Basildon EM Handbook 2018

Regional: spine

March 2018 | by EMauthor

Cervical Spine injuries: suspicion

•All multiple trauma patients

•Patients with minor trauma and significant neck pain and/or neurological signs and symptoms

•Altered level of consciousness after injury

•Minor trauma in the elderly and in people with severe arthritis of the spine

If C-spine injury is suspected, triple immobilisation should be maintained until that injury is excluded.  Perform a baseline thorough neurological examination to exclude spinal cord injury.  Any patient with neurological deficit should be referred urgently to orthopaedics.  If a neurological deficit is identified it is important to document the sensory and motor level of the deficit.  Examine for peri-anal sensation and perform PR to assess anal tone.

•Log roll patients and examine the whole of the spine

•C-spine x-rays should be done in all patients who do not fulfull NEXUS or CANADIAN criteria

•Good quality radiographs are essential to identify C-spine injury

•The gold standard are AP, lateral and odontoid views,

•You should visualise the upper border of T1 on the lateral radiograph

Thoraco-lumbar injuries

•Fall from height

•Road traffic accidents

•Minor injuries can cause fractures in the elderly and in people with osteoporosis

•People with malignancy and possible bony metastasis

Neurological assessment follow the same lines as in C.spine injuries.  AP and lateral radiographs are the initial imaging required to detect most bony injuries, further imaging might be required depending on radiological and or clinical finding.  The important thing to decide is whether the fracture is stable or unstable

•The most common fracture is flexion/compression wedge fracture, this can be stable or unstable

•Other types of injuries are more likely to be unstable

All identified thoraco-lumbar fractures should be discussed with senior EM doctors or referred to orthopaedics

Sacral injuries  

They result most commonly from falls which will lead to transverse fractures, but can also result from compression.  Fractures can lead to injuries to the spinal nerve roots leading to cauda equina lesions with sensory and motor deficits, saddle anaesthesia and incontinence

•There will be local tenderness over sacral area

•AP and lateral x-rays should be ordered and examined carefully for these fractures

•Refer all sacral fractures to orthopaedics

Coccygeal injuries   

•These injuries occur with fall in the seated position

•The diagnosis is a clinical one with localised tenderness over the coccyx, x-rays are not indicated

•Treatment is symptomatic, warn the patient that it may take some time for the symptoms to settle

•The pain from these injuries may become chronic so a GP follow up should be arranged as these patients may require further treatment

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