1. Assessment of Spinal Injury
Policy #
Stephen Schutts, Master Sergeant, WA ANG
National Registry Emergency Medical Technician - Paramedic 1

2. Objectives Identify the anatomical levels of the spine.
Understand the function of the spinal cord/column.
View Types and Mechanisms of injury that can cause spine injury.
Discuss the difference between Spinal Column Injury vs Spinal Cord Injury. 2

3. Objectives Overview of Spinal Regions and Injuries
Step by step view of the EMS Spinal Immobilization Assessment Protocol
Discuss Common Treatment/Management Mistakes 3

4. Introduction Spinal injuries are devastating
Improper management can have horrible and permanent results
Appropriate use of spinal immobilization can mean the difference between a patient who fully recovers and one who must spent the rest of his/her life paralyzed 4

5. Mechanism based assessment (the current method)
Low-speed fender bender
An elderly man trips over a lamp cord and falls
When in doubt back board ‘em 5
Are all 8 patients assumed to have spinal injuries?
Does this man have a spinal injury? Do all such falls cause spinal injuries?
Not necessarily, apply EMS Spinal Immobilization.
How am I supposed to convince a guy in a low-speed fender bender, who is late for work and mad as hell already, that doesn’t seem injured at all that he needs to let me tie him up on a board an let me take him to the hospital for a bunch of x-rays?
Current spinal immobilization decisions are based strictly on evaluation of the MOI.
Shot gun approach- when in doubt back board all pt.s w/ suspicious MOI.
No guidelines provided indicate when spinal immobilization is not necessary.

6. Anatomy & Physiology- General Structure & Function
Spinal Column
Made up of 26 vertebrae stacked on top of one another
Divided into 5 areas; cervical, thoracic, lumbar, sacral, and coccyx 6
Cervical- 7 vertebrae
Thoracic 12
Lumbar 5
Sacrum 5 fused
Coccyx fused
Nerves & blood vessels run along the spine
Ligaments and tendons tether spine from the base of the skull to the pelvis

7. Vertebrae
vertebral body- bears weight, size increases progressively from cervical to lumbar
spinous process- ligament and tendon attachment points, only palpable part of spine
transverse processes- ligament and tendon attachment points
facets
vertebral foramen
opening formed in vertebrae to surround the spinal cord
together these openings form the hollow spinal canal which houses the spinal cord
Intervertebral disc
cartilage-like
shock absorber
opens space between vertebrae for nerve roots to pass through

8. Anatomy & Physiology-“Long Bone”
Think of the Spinal Column as on “Long Bone” with “Joints” at each end
The Cervical spine makes up one “joint”
The Hip makes up the other 8

9. Anatomy & Physiology- Cervical Spine (7)
“Joint” at the superior end of the spinal “Long Bone”
Very flexible
Allows flexion, extension, and rotation of the head
The head acts as a weighted lever during acceleration/ deceleration
Common site of spinal injuries 9
C-spine is particularly vulnerable to injury.

11. C-1 supports the full weight of the head
C-1 “Atlas”
C-2 “Axis”
C-1 supports the full weight of the head
C-1 and C-2 allow head rotation and fine flexion and extension 11

12. Anatomy & Physiology- Thoracic Spine (12)
Much less flexible than C-Spine
Stabilized by rib cage (especially down to T-10)
Spinal canal narrow through T-Spine
Spinal cord tightly fitted into narrow space
Spinal cord ends about T-12 or L-1 12

14. Anatomy & Physiology- Lumbosacral Spine
5 Lumbar vertebrae plus sacrum and coccyx
More flexible than T-spine
More room in spinal canal
Spinal cord ends about T-12 or L-1
flexible nerve roots (Cauda equina) flow through LS spine 14

16. Anatomy & Physiology- Spinal Cord
Bundles of nerve fibers originating in the brain
Bundles or tracts travel in right and left pairs
Spinal Tract pairs crossover midline at various specific levels
always in specific anatomical areas
understanding of the structure of these tracts helps in assessing spinal cord injuries 16
Spinal Cord
Long nerve fibers originating in the brain
Fibers run together in bundles (called tracts) like telephone cables
Tracts travel in right and left pairs
Each pair crosses over from right to left at specific places depending on what tract they are in
Assessment of the spinal cord easier if one understands how this works

17. Nerve roots flowing out from the spinal cord

18. Mechanism of Injury
Physical manner and forces involved in producing injuries or potential injuries
Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury
Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents) 18
Physical manner and forces involved in producing injuries or potential injuries
Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury
Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)

19. Hyperflexion
Hyperflexion- Excessive/abnormal bending forward of the chin toward the chest. This is one mechanism seen when patients are ejected from moving vehicles

20. Hyperextension
Hyperextension- Excessive/abnormal bending back of the head beyond its normal range of motion

21. Hyperotation
Hyperotation- Excessive/abnormal rotation. This may produce injuries in any area of the spine.

22. Axial Loading
Axial Loading- Sudden/excessive compression of the spine. Examples include falling and landing on your feet or ejection from a vehicle and landing on your head

23. Axial Distraction
This is a hang man’s fracture suffered by a woman that was ejected from her car in a roll-over MVA. She apparently got hung up on the shoulder belt and got hung.
Axial Distraction- Sudden/excessive elongation of the spine caused by stretching or tearing anywhere along the spinal column. Example: hanging.

24. Sudden/Extreme Lateral Bending
Excessive/abnormal lateral movement of the spine
Can affect any portion of the spine
Example: T-bone MVAs 24
Sudden/Extreme Lateral Bending- Excessive/abnormal lateral movement. This also may affect any level of the spine. Example: T-bone MVA.

