Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 7 n Spine and Spinal Cord Trauma
injuries and occurs most commonly following
cord ischemia.
Brown-Séquard syndrome results from hemisection of
the cord, usually due to a penetrating trauma. In its pure
form, the syndrome consists of ipsilateral motor loss
(corticospinal tract) and loss of position sense (dorsal
column), associated with contralateral loss of pain and
temperature sensation beginning one to two levels
below the level of injury (spino-thalamic tract). Even
when the syndrome is caused by a direct penetrating
injury to the cord, some recovery is usually achieved.
Morphology
Spinal injuries can be described as fractures, fracturedislocations,
spinal cord injury without radiographic
abnormalities (SCIWORA), and penetrating injuries.
Each of these categories can be further described as
stable or unstable. However, determining the stability
of a particular type of injury is not always simple and,
indeed, even experts may disagree. Particularly during
the initial treatment, all patients with radiographic
evidence of injury and all those with neurological
deficits should be considered to have an unstable
spinal injury. Spinal motion of these patients should
be restricted, and turning and/or repositioning requires
adequate personnel using logrolling technique until
consultation with a specialist, typically a neurosurgeon
or orthopedic surgeon.
Specific Types of Spinal
Injuries
Spinal injuries of particular concern to clinicians in
the trauma setting include cervical spine fractures,
thoracic spine fractures, thoracolumbar junction
fractures, lumbar fractures, penetrating injuries, and
the potential for associated blunt carotid and vertebral
vascular injuries.
Cervical Spine Fractures
Cervical spine injuries can result from one or a
combination of the following mechanisms of injury:
axial loading, flexion, extension, rotation, lateral
bending, and distraction.
Cervical spine injury in children is a relatively rare
event, occurring in less than 1% of cases. Of note, upper
cervical spine injuries in children (C1–C4) are almost
twice as common as lower cervical spine injuries.
Additionally, anatomical differences, emotional
distress, and inability to communicate make evaluation
of the spine even more challenging in this population.
(See Chapter 10: Pediatric Trauma.)
Specific types of cervical spine injuries of note to
clinicians in the trauma setting are atlanto-occipital
dislocation, atlas (C1) fracture, C1 rotary subluxation,
and axis (C2) fractures.
Atlanto-Occipital Dislocation
Craniocervical disruption injuries are uncommon
and result from severe traumatic flexion and
distraction. Most patients with this injury die of
brainstem destruction and apnea or have profound
neurological impairments (e.g., ventilator dependence
and quadriplegia/tetraplegia). Patients may survive
if they are promptly resuscitated at the injury scene.
Atlanto-occipital dislocation is a common cause of
death in cases of shaken baby syndrome.
Atlas (C1) Fracture
The atlas is a thin, bony ring with broad articular
surfaces. Fractures of the atlas represent approximately
5% of acute cervical spine fractures, and up to 40%
of atlas fractures are associated with fractures of the
axis (C2). The most common C1 fracture is a burst
fracture (Jefferson fracture). The typical mechanism
of injury is axial loading, which occurs when a large
load falls vertically on the head or a patient lands
on the top of his or her head in a relatively neutral
position. Jefferson fractures involve disruption of
the anterior and posterior rings of C1 with lateral
displacement of the lateral masses. The fracture
is best seen on an open-mouth view of the C1 to
C2 region and axial computed tomography (CT)
scans (n FIGURE 7-4).
These fractures usually are not associated with spinal
cord injuries; however, they are unstable and should
be initially treated with a properly sized rigid cervical
collar. Unilateral ring or lateral mass fractures are not
uncommon and tend to be stable injuries. However,
treat all such fractures as unstable until the patient is
examined by a specialist, typically a neurosurgeon or
orthopedic surgeon.
C1 Rotary Subluxation
The C1 rotary subluxation injury is most often seen in
children. It can occur spontaneously, after major or
minor trauma, with an upper respiratory infection, or
with rheumatoid arthritis. The patient presents with
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