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58 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
tomography (CT) is required in most cases. Magnetic resonance imaging
(MRI) of injured spinal regions should be considered after formal Spine
Surgery consultation.
• Complete and thorough neurological examination is mandatory.
• Classification of spinal injuries helps guide treatment. Early and accurate
diagnosis of spinal injuries is essential.
• Spinal surgeons work to accomplish three goals within 24-hours of injury:
(1) Obtain proper spinal Alignment.
(2) Provide spinal Stability.
(3) Decompress neurological structures when indicated.
• Early mobilization of critically injured patients is absolutely essential. This
requires either spinal clearance or spinal stabilization — surgical and/or
nonsurgical means may be employed.
• If possible, “Spinal Clearance” should be provided early in critical care
management to enable removal of unnecessary braces and immobilizers,
thereby minimizing complications.
• Spinal cord injured patients benefit from standardized institutional practice
protocols to facilitate quality care. An example is DHMC’s Spinal Cord Injury
Clinical Practice Guideline.
• The uncritical use of steroids is considered obsolete in the management of
acute, traumatic spinal cord injury except in selected circumstances.
• A multidisciplinary approach is needed to ensure proper care of critically
injured patients with concomitant spinal injury. Timely transparent communication is paramount for the successful multidisciplinary management
of this highly vulnerable patient cohort.
Background
• Spinal injury amongst multiply injured patients is very common. Spinal cord
injury is a devastating occurrence that has far-reaching implications on the
patient, family and loved ones, care providers, and the medical community.
Cost is high. Preservation of function is the task bestowed upon all of the care
providers tending to these severely injured patients.
• Critically injured patients with concomitant spinal injury can suffer from
hemodynamic collapse and respiratory compromise that lead to hypotension
and hypoxemia which can further exacerbate the spinal injury. Most
specifically, this pertains to spinal injuries with associated spinal cord insult.
As such, early recognition and treatment is mandatory.
Spine Trauma: Diagnosis, Clearance, and Mobility 59
• Critically ill patients with spinal injuries that experience hemodynamic
instability and end-organ hypo-perfusion need to be closely assessed for
neurogenic shock. Intensive care specialists need to recognize and appropriately treat this entity and also understand the difference between this
problem and its often confused counterpart — spinal shock. Spinal Shock
is a transient syndrome of sensorimotor dysfunction. It is characterized by
flaccid areflexic paralysis and anesthesia below the level of a spinal cord
injury. The syndrome typically lasts between 24–72 hours and has ended
when reflex activity returns below the injury. Neurogenic Shock results
from impaired sympathetic outflow tracts as a result of spinal cord injury
and is accompanied by hypotension and bradycardia. It is diagnosed only
after ruling out hemodynamic shock in poly-trauma patients and is typically
associated with more cephalad levels of spinal injury.
• “ Spine Clearance” continues to be a topic of debate. Multiple concepts for
spinal clearance exist. Multiple algorithms attempt to “clear” the spine in
critically injured patients. The ultimate goal of spinal clearance should be to
confirm the absence of an injury to the spine. Once this is accomplished, the
diagnostic phase of spinal assessment is complete and providers can allow
immediate mobilization of patients and removal of unnecessary braces.
• Early mobilization of critically ill patients is paramount. The spine should
either be “cleared” or the spine surgeon should stabilize unstable injuries to
allow early patient mobility — both surgical and/or nonsurgical methods can
be employed. This will allow prevention of dreaded complications associated
with recumbency: pneumonia, urinary tract infections, thromboembolic
events, and pressure sores to name a few.
• Spinal surgery treatment concepts involve upholding the “ Holy Trinity of
Spine.”
(1) Provide and maintain Alignment of spinal segments.
(2) Provide immediate, rock-solid Stability to the unstable spine.
(3) Decompress neurological structures (brain stem, spinal cord, spinal
nerve-rootlets, cauda equina, conus medullaris, nerve-roots) if indicated
and clinically relevant.
• Defining “ Spinal Stability” is a difficult task. The working definition of
stability should consider that under physiological loads (the influence of
gravity on body mass), the spine does not experience increasing deformity,
onset of neurological insult, or drastic increase in patient’s pain. If spinal
stability can be confirmed without the need for surgical intervention, then immediate mobilization of patients with or without bracing may be appropriate.
60 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
If the spine is deemed unstable, then early surgical treatment is necessary to
enable safe mobilization.
• “ Spine-Damage-Control” is a concept focused on providing immediate
spinal stability within 24-hours of injury (posterior surgical approach)
followed by delayed secondary surgery to complete 360° of spinal stabilization (anterior surgical approach). Much like external fixation of long-bone
fractures, “spine-damage-control” enables early mobilization while facilitating patient recovery and delaying more invasive spinal procedures that may
be needed for completion of spinal injury reconstruction.
• Once spinal injuries are stabilized, whether through surgical or nonsurgical
means, patients often require ongoing “ Spinal Precautions.” These can create confusion amongst care providers and therefore must be clarified to
ensure proper and safe mobilization of critically ill patients. If spinal precautions are significantly prohibitive, then the spine surgeon must consider
surgical fixation and stabilization to enable removal of restrictions and thus
facilitate the proper care by intensivists, therapists, and nurses.
