Spine Trauma & Spinal Cord Injury
Comprehensive emergency trauma management of spinal column and spinal cord injuries. Details NEXUS and Canadian C-Spine rules, incomplete spinal cord syndromes (central cord, anterior cord, Brown-Séquard), differentiating spinal vs. neurogenic shock, and MAP augmentation protocols (85-90 mmHg).
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Neurogenic shock is a distributive shock characterized by hypotension with relative bradycardia and warm extremities due to loss of sympathetic tone (T1-L2). Resuscitate with IV vasopressors (norepinephrine) targeting MAP 85-90 mmHg for 7 days to preserve spinal cord perfusion.
Two well-validated clinical decision instruments guide radiographic clearance of the cervical spine in alert trauma patients:
| Decision Rule | Criteria Required for Clinical Clearance (No Imaging) | Sensitivity & Practical Pearls |
|---|---|---|
| NEXUS Low-Risk Criteria (All 5 must be absent) | 1. No posterior midline cervical spine tenderness 2. No evidence of intoxication 3. Normal level of alertness (GCS 15) 4. No focal neurologic deficit 5. No painful distracting injuries | Sensitivity 99.6% for clinically significant C-spine injury. If any one criterion is positive, obtain non-contrast CT C-Spine. |
| Canadian C-Spine Rule (High-risk -> Low-risk -> Exam) | Step 1: Any high-risk factor? (Age >= 65, dangerous mechanism, paresthesias in extremities) -> CT C-spine. Step 2: Any low-risk factor allowing safe ROM assessment? (Simple rear-end MVC, sitting in ED, ambulatory at any time, delayed onset neck pain, absence of midline tenderness) -> If NO, CT C-spine. Step 3: Can patient actively rotate neck 45 degrees left and right? -> If NO, CT C-spine. If YES, clinically cleared. | Sensitivity 99-100%. Slightly higher specificity than NEXUS in prospective comparisons. |
| Syndrome | Mechanism & Injury Site | Clinical Presentation & Exam | Prognosis & Management |
|---|---|---|---|
| Central Cord Syndrome | Hyperextension injury in elderly patients with pre-existing cervical spondylosis; compression of central corticospinal tract | Motor weakness significantly worse in upper extremities than lower extremities ('man in a barrel'); variable sensory loss | Favorable recovery (~50-70% regain ambulation); collar immobilization, neurosurgery consult, delayed surgical decompression. |
| Anterior Cord Syndrome | Hyperflexion injury, burst fracture, or anterior spinal artery thrombosis/ischemia; ventral 2/3 of cord damaged | Complete bilateral loss of motor function and pain/temperature sensation below the lesion; PRESERVED dorsal columns (vibration and proprioception intact) | Poor functional recovery (< 10-20% functional ambulation); emergent MRI and surgical decompression if retropulsed bone. |
| Brown-Séquard Syndrome | Spinal cord hemisection (penetrating trauma: gunshot, stab wound; lateral cord compression) | Ipsilateral motor weakness (corticospinal) and proprioception/vibration loss (dorsal column); Contralateral pain and temperature sensation loss (spinothalamic, 1-2 levels below lesion) | Best prognosis of incomplete cord syndromes; > 75-90% regain independent ambulation and bowel/bladder control. |
| Cauda Equina Syndrome | Massive central disc herniation or trauma compressing lumbosacral nerve roots (L2-S5) | Saddle anesthesia (perineal numbness), bilateral lower extremity sciatica/weakness, bowel/bladder incontinence, decreased rectal sphincter tone, urinary retention (PVR > 200 mL) | Surgical emergency: Stat non-contrast or contrast MRI spine and urgent operative decompression within 24-48 hours. |
| Parameter | Neurogenic Shock | Spinal Shock |
|---|---|---|
| Core Pathophysiology | True hemodynamic shock: Loss of sympathetic vasomotor tone from injury at or above T6 | Temporary physiological loss of all spinal cord reflex and motor function below the level of injury |
| Hemodynamics | Hypotension + Bradycardia (or inappropriately normal HR) + Warm, vasodilation-flushed peripheries | Normal blood pressure and heart rate (unless concurrent neurogenic or hemorrhagic shock exists) |
| Reflexes & Sphincter | Normal or reduced reflexes; bulbocavernosus reflex may be present | Areflexia, flaccid paralysis, absent bulbocavernosus reflex |
| Duration & Resolution | Days to weeks; requires vasoactive support | 24-72 hours up to weeks; resolution signaled by return of bulbocavernosus reflex |
Spinal Cord Perfusion Goal: The injured spinal cord loses autoregulation. Maintain Mean Arterial Pressure (MAP) >= 85-90 mmHg for 7 days post-injury (AANS/CNS guidelines). Start IV Norepinephrine as first-line agent (provides alpha-1 vasoconstriction + beta-1 inotropic/chronotropic support). Add Phenylephrine or Epinephrine if refractory. Avoid excessive crystalloids which exacerbate cord edema.
- Stat MRI of the Spine: Indicated for any acute neurological deficit, suspected ligamentous injury, or unevaluable obtunded trauma patients with abnormal CT findings.
- Operative Indications: Progressive neurological decline, unstable spinal column disruption (Three-Column model by Denis), spinal canal stenosis with cord compression, or open penetrating spine wounds.
- ICU Admission: Mandatory for all acute spinal cord injuries, patients on vasopressors for MAP goals, or cervical spine injuries at C3-C5 (risk of respiratory failure due to phrenic nerve impairment).
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