spinal Cord Injury

12.3.1 Cervical Strain (Whiplash Injury)

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  Hyperextension injury

  
  
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  Common in the United States, with about 1 million cases per year from high-velocity (whiplash type) injuries

  
  
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  Can occur after high- or low-velocity injuries

  
  
  
  
  • 
    

    High-velocity injuries cause the neck muscles and ligaments to stretch due to the traumatic mechanisms that cause rapid whipping of the head

    
    
  • 
    

    Low-velocity injuries are not as easy to attribute to one precise event and can vary from acute to chronic

  
  
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  Cervical strain can be caused by unnatural cervical postures (e.g., painting overhead or sitting in the front row at the theater)

  
  
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  Plain radiographs are nondiagnostic

  
  
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  Treatment may include a cervical soft collar, rest, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs)

12.3.2 Vertebral Fractures

Types of Fractures

Simple

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  Usually a single break in one vertebral body, spinous process, facet, or pedicle (▶ Fig. 12.7)

  
  
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  No resultant alteration in vertebral alignment

  
  
• 
  

  Usually no neurologic compromise.

  
  
  
  

  

  
  

  Fig. 12.7 Simple lumbar fracture.

Compression

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  Caused by axial loading (▶ Fig. 12.8)

  
  
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  May be further classified as a burst (▶ Fig. 12.9), wedge, or teardrop fracture (all discussed in greater detail later).

  
  
  
  

  

  
  

  Fig. 12.8 Compression fracture.

  
  
  
  

  

  
  

  Fig. 12.9 Burst fracture.

Dislocation

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  Occurs when one vertebra slides over another with disruption of one or both facets (▶ Fig. 12.10)

  
  
• 
  

  May occur with or without fracture

  
  
• 
  

  Subluxation

  
  
  
  
  • 
    

    Partial dislocation

    
    
  • 
    

    May cause SCI.

    
    
    
    

    

    
    

    Fig. 12.10 Fracture and dislocation of the cervical spine.

Cervical Fractures

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  A break in one or more cervical vertebrae

  
  
• 
  

  Cervical fractures account for most spinal injuries and may cause injury to the spinal cord, spinal nerve, or vertebral artery

Brief Review of Anatomy

• 
  

  Seven cervical vertebrae compose the cervical spine (C1 through C7)

  
  
• 
  

  Occipital condyles of the skull rest upon lateral masses of C1, forming the atlanto-occipital joint; this joint allows most of the flexion and extension of the neck (about 25 degrees)

  
  
• 
  

  Together, C1 (the atlas) and C2 (the axis) form the upper cervical spine

  
  
• 
  

  The atlantoaxial region (i.e., the joint between C1 and C2) is uniquely shaped, extremely mobile, and stabilized by surrounding ligamentous structures

  
  
• 
  

  The ring of C1 has no vertebral body; the odontoid process of C2 (also called the dens) projects up from the vertebral body to form the joint with C1 that provides most lateral head and neck rotation

  
  
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  The vertebral artery passes through C1 and is susceptible to injury in cases of neck trauma

  
  
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  C3 through C7 form the lower cervical spine

  
  
• 
  

  The primary motion of the lower cervical spine is flexion-extension, but the anatomy of the cervical spine allows motion in all planes

Pathophysiology

• 
  

  The cervical spine is composed of an anterior and a posterior column (▶ Fig. 12.11)

  
  
• 
  

  The anterior column is responsible for load bearing and includes the posterior longitudinal ligament and all structures anterior to it

  
  
• 
  

  The posterior column of the cervical spine includes the pedicles, laminae, facet joints, spinous processes, and posterior ligament complexes (ligamenta flava, interspinous ligaments, and supraspinous ligaments)

  
  
• 
  

  Tension is resisted by the posterior column, which fails under extreme flexion and may be associated with injury to the anterior column.

  
  
  
  

  

  
  

  Fig. 12.11 Cervical spine.

Etiology of Cervical Fractures

• 
  

  Usually caused by trauma to head and neck

  
  
• 
  

  Common causes include diving into a shallow pool, high-velocity trauma from motor vehicle accidents or falls, or a sudden severe twist of neck (Box 12.4 Risk Factors for Cervical Fractures)

Clinical Manifestations of Cervical Fractures

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  Limited ability to move the neck or head

  
  
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  Neck pain, stiffness, or spasm

  
  
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  Neck bruising and swelling

  
  
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  Loss of sensation in the arms or hands

  
  
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  Burning or aching pain that radiates to the shoulders or arms

  
  
• 
  

  Headache or pain in the back of the head

  
  
• 
  

  Weakness in extremities

Types of Cervical Fractures

• 
  

  Atlanto-occipital dislocation (cervical–cranial disruption)

  
  
  
  