25. Spinal Column Injury
Bony spinal injuries may or may not be associated with spinal cord injury
These bony injuries include:
Compression fractures of the vertebrae
Comminuted fractures of the vertebrae
Subluxation (partial dislocation) of the vertebrae
Other injuries may include:
Sprains- over-stretching or tearing of ligaments
Strains- over-stretching or tearing of the muscles 25

26. Spinal Cord Injury
Cutting, compression, or stretching of the spinal cord
Causing loss of distal function, sensation, or motion
Caused by:
Unstable or sharp bony fragments pushing on the cord, or
Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia 26

27. Primary Spinal Cord Injury
Immediate and irreversible loss of sensation and motion
Cutting, compression, or stretching of the spinal cord
Occurs at the time of impact/injury 27

28. Secondary Spinal Cord Injury
Injury Delayed
Occurs later due to swelling, ischemia, or movement of sharp or unstable bone fragments
May be avoided if spine immobilized during extrication, packaging, treatment, and transport 28
Damaged vertebrae may cause spinal column to become unstable
May not produce immediate spinal cord injury or damage
Poor immobilization technique, rough handling, unnecessary movement may cause injury some time after the initial insult
Avoiding secondary spinal cord injury has long been a major part of prehospital trauma care.
This is why we use full spinal immobilization in the first place!

29. Incomplete Spinal Cord Injury
Complete injury to specific spinal tracts with reduced function distally
Other tracts continue to function normally with distal function intact 29

30. Spinal Region Overview
Cervical Spine Injuries
Thoracic Spine Injuries
Lumbosacral Spine Injuries
Spinal Injury Summary 30
Cervical Spine Injuries
Most frequently injured area of spine
Head = weighted lever supported by C-1/C-2
Most injuries at C-5 & C-6
Any movement from anatomical position
Can be harmful
May result in secondary injury
C-spine may be unstable
Thoracic Spine Injuries
Less flexible ribs anchor vertebrae/Spinal canal narrow
Cord injury may occur with minimal spinal column movement
Thoracic cord injuries usually complete most occur at T-9 & T-10
Danger of secondary injury very real in T-spine
Lumbosacral Spine Injuries
More flexible / More room in spinal canal
Bony injury may not involve spinal cord or nerve root damage
Injuries may be unstable / Secondary injury can occur
Spinal Injury Summary
Injuries often occur at more than one level
Best to assume injury to entire spine

31. Cervical Spine Injuries
C-spine very flexible
Most frequently injured area of spine
Most injuries at C-5/C-6 level 31
Cervical Spine Injuries
Very flexible
Most frequently injured area of spine
Most injuries at C-5/C-6 level
Loss of elbow extension/triceps function
Sparing elbow flexion/biceps function
Sparing shoulder shrug/trapezius function
Mechanisms vary including: flexion, extension, lateral bending, rotation, axial loading, and axial distraction
Most injuries unstable
Serious secondary injury possible with improper extrication/packaging
Most dangerous movement = forward flexion

32. Thoracic Spine Injuries
T-spine less flexible
Narrow spinal canal
Cord injury occurs with minimal displacement
Common mechanisms
Any cord damage usually complete at this level
Most T-spine injuries occur at T-9/T-10 32
Thoracic Spine Injuries
T-spine less flexible
Narrow spinal canal
Cord injury occurs with minimal displacement
Common mechanisms include:
severe flexion w/ wedge compression of vertebra
axial loading w/ vertebral fragmentation
either way bony fragments directly damage cord
Any cord damage usually complete at this level
Most T-spine injuries occur at T-9/T-10
junction of fixed (rib support) and flexible components of T-spine
Consider unstable

33. Lumbosacral Spine Injuries
LS spine flexible nerve roots in roomy spinal canal
May have bony injury w/o cord or nerve root damage
Secondary injury still possible
Neurological injury rare w/ isolated sacral injuries 33

34. Assessment Overview
Decision to apply spinal immobilization in past based was solely on mechanism of injury
Utilize EMS Spinal Immobilization Algorithm to determine when spinal immobilization is NOT needed 34
Refer to NCEMS Policy #
Display Assessment Algorithm on Overhead

35. Spinal Immobilization Algorithm
Patient Mentation:
Decreased Level of Consciousness?
No Yes Immobilize
ETOH/Drug Impairment?
No Yes Immobilize
Subjective Assessment:
Cervical/Thoracic/Lumbar Spinal pain?
No Yes Immobilize
Numbness/Tingling/Burning/Weakness?
No Yes Immobilize
Objective Assessment:
Cervical/Thoracic/Lumbar Deformity or Tenderness?
Other Severe Injury?
No Yes Immobilize
Pain w/Cervical Range of Motion?
MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS 35

36. Principles of Treatment
Protect spinal cord from secondary injury
We have little or no effect on primary injury
Focus on prevention of secondary injury 36

37. Complete Spinal Immobilization
Must act as if whole spine unstable
Immobilize entire spine
To do this we must immobilize the head, neck, shoulders/chest, and pelvis /hips 37

38. Common Treatment/Management Mistakes
Improperly sized C-Collar
Spine not supported due to improper positioning on backboard
Inadequate strapping allows excessive movement
Movement possible due to little or no padding to shim the body
C-spine movement by inadequate or improperly applied head immobilization device
C-spine hyperextension due to improperly applied C-collar or head immobilization device 38

39. Common Treatment/Management Mistakes (cont.)
Readjusting torso straps after immobilization of the head, causing misalignment of the spine
Securing head to backboard prior to securing shoulders, torso, hips, and legs 39

40. Any Questions???