1. Evaluation of the Traumatic Spine
Naftaly Attias, MD
Orthopedic Department
St Josephs HMC - Phoenix, AZ

2. Emergency Room Thorough, documented initial neurological examination
In the first 24 hours, all care taker should do their own thorough documented evaluation
Get Info about neuro status in the accident scene

3. Inspection & Palpation
Remove all clothing
Note abrasions, contusions and limb asymmetry
Breathing ( paradoxical respiration, etc)
Spine deformity
Anteriorly: carotid pulses , tracheal deviation
Posteriorly: palpate the cervical, thoracic and lumbar spine ⇒ pain, tenderness, widening or malrotation

4. Log rolling
Necessary - should be done very carefully, as has been shown to create a potential for neuro compromise.

5. Physical Examination Sensory, Motor and Reflexes.
Attempt to determine neurologic injury location and type ( complete/ incomplete)

6. Root Level. Key Muscles C3. C4. Diaphragm C5
  Root Level Key Muscles   C3. C Diaphragm C5 Deltoid, elbow flexors, diaphragm C6 Elbow flexors, wrist extensors C7 Elbow extensors, wrist flexors C8 Finger flexors (distal phalanx of middle finger) T1 Finger abductors (5th digit), intrinsics of hand T1‑T12 Segmental innervation to intercostal muscles, abdominal and paraspinal muscles (T12) L1, L2, L3 Hip flexors L2, L3, L4 Quadriceps L4 Tibialis anterior L5 Toe extensors, hip abductors S1 Ankle plantarflexors, peronei   Reference: Kasser 3R: OKU 5, Rosemont, IL, American Academy of Orthopaedic Surgeoms, 1996, pp573‑588.

7. Motor exam 5. full strength adequate to powerfully resist the examiner
4. power to resist but not overcome the examiner
3. power to overcome gravity
2. power to move the joint but not to overcome gravity
1. capacity to contract the muscle without functional power
0. no motor function at all

8. Sensory exam Do not be limit to touch
Test temperature, pain, pressure differentials, vibration
This will give us some idea if this is more anterior vs. dorsal column injury.

9. Sensory exam
Utmost importance: the innervation of S2-S5 indicates the functional status of the distal-most aspect of the spinal cord = prognosis for a functional recovery
Babinski & Oppenheim reflexes are suggestive of an upper motor neuron problem

10. Reflexes
Spinal cord injury = cerebral inhibition is lost . At first - spinal shock with hyporeflexia. Later - hyperreflexia
Lower motor neuron injury = flaccid, hyporeflexia secondary to both an interruption of the nerve and the reflex arc.

11. Spinal shock About 24 hours
bulbocavernosus reflex indicates the end of spinal shock, and then complete vs incomplete spinal cord injury can be determined

12. Clearing the Spine The necessary elements :
History to assess for high-risk events and factors
Clinical examination to check for physical signs of spinal injury or neurologic deficit.
In alert asymptomatic patients, cervical spine radiography may be omitted.
Need radiography if midline neck tenderness, neck pain, evidence of intoxication, abnormal level of alertness, neuro deficit, or painful injuries elsewhere.

13. Radiology - Plain Film
AP/Lat + dense + swimer
Need to see C7-T1

14. Radiology - CT
More info
Difficult areas
2D, 3D

15. Radiology - MRI
Helpful in showing disruptions of ligaments and posterior tissues and thereby provides an indication of stability
Before reduction of facet dislocation in obtunded patient or if during reduction neuro deficit

16. Cervical Spine Be systematic Anteriorly - look at the soft tissues
Ant & post cortex (lines A & B) - look for translation or angulation
Canal and facets - spinolaminar line (line C)
Outline of the spinous processes (line D) – look for widening

17. Cervical Spine - Stability
White and Punjabi defined spinal stability in terms of step-off and angular deformity on a single static lateral view
Dynamic studies can be done for patients who are neurologically intact and are border-line unstable - as long as these studies are done under your direct supervision

18. Thoracic Spine
AP / Lat
Multiple rib Fx - warning sign for possible spinal injury
Look carefully for rotation or translation
The upper thoracic spine is especially difficult to visualize

19. Lumbar Spine Critical descriptors :
amount of vertebral body height loss
kyphosis
% canal compromise
translation
pedicle widening
interspinous process widening
help define stability and appropriate treatment

20. NO! Pitfalls Erroneous classifications Missed associated injuries
Clay shoveler's fracture???
Pitfalls
Erroneous classifications
Missed associated injuries
Inadequate exams and films
Ankylosed spine: (i.e. ankylosing spondylitis and DISH) pain = fracture until proved otherwise
Sacral fractures
NO!
Almost complete bilateral facet dislocation

21. Thank You

22. Helpfulness of Material
SWOTA : 2010 Resident Course - Fundamentals of Fracture Care
Evaluation of the Traumatic Spine
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23. Quality of Presentation
SWOTA : 2010 Resident Course - Fundamentals of Fracture Care
Evaluation of the Traumatic Spine
Quality of Presentation
A) B) C) D) E)
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