• A multidisciplinary approach to critically injured patients that also suffer
from spinal injury is mandatory. Explicit communication is required between
care providers to ensure all body systems are appropriately managed with
specific attention paid to the impact that serious spinal injury can have on
each of these areas.
Main Body
• “Spinal Clearance”
{ A thorough spinal evaluation has occurred to ensure that no spinal injury
exists that requires treatment. Spinal injury is confirmed absent. Evaluation
includes thorough history, physical examination, and radiographic analysis
of advanced imaging studies. Immobilizers are thus immediately removed
and patients are mobilized with nursing staff and therapists.
{ Patients should be divided into distinct groups for coherent spinal
clearance algorithms:
Asymptomatic
Symptomatic
Temporarily Non-Assessable
Obtunded
{ Asymptomatic Patients without distracting injuries that are examinable
and not intoxicated are usually clinically assessable and potentially cleared.
Spine Trauma: Diagnosis, Clearance, and Mobility 61
Assessment involves range-of-motion analysis, full neurological exam, and
potentially radiographic interpretation. If any symptoms present during
evaluation, patients are immediately placed into the symptomatic group.
{ Symptomatic Patients require further radiographic analysis to determine
diagnosis. Swift delivery of treatment options must then follow. Spine
Surgery consultation is typically appropriate in this patient cohort.
{ Temporarily Non-Assessable Patients require temporary rigid cervical
immobilization until clearance of intoxicating substances, return of
normal mentation, and/or stabilization of distracting injuries before they
can be reliably assessed and potentially cleared. This entails a 24–48 hour
“holding-period” and also serves to distinguish this distinct patient group
from “obtunded patients.”
{ Obtunded Patients require imaging to rule out spinal injuries. Critically
ill, multiply injured, poly-trauma patients typically fit into this category.
{ Prolonged obtundation can present a dilemma regarding “spinal clear-
ance.” If an injury is identified, then a definitive treatment plan is
determined and executed. If no injury is identified on CT scan, then the
care providers must decide whether to remove the rigid cervical collar.
Some providers believe an MRI scan is mandatory in this situation. Other
providers feel that monitored flexion and extension radiographs
(or fluoroscopic analysis) are warranted. However, the incidence of occult
unstable spinal injuries occurring in the presence of a normal CT scan is
extremely low. Therefore, DHMC chooses to remove the cervical collar in
obtunded patients without neurological deficits that have no identified
spinal injury on CT scan.
{ Once allocated to a group, a patient’s “spinal clearance” analysis should
entail a logical, step-wise, algorithmic approach.
Asymptomatic Patients are placed into the Clinical Pathway (Fig. 1).
Symptomatic Patients are placed into the Imaging Pathway (Fig. 2).
Obtunded Patients and Temporarily Non-Assessable Patients are
placed into the Obtunded Pathway (Fig. 3).
{ Completing the spinal clearance pathways should always result in
accurate spinal diagnoses, appropriate treatment delivery, and insurance
of preserving the “ Holy Trinity of Spine” with the end-goal of early
mobilization and facilitation of streamlined critical care.
• “ Spinal Precautions”
{ “Spinal Precautions” are the restrictions placed on patient mobility to
ensure safe movement and care of spine-injured patients. Precautions are
62 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
upheld by all members of the care team and should therefore be simple,
explicit, and easily followed.
{ Critically injured patients are initially treated as if serious spinal injuries
have occurred. “ Log-Roll Precautions” are followed until accurate diagnoses are made, treatments delivered, or the spine is “cleared.” Log-Roll
Precautions include supine positioning of the patient, maintaining a rigid
cervical immobilizer, and moving patients with a team of care providers.
Back boards should also be removed as early as possible upon arrival to
the treating institution.
{ “Routine Spinal Precautions” are common-sense precautions that
patients should follow once definitive treatment has been applied to the
spinal injury. This holds true whether surgical or nonsurgical solutions
have been provided. Care providers should remember “B.L.T.” Commonsense limitations call for precautions in “bending,” “lifting,” and “twisting.”
Although very specific restrictions cannot be applied, the general rule is
that patients should avoid painful positions and activities. Patients should
not “bend too much,” “lift too much,” or “twist too much” so as to enact
extremes of range-of-motion that may result in pain. If spinal precautions
are instituted that result in restrictions above and beyond these routine
limitations, then the spinal stability is in question. Therefore, spinal surgeons should rethink treatment options and act to provide adequate
stability so that only routine spinal precautions are necessary for mobilizing these critically ill patients.
{ “Spinal Precautions” that also need to be communicated to care
providers are:
Head-of-Bed Restrictions: Care providers must know the safe limits
of sitting patients up in bed. Head-of-bed restrictions are reasonable
upon patient’s arrival to the institution, but spine treatments must
always result in elimination of these restrictions so as to insure proper
and early mobilization.
