20.1

Wounds and Injuries of the Spinal Column and Cord

Chapter 20

Wounds and Injuries of the Spinal

Column and Cord

Introduction

Combat injuries of the spinal column, with or without associated

spinal cord injury, differ from those encountered in civilian

practice. These injuries are often open, contaminated, and

usually associated with other organ injuries.

Following the ABCs of advanced trauma life support (ATLS),

management principles include:

 Initial spine stabilization to prevent neurologic deterioration.

 Diagnosis.

 Definitive spinal stabilization.

 Functional recovery.

In complete injuries, the likelihood of neurological

recovery is minimal and is not influenced by emergent

surgical intervention. However, incomplete injuries with

neurological deterioration may benefit from emergent

surgical decompression. Emergent, life-saving, soft

tissue exploration, and debridement may still be

required, particularly with colorectal involvement.

Classification

Four discriminators must be considered in the classification and

treatment of spinal injuries.

 Is injury open or closed?

 Neurologic status: complete vs incomplete vs intact.

ο Complete injury demonstrates no neurologic function

below the level of injury after the period of spinal shock
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Emergency War Surgery

(usually 24–48 h, evidenced by return of the bulbocavernosus reflex).

 Location of the injury: cervical, thoracic, lumbar, or sacral.

 Degree of bony and ligamentous disruption: stable vs

unstable.

Pathophysiology of the Injury to the Spinal Cord

 Injury to the spinal cord is the result of both primary and

secondary mechanisms.

ο Primary: the initial mechanical injury due to local

deformation and energy transmission.

♦ High-velocity missile wounds in the paravertebral area

can cause injuries even without direct trauma.

Stretching of the tissue around the missile’s path during

formation of the temporary cavity, or fragmentation of

the projectile and bone resulting in secondary missiles,

cause injury without any direct destruction of the spinal

column.

The destructive nature of high-velocity wounds explains

the futility of decompressive laminectomy in the

management of these wounds.

ο Secondary: the cascade of biochemical and cellular

processes initiated by the primary process that causes

cellular damage and even cell death.

The critical care of spinal cord injury patients includes

attempts to minimize secondary injury from hypoxia,

hypotension, hyperthermia, and edema.

Mechanical integrity of the vertebral column

The vertebral column is composed of three structural columns

(Table 20-1).
20.3

Wounds and Injuries of the Spinal Column and Cord

Table 20-1. Support of the Spinal Column.

Column Bony Elements Soft-Tissue Elements

Anterior Anterior two-thirds of vertebral Anterior longitudinal ligament

body Anterior annulus fibrosus

Middle Posterior one-third of vertebral Posterior longitudinal ligament

body Posterior annulus fibrosus

Pedicles

Posterior Lamina Ligamentum flavum

Spinous processes Interspinous ligaments

Facet joints

 Injuries occur by either direct penetrating forces or a

combination of flexion, axial loading, rotation, and distraction

forces.

 Loss of integrity of two of the three columns results in

instability of the spine.

 Instability is common following blunt injury of the

vertebral column, but is not usually the case with gunshot

or fragment wounds of the vertebral column.

 Cervical instability by lateral radiograph (must include C7/T-1 junction) is defined by:

ο 3.5 mm or greater sagittal displacement or translation.

ο Angulation of 11° or more on the lateral view.

ο Should questions exist regarding cervical stability, flexion

and extension lateral radiographs can be obtained in the

awake, cooperative patient.

 Thoracic and lumbar spine instability:

ο 5 mm of sagittal translation.

ο 20°–30° of sagittal angulation.

ο 50% loss of vertebral body height.

ο Widened pedicles on anterior-posterior (AP) radiographs.

Computed tomography (CT) is very effective in demonstrating

spinal instability and has become available in some field

environments.
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Emergency War Surgery

Instability must be presumed (and the spine stabilized) in

any patient with:

 Complaints of a sense of instability (holds his head

in his hands).

 Vertebral column pain.

 Tenderness in the midline over the spinous

processes.

 Neurologic deficit.

 Altered mental status.

 SUSPECTED, but NOT PROVEN injury.

Patient Transport

On the battlefield, preservation of the life of the casualty

and medic are of paramount importance. In these circumstances, EVACUATION TO A MORE SECURE AREA

TAKES PRECEDENCE OVER SPINE IMMOBILIZATION. Data do not support the use of cervical collars and

spine boards for PENETRATING spine injuries on the

battlefield.

