Advanced Trauma Life Support ATLS Student Course Manual 2018

GENERAL MANAGEMENT 141
When the lower cervical spine is not adequately
visualized on the plain films or areas suspicious for
injury are identified, MDCT scans can be obtained.
MDCT scans may be used instead of plain images to
evaluate the cervical spine.
It is possible for patients to have an isolated
ligamentous spine injury that results in instability
without an associated fracture and/or subluxation.
Patients with neck pain and normal radiography should
be evaluated by magnetic resonance imaging (MRI)
or flexion-extension x-ray films. Flexion-extension
x-rays of the cervical spine can detect occult instability
or determine the stability of a known fracture. When
patient transfer is planned, spinal imaging can be
deferred to the receiving facility while maintaining
spinal motion restriction. Under no circumstances
should clinicians force the patient’s neck into a position
that elicits pain. All movements must be voluntary.
Obtain these films under the direct supervision and
control of a doctor experienced in their interpretation.
In some patients with significant soft-tissue injury,
paraspinal muscle spasm may severely limit the degree
of flexion and extension that the patient allows. MRI
may be the most sensitive tool for identifying softtissue
injury if performed within 72 hours of injury.
However, data regarding correlation of cervical spine
instability with positive MRI findings are lacking.
Approximately 10% of patients with a cervical spine
fracture have a second, noncontiguous vertebral
column fracture. This fact warrants a complete
radiographic screening of the entire spine in patients
with a cervical spine fracture.
In the presence of neurological deficits, MRI is
recommended to detect any soft-tissue compressive
lesion that cannot be detected with plain films
or MDCT, such as a spinal epidural hematoma or
traumatic herniated disk. MRI may also detect spinal
cord contusions or disruption, as well as paraspinal
ligamentous and soft-tissue injury. However, MRI is
frequently not feasible in patients with hemodynamic
instability. These specialized studies should be performed
at the discretion of a spine surgery consultant.
n BOX 7-1 presents guidelines for screening trauma
patients with suspected spine injury.
Thoracic and Lumbar Spine
The indications for screening radiography of the
thoracic and lumbar spine are essentially the same as
those for the cervical spine. Where available, MDCT
scanning of the thoracic and lumbar spine can be
used as the initial screening modality. Reformatted
views from the chest/abdomen/pelvis MDCT may be
used. If MDCT is unavailable, obtain AP and lateral
plain radiographs; however, note that MDCT has
superior sensitivity.
On the AP views, observe the vertical alignment
of the pedicles and distance between the pedicles of
each vertebra. Unstable fractures commonly cause
widening of the interpedicular distance. The lateral
films detect subluxations, compression fractures, and
Chance fractures.
CT scanning is particularly useful for detecting
fractures of the posterior elements (pedicles, lamina,
and spinous processes) and determining the degree of
canal compromise caused by burst fractures. Sagittal
and coronal reconstruction of axial CT images should
be performed.
As with the cervical spine, a complete series of highquality
radiographs must be properly interpreted
as without injury by a qualified doctor before spine
precautions are discontinued. However, due to the
possibility of pressure ulcers, do not wait for final
radiographic interpretation before removing the
patient from a long board.
Pitfall
An inadequate secondary
assessment results in
the failure to recognize
a spinal cord injury,
particularly an incomplete
spinal cord injury.
Patients with a diminished
level of consciousness
and those who arrive in
shock are often difficult
to assess for the presence
of spinal cord injury.
prevention
General mANAgement
General management of spine and spinal cord trauma
includes restricting spinal motion, intravenous fluids,
medications, and transfer, if appropriate. (See Appendix
G: Disability Skills.)
Spinal Motion Restriction
• Be sure to perform a
thorough neurological
assessment during the
secondary survey or
once life-threatening
injuries have been
managed.
• For these patients,
perform a careful
repeat assessment after
managing initial lifethreatening
injuries.
Prehospital care personnel typically restrict the
movement of the spine of patients before transporting
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