Don/Doff Criteria: Care providers must know the safe location of
brace application and brace removal. Ideally, “edge-of-bed” is the
preferred location for placing and removing orthoses. This is an
easy position in which to manipulate a patient’s brace. Alternatively,
“brace only when ambulating” restrictions can allow the delivery of
the most effective intensive and nursing care. Some situations, however, require application of braces in the supine position. If braces are
to be applied in bed, in the supine position, then the spine’s stability
is in question and the spine surgeon should consider internal fixation
Spine Trauma: Diagnosis, Clearance, and Mobility 63
and stabilization to eliminate reliance on brace treatment. One should
consider, however, that significant force is applied to the spine when
patient’s move from supine to seated to standing positions and vice
versa. As such, patient comfort and improved stability can be achieved
when applying braces in bed in the supine position. This requires more
focused effort on the part of the nurses and therapist caring for the
patient.
Nursing and Activity Orders: Care providers must know the appro-
priate precautions to take with regard to patient care, activities, and
mobilization. Nurses and intensive care specialists need to know the
types of braces that are required, how to appropriately administer
them, when and where to place them, whether they are needed for
showers or cleaning activities, and the duration of treatment. The
prosthetics and orthotics specialist can be a valuable member of the
care team in communicating these instructions.
Halo-Fixators and Gardner-Wells Tongs: If due to a patient’s com-
promised physiological status early surgical fixation cannot be
employed, then alternative methods can be used. These methods
include application of Gardner-Wells tongs traction, halo-ring traction, or halo-fixator application to reduce subluxations/dislocations in
a closed manner. Halo-vest fixator application can also temporarily
reduce and stabilize unstable occipitocervical and cervical injuries
until internal fixation strategies can be utilized. Occasionally, halofixators are used as definitive treatment devices. This can present
challenges to nursing and intensive care specialists. Halo-fixators
should be applied early in the course of treatment so as to enable
early patient mobilization. Vest and pin-site care should also be
administered routinely.
{ Spinal Surgical Intervention
The “ Holy Trinity of Spine” must be upheld:
Ö Alignment.
Ö Stability.
Ö Decompression.
“ Spinal Stability” must be provided:
Ö Definition: Under normal loading patterns, the spine must be pro-
tected against increasing deformity, onset of neurological insult,
and significant increase in pain.
64 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
If spinal alignment, spinal stability, or spinal neurological status is in
question, then Critical Care Specialists are encouraged to call a formal
Spine Surgery consultation.
If and when “spinal clearance” cannot be provided and/or when even
the strictest precautions cannot ensure spinal stability, then spinal
surgical intervention is required.
“ Spine-Damage-Control” is a strategy often employed to provide
rigid stabilization of spinal injuries within the first 24-hours. The
associated fixation enables immediate mobilization and nursing care
for patients. Once patients have been further resuscitated and compromised physiology corrected, then patients can better tolerate
anterior spinal procedures for completion of total 360° spinal reconstruction. The spine surgery team at DHMC strives to fixate spinal
injuries within the first 24-hours of arrival so that further intensive
care is more easily delivered.
Although spine surgical techniques are many and variable, the goals
of providing and maintaining proper spinal alignment, ensuring
immediate and rock-solid stabilization, and decompressing impinged
neurological structures remain constant. Spine surgeons may employ
anterior approaches, posterior approaches, lateral approaches, or a
combination of approaches to ensure that the principles of spinal surgery and stabilization are upheld. This can frequently necessitate the
expertise of general surgeons to assist with spinal exposure. As such,
proper communication and teamwork are indicated to deliver proper
treatment modalities.
Accurate diagnosis and injury classification can assist spinal surgeons
in clinical decision making processes as it relates to choosing operative versus non-operative management as well as choosing treatment
approach and fixation methods when it comes to surgical intervention.
Several classification schemes exists, but all rely upon determination
of the injury mechanism and morphology, the neurological status of
the patient, and the integrity of the intervertebral disk and supporting
posterior ligamentous complex. Regardless of the classification
system chosen, the “ Holy Trinity of Spine” is honored.
Spine Trauma: Diagnosis, Clearance, and Mobility 65
Practical Algorithm
Fig. 1. Spinal Clearance: Clinical Pathway. With an “Asymptomatic Patient” that is
awake, alert and oriented, non-painful, non-tender, and neurologically intact, the physician
can usually rely on clinical findings. If any questions remain, the patient should be placed
into the Imaging Pathway.
66 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
Fig. 2. Spinal Clearance: Imaging Pathway. With a “Symptomatic Patient” that has spinal
pain and/or tenderness on examination, a visible deformity, an abnormal neurological
finding, or a combination of these problems, the physician requires imaging data in
addition to clinical information to support decision-making.
Spine Trauma: Diagnosis, Clearance, and Mobility 67
Fig. 3. Spinal Clearance: Obtunded Pathway. With a “Temporarily non-Assessable
Patient” or “Obtunded Patient,” the physician typically relies upon the imaging data to
inform clinical decision-making. The distinction between these two groups is typically
present after a 24–48 hour holding period where the “Temporarily non-Assessable Patient”
has declared themselves assessable and can now be categorized as either a “Symptomatic
Patient” or an “Asymptomatic Patient.”