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Initial Assessment of Spinal Trauma
Karim Brohi, 7:4, April 2002


The diagnosis of an unstable spinal injury and its subsequent management can be difficult, and a missed spine injury can have devastating long-term consequences. Spinal column injury must therefore be presumed until it is excluded.

Initial Assessment of Spinal Trauma

     Spinal Stabilization
     Clinical Clearance
     Conscious Patients
     Unconscious Patients
     Thoracic & Lumbar Spine
     Paediatric Spinal Injury

Some studies of spinal trauma have recorded a missed injury rate as high as 33%. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology and incorrect interpretation of radiographs. An appropriate procedure for the evaluation of the potentially unstable spine must be robust and easy to implement, with a high sensitivity, given the potential importance of such injuries. It must also address the main issues raised by the modalities available for diagnosis.

For spinal trauma, the main concerns are which patients can be cleared by clinical exam alone, how many plain X-rays are necessary and when should additional imaging using Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) be used. An assessment for ligamentous injury in the absence of a fracture is also important, especially in unconscious patients who are unable to complain of neck pain or tenderness.

While it is tempting to focus on the cervical spine, it is important to assess and clear the entire spinal column. The thoracolumbar spine, while more protected, is at risk in major trauma and must be assessed both clinically and radiologically. Additionally, 5% of spinal injuries have a second, possibly non-adjacent, fracture elsewhere in the spine.

These pages discuss the initial assessment and management of the potentially spine injured patient. The actual protocol implemented at any given institution will depend on the expertise and facilities available. Where the required expertise or imaging are not available in a given institution, the protocol should encompass criteria for expeditious transfer of patients to specialist care.

Spinal Stabilization


Incidence of Cervical Spine Injury

Bohlman HH. Acute Fractures and Dislocations of the Cervical Spine J Bone Joint Surg 1979; 61A: p. 1119-1140

Roberge RJ, Samuels JR. Cervical spine injury in low-impact blunt trauma. Am J Emerg Med. 17:125-9, 1999

Ryan MD, Henderson JJ. The epidemiology of fractures and fracture-dislocations of the cervical spine. Injury 23(1): 38-40, 1992

Associated Injuries

Bayless P, Ray VG: Incidence of cervical spine injuries in association with blunt head trauma. Am J Emerg Med 7:139-42, 1989

Hills MW, Deane SA: Head injury and facial injury: Is there an increased risk of cervical spine injury? J Trauma 34:549-54, 1993

Iida H, Tachibana S, Kitahara T, Horiike S, et al. Association of head trauma with cervical spine injury, spinal cord injury, or both. J Trauma 46(3): 450-452, 1999

Neifeld GL, Keene JG, Hevesy G, et al: Cervical injury in head trauma. J Emerg Med 6:203-7, 1988

Reiss SJ, Raque GH Jr, Shields CB, et al: Cervical spine fractures with major associated trauma. Neurosurgery 18:327-30, 1986

Williams J, Jehle D, Cottington E, et al: Head, facial, and clavicular trauma as a predictor of cervical-spine injury. Ann Emerg Med 21:719-22, 1992

Multiple Level Injuries

Calenoff L, Chessare JW, Rogers LF, Toerge J, Rosen JS. Multiple Level Spinal Injuries: Importance of Early Recognition. Am J Roentgenology 1978; 130: p. 665-669

Gleizes V, Jacquot FP, Signoret F and Feron JM Combined injuries in the upper cervical spine: clinical and epidemiological data over a 14-year period Eur Spine J 9(5): 386-392, 2000

Kewalramani LS, Taylor RG. Multiple Non-contiguous Injuries to the Spine. Acta Orthop Scand 1976; 47: p. 52-58

Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level Non-contiguous Spinal Fractures. J of Trauma 1989; 29: p. 1146-1151

Penetrating trauma

Apfelbaum JD, Cantrill SV and Waldman N. Unstable cervical spine without spinal cord injury in penetrating neck trauma. Am J Emerg Med 18(1): 55-57.

Chong CL, Ware DN and Harris JH, Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? J Trauma 44(3): 501-502, 1998

Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilisation and evaluation. J Trauma 44:865-7, 1998

Kennedy FR, Gonzalez P, Beitler A, Sterling-Scott R, et al. Incidence of cervical spine injury in patients with gunshot wounds to the head. South Med J 87(6): 621-623, 1994

Missed Injuries

Davis JW, Phreaner DL, Hoyt DB, et al: The etiology of missed cervical spine injuries. J Trauma 34:342-6, 1993

Gerrelts BD, Petersen EU, Mabry J, et al: Delayed diagnosis of cervical spine injuries. J Trauma 31:1622-6, 1991

Mace SE: Unstable occult cervical-spine fracture. Ann Emerg Med 20:1373-5, 1991

Reid DC, Henderson R, Saboe L, et al: Etiology and clinical course of missed spine fractures. J Trauma 27:980-6, 1987

Sweeney JF, Rosemurgy AS, Gill S, et al: Is the cervical spine clear? Undetected cervical fractures diagnosed only at autopsy. Ann Emerg Med 21:1288-90, 1992


Ajani AE, Cooper DJ, Scheinkestel CD et al. Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Anaesth Intensive Care 26:487-91, 1998

Banit DM, Grau G and Fisher JR. Evaluation of the acute cervical spine: a management algorithm. J Trauma 49(3): 450-456, 2000

Brohi K, Wilson-Macdonald J. Evaluation of unstable cervical spine injury: a 6-year experience. J Trauma 49(1): 76-80, 2000

Cohn SM, Lyle WG, Linden CH, et al: Exclusion of cervical spine injury: A prospective study. J Trauma 31:570-4, 1991

Gabram SGA, Schwartz RJ, Jacobs LM: The impact of a cervical spine radiographic protocol on cost and prophylactic spinal immobilization. Ann Emerg Med 18:453, 1989


Spinal Stabilization (7:4) April 2002