  • 
    

    Accounts for about 1% of cervical spine injuries; occurs when a traumatic event causes severe flexion and distraction of the head and neck, resulting in instability (▶ Fig. 12.12)

    
    
  • 
    

    Dissociation may be complete (dislocation) or incomplete (subluxation)

    
    
  • 
    

    Often fatal because injury to the lower brainstem frequently causes respiratory arrest

    
    
  • 
    

    Nontraumatic atlanto-occipital subluxation may occur; this is usually related to Down’s syndrome and rheumatoid arthritis; see also Chapter 11: Spinal Disorders

    
    
  • 
    

    Treatment is a halo orthosis (e.g., halo ring and vest brace) (Fig. 12.19) or occipitocervical fusion

  
  
• 
  

  Atlantoaxial dislocation (atlantoaxial instability)

  
  
  
  
  • 
    

    Caused by bony or ligamentous abnormality, results in excessive movement at the junction between C1 and C2

    
    
  • 
    

    Treatment may include a halo orthosis or cervical fixation

  
  
• 
  

  C1 (atlas) fracture

  
  
  
  
  • 
    

    Jefferson’s fracture of C1 (C1 burst fracture)

    
    
    
    
    • 
      

      These fractures account for 10% of cervical spine injuries and result from axial loading on the head through the occiput, leading to a burst-type fracture of C1 (▶ Fig. 12.13)

      
      
    • 
      

      Most frequently caused by diving into shallow water, being thrown against the roof of a moving vehicle, and falling directly onto one’s head

      
      
    • 
      

      May include unilateral or bilateral fractures of the anterior or posterior arches of C1

      
      
    • 
      

      Elements of the posterior column can be displaced into the spinal cord

      
      
    • 
      

      Neurologic injury rarely occurs because the spinal cord is very wide at C1; however, vertebral artery injury is possible

      
      
    • 
      

      Treated with an external orthosis to immobilize the head and neck

      
      
    • 
      

      Unstable fracture that may require surgical stabilization

  
  
• 
  

  C2 (axis) fractures

  
  
  
  
  • 
    

    Odontoid fractures

    
    
    
    
    • 
      

      Result from extreme flexion, rotation, or extension of the head and neck

      
      
    • 
      

      The odontoid process is increasingly susceptible to fracture with age (▶ Fig. 12.14)

      
      
    • 
      

      Rarely associated with SCI

      
      
    • 
      

      Occipital pain and neck muscle spasms are common symptoms (▶ Table 12.3)

    
    
  • 
    

    Hangman’s fracture (▶ Fig. 12.15)

    
    
    
    
    • 
      

      This is so named as this injury can occur as the result of hanging

      
      
    • 
      

      In older adults, this type of injury can occur after falls, but it is also seen after motor vehicle accidents

      
      
    • 
      

      Caused by hyperextension of the neck and axial load onto the C2 vertebra (▶ Table 12.4)

      
      
    • 
      

      Involves fracture through the pedicles of C2, with or without subluxation on C3

      
      
    • 
      

      The spinal cord is crushed only in cases of severe subluxation of C3 from C2

  
  
• 
  

  Lower cervical spine fractures (subaxial fractures)

  
  
  
  
  • 
    

    Involve fractures from C3 to C7

    
    
  • 
    

    High-energy trauma (e.g., motor vehicle accidents, sporting activities, or violence) is the likely cause of lower cervical spine fractures in younger patients (i.e., 15–24 years)

    
    
  • 
    

    Low-energy trauma (e.g., ground-level falls) is most common in patients over age 55 years

    
    
  • 
    

    Age-associated cervical spondylosis narrows the spinal canal and may predispose an individual to cervical cord injury

    
    
  • 
    

    Teardrop fractures

    
    
    
    
    • 
      

      Named for the teardrop-shaped bone chips from the anterior edge of the vertebral body

      
      
    • 
      

      Result from compression and flexion of the neck (e.g., from diving accidents or falling directly onto the head)

      
      
    • 
      

      Unstable due to disruption of ligaments and disk

      
      
    • 
      

      Often results in quadriplegia from posterior displacement of bone fragments into the spinal canal

      
      
    • 
      

      Posterior fusion is the most common treatment

    
    
  • 
    

    Locked facets (also called perched or jumped facets)

    
    
    
    
    • 
      

      Caused by neck flexion and distraction

      
      
    • 
      

      Occur when the facet joint ruptures and the facet of the superior vertebra is displaced anteriorly over the lower vertebra (▶ Fig. 12.16)

      
      
    • 
      

      May be unilateral or bilateral and can result in herniation of adjacent-level disk

      
      
    • 
      

      Often results in SCI

      
      
    • 
      

      Unstable fractures are usually treated with closed reduction, followed by surgical stabilization.

      
      
      
      

      

      
      

      Fig. 12.12 Atlanto-occipital dislocation.

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