Extrication

 Cervical spine.

ο The neck should never be hyperextended.

ο If an airway is needed.

♦ If appropriate, attempt endotracheal intubation with inline neck stabilization.

♦ Cricothyroidotomy is necessary if intubation fails.

ο The head should be maintained in alignment with the

body.

♦ Requires several people, including one just to stabilize

the neck.

♦ Log roll with the most experienced person stabilizing

the neck.

ο A stiff cervical collar and sandbags provide stabilization

of the neck during the transport. The head and body should

be secured to the extrication device.

 Thoracic and lumbar spine.
20.5

Wounds and Injuries of the Spinal Column and Cord

ο Use log roll or two-man carry as demonstrated in Fig. 20-1.

♦ The two-man carry alone does not protect the cervical

spine.

♦ The cradle-drop drag may also be used.

ο In the absence of a spine board, makeshift litters can be

fashioned from local materials.

Anatomical Considerations

Cervical Spine

All potentially unstable cervical spine injuries should be immobilized in a rigid collar, unless halo immobilization is required.

 Indications for halo use:

Fig. 20-1. (a) Log roll (b) two-man carry.

a

b
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Emergency War Surgery

ο The role of halo immobilization in the acute combat setting

is quite limited. In nonpenetrating trauma to the cervical

spine, immobilization with a cervical hard collar or sand bags

is preferable until arrival at a definitive treatment site.

ο Should traction be indicated for cervical spine injuries (eg,

facet joint dislocations or burst fractures with a tenuous

neurologic status), the Gardner-Wells tongs should be

applied and sufficient weight (generally 2–10 kg) placed

in line of the spine (Fig. 20-2, Table 20-2). It is paramount

to remember that injuries to occipitocervical articulation

should not be treated with traction-in effect, putting these

injuries in traction “pulls the head off”. If traction is

applied, radiographs must be obtained to be certain that

no undiagnosed ligamentous injury has been exacerbated

by the weight.

ο The role of collar immobilization in penetrating injuries

to the cervical spine is less well established. Soft-tissue care

is compromised by the collar’s position and, in general,

penetrating injuries coupled with osseous instability

should be managed in Gardner-Wells traction.

Fig. 20-2. Gardner-Wells tongs.
20.7

Wounds and Injuries of the Spinal Column and Cord

Table 20-2. Application of Gardner-Wells Tongs.

Step Procedure Comment

1 Inspect Insertion Site: Select a Rule out depressed skull fracture

point just above apex of each ear. in this area.

2 Shave and Prep Pin Insertion Site.

3 Inject Local Anesthetic: Inject 2–3 May omit if patient is unconscious.

cc of 1% Xylocaine or equivalent

agent 1 cm above each ear in line

with the external auditory meatus.

4 Advance Gardner-Wells Tong Pins: A spring-loaded device in one of

Insert pins into skull by symmet- the two pins will protrude when

rically tightening the knobs. the pins are appropriately seated.

(A data plate on the tongs provides

additional information.)

5 Apply Skeletal Traction: Use a Use 5 lb rule (ie, 5 lb of weight for

pulley fixed to the head of the each level of injury). High cervical

litter or frame to direct horizontal fractures usually require minimal

traction to the tongs. traction to reduce. Monitor with

series radiographs. The tong-pin

site requires anterior or posterior

positioning to adjust for cervical

spine flexing or extension as

indicated.

6 Elevate Head of Litter: Use blocks The knot in the cord should not be

in order to provide body-weight permitted to drift up against the

counter traction. pulley. Should this occur, traction

is no longer being applied.

7 Decrease Traction Weight: When Unreducible or unstable fractures

radiographs confirm that should be maintained in

reduction is adequate, decrease moderate traction until surgical

traction to 5–15 lb. intervention. If neurological

deterioration occurs, immediate

surgical intervention must be

considered.

8 Daily Pin Care. Cleanse tracts with saline and apply

antibiotic ointment to the pin sites.

Maintain pin force (see Step 4)

by tightening as necessary to keep

spring-loaded device in the

protruded position.
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Emergency War Surgery

9 Turn Patient Appropriately: Use When initially proned, obtain radioStryker, Foster, or similar frame graphs to ensure that the reduction

and turn patient every 4 h. is maintained. If reduction is not

maintained when the patient is

proned, rotate the patient only

between the 30° right and left

quarter positions. The use of a

circle electric bed is contraindicated

with injuries of the spinal cord

or column.

