Assessment and management of spinal and neurological injuries
Aim: The trainee should have an understanding of injuries to the spine and spinal cord, including
the management of such patients.
Objectives:
Knowledge objectives:
The trainee should have acquired the following knowledge:
 An understand of the anatomy of the spine and spinal cord, and associated changes with
age
 The role of spinal immobilization including
o Spinal hard board and strapping
o Scoop stretchers
o C-spine collars with bricks
o Pediatric boards with clearance for occiput to maintain spinal alignment
 Understand the complications related to prolonged spinal immobilization, including
decubitus ulcers
 Prioritize resuscitation of such patients, and minimizing further injury
 Define complete versus incomplete spinal cord injury
 Specific spinal cord injuries, including
o Complete transection
o Hemi-transection (Brown-Sequard syndrome)
o Anterior spinal cord syndrome
o Posterior spinal cord syndrome
o Cauda equina syndrome
o Central cord syndrome
 Understand that children under 8 years of age are more likely to have injuries from the
base of the skull to C2 based on the anatomy
 Understand the principles behind clearance of the C-spine in a neurologically alert and
cooperative child as well as an obtunded and/or uncooperative child (the need for further
imaging and the evidence for clearing without imaging in older children)
 Understand the factors that underly the increased risk of the pediatric spine to the
development of spinal cord injury without radiologic abnormality and the
pathophysiology of this process
 Classify and manage spinal injuries / fractures and appreciate pediatric spinal variants,
including:
o SCIWORA
o Potential for non-contiguous fractures and therefore consider imaging the entire
spine of one fracture is founds
o Appreciate the differences in the pediatric, adolescent, and young adult spine
 Differentiate between neurogenic shock and spinal shock
 Appreciate the controversy in the use of steroids in the spinal injured patient, and to liaise
with local neurosurgical team for their practice preference
 Indications for imaging (X-ray, CT, and / or MRI) of the following regions:
o Cervical spine
o Thoracic spine
o Lumbosacral spine
 Thorough knowledge of pediatric cervical spine radiographs:
o An approach to reviewing the films
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o Normal variants
o Pseudosubluxation
Understand the principles behind cervical spine clearance and the need for further
imaging based on history, mechanism of injury, and clinical exam
Know the following injuries:
o Atlanto-occiptal dislocation and subluxation (especially with Downs syndrome
patients)
o Atlas fracture
o C1 rotatory subluxation
o C2 fractures, including the odontoid (Type I-III) and posterior elements
o Thoracic fractures
o L1-3 chance fractures associated with lap-belt injuries
o Fractures and dislocations of the remainder of the cervical spine, thoracic spine,
and lumbar spine
Know the unstable cervical spine fractures
Patients with spinal cord concussion may recover from their neurological deficit
Know the clinical findings that correlate with injuries at specific levels
Know the risk, identification, and management strategies of multiple spinal injuries
Know and appreciate the effect of spinal cord injury on the assessment and management
of other injuries (e.g. Intra-abdominal injuries)
Understand the recent literature on the use of methylprednisolone use in spine injuries,
including knowledge of specialist position papers (Canadian Association of Emergency
Physicians guidelines, Canadian Neurological position paper, Canadian Spine Society
position paper)
Skills objectives:
The trainee should have an understanding of the following skill set:
 Ensure patients are appropriately immobilized with a C-spine collar and bricks, and a
hard spinal board / scoop
 Carry out a complete neurological exam in a spinal injured patient, including
o Sensory exam with dermatonal identification
o Motor exam with myotome identification
o Reflexes
 Demonstrate ability to correctly log roll and examine the spine of a child
 Demonstrate the ability to ensure C-spine immobilization during endotracheal tube
intubation
 Identify sacral sparing and incomplete cord lesions
 Interpret X-rays of the following areas, and when to proceed with further imaging:
o C-spine (3 views)
o T- spine
L- spine