10 If Satisfactory Alignment Cannot Consider myelogram, CT scan,

Be Obtained, Further Workup Is tomograms, and neurosurgical

Necessary. /orthopedic consultations.

Thoracic and Lumbar Spine

 Although the thoracic rib cage contributes considerable

rotatory stability, it does not protect completely against

injuries.

 The vascular supply of the spinal cord is most vulnerable

between T-4 and T-6 where the canal is most narrow. Even

minor deformity may result in cord injury.

 The most common place for compression injuries is at the

thoracolumbar junction between T-10 and L-2.

 Most burst fractures result from an axial load, and occur at

the thoracolumbar junction. These fractures are associated

with compromise of the spinal canal and progressive angular

deformity. They are often associated with significant

neurologic injury.

 Evaluation for surgical stabilization and spinal cord

decompression should be done with advanced imaging such

as CT and/or magnetic resonance imaging (MRI).

When complex wounds involving the head, thorax,

abdomen, or extremities coexist with vertebral column

injuries, lifesaving measures take precedence over the

definitive diagnosis and management of spinal column

and cord problems. During these interventions, further

injury to the unstable spine must be prevented by

appropriate protective measures.
20.9

Wounds and Injuries of the Spinal Column and Cord

Emergent Surgery

Emergent spine surgery for penetrating or closed injuries

of the spinal cord is indicated only in the presence of

neurological deterioration.

 Penetrating Spine Injuries.

ο Injuries associated with a hollow-viscus should undergo

appropriate treatment of the viscus injury without

extensive debridement of the spinal injury, followed by

appropriate broad-spectrum antibiotics for 1–2 weeks.

Inadequate debridement and irrigation may lead to

meningitis.

ο Removal of a fragment from the spinal canal is indicated

for patients with neurologic deterioration.

ο In neurologically stable patients with fragments in the

cervical canal, delaying surgery for 7–10 days reduces

problems with dural leak and makes dural repair

considerably easier.

ο Casualties not requiring immediate surgery may be

observed with spine immobilization and treated with 3

days of IV antibiotics. Surgical stabilization can be

performed following evacuation.

Pharmacologic Treatment

 Penetrating injuries of the spine should NOT receive

corticosteroid treatment.

 Closed spinal cord injuries may be treated with an IV

corticosteroid if started within 8 hours of injury.

ο 30 mg/kg bolus of methylprednisolone initially.

ο 5.4 mg/kg/h of methylprednisolone for the next 24–48

hours.

♦ If therapy is started within 3 hours of injury, continue

treatment for 24 hours.

♦ If therapy is started within 3–8 hours after injury, then

treat for 48 hours.
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Emergency War Surgery

General Management Considerations

Neurogenic shock

 Traumatically induced sympathectomy with spinal cord

injury.

 Symptoms include bradycardia and hypotension.

 Treatment:

ο Volume resuscitation to maintain systolic BP > 90 mm Hg.

ο May use phenylephrine (50–300 μg/min) or dopamine (2–

10 μg/kg/min) to maintain BP.

Gastrointestinal tract

 Ileus is common and requires use of a nasogastric tube.

 Stress ulcer prevention using medical prophylaxis.

 Bowel training includes a schedule of suppositories and may

be initiated within one week of injury.

Deep vein thrombosis

 Start mechanical prophylaxis immediately.

 Initiate chemical prophylaxis after acute bleeding has stopped

(See Chapter 11, ICU Care).

Bladder Dysfunction

 Failure to decompress the bladder may lead to autonomic

dysreflexia and a hypertensive crisis.

 The bladder is emptied by intermittent or indwelling

catheterization.

 Antibiotic prophylaxis for the urinary tract is not advised.

Decubitus ulcers

 Skin breakdown begins within 30 minutes in the immobilized

hypotensive patient.

 For prolonged transport, the casualty should be removed

from the hard spine board and placed on a litter.

 Frequent turning and padding of prominences and diligence

on the part of caretakers are essential to protect the insensate

limbs.

 All bony prominences are inspected daily.

 Physical therapy is started early to maintain range of motion

in all joints to make seating and perineal care easier.