Spinal and neurogenic shock
 Transient loss of spinal cord function can occur following spinal column injury
 Clinicians must assume that hypotension following trauma results from hemorrhage
 Neurogenic shock from spinal cord injury may cause hypotension and bradycardia
o Use of pressors may be necessary to stabilize blood pressure
o Use of atropine or pacing may be necessary to stabilize heart rate
Secondary survey
 Carefully inspect the patient's entire body, beginning with the head
 Palpate entire spine and paraspinal musculature for areas of tenderness or deformity
 A step-off in the spine may indicate vertebral subluxation or fracture
 Widening of an interspinous space indicates a tear in the posterior ligament complex and a potentially unstable
spinal injury (this finding may be difficult to appreciate)
 A focused but systematic neurologic evaluation should be performed in all patients
o Assess the presence and symmetry of both voluntary and involuntary movements
o Priapism may occur with severe spinal cord injury
o An abnormal breathing pattern may indicate a cervical injury (diaphragm innervated by the phrenic nerve)
o Attention should be paid to the symmetry of peripheral strength, sensation, reflexes, and proprioception
o Any sensory deficits, including the dermatome where they occur, should be noted
o Bowel or bladder incontinence is an important finding
Clinical decision rules for obtaining radiographs — Both the NEXUS Low-risk Criteria and the Canadian C-spine rule
are well validated and sensitive, and either can be used to determine the need for cervical spine imaging.
NEXUS — The first decision rule to be developed was the NEXUS Low-risk Criteria (NLC), which was prospectively
validated in a large, multicenter, observational study.
The NLC decision instrument stipulates that radiography is not necessary if patients satisfy ALL five of the following lowrisk criteria:
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Absence of posterior midline cervical tenderness
Normal level of alertness
No evidence of intoxication
No abnormal neurologic findings
No painful distracting injuries
Altered level of consciousness is defined in the NLC as follows:
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Glasgow coma scale score below 15
Disorientation to person, place, time, or events
Inability to remember three objects at five minutes
Delayed or inappropriate response to external stimuli
A brief, transient loss of consciousness at the time of a motor vehicle collision does not preclude the application of the
NLC, assuming the patient meets all other criteria.
Canadian C-spine rule — Due to the low specificity of NEXUS Low-risk Criteria (12.9 percent), some researchers
expressed concern that use of these criteria might increase the use of radiography in some regions of the United State
(US) and in the majority of countries outside of the US. These researchers subsequently developed the Canadian C-spine
rule (CCR), based upon three clinical questions derived from 25 clinical variables associated with spine injury.
The CCR involves the following steps:
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Condition One: Perform radiography in patients with any of the following:
 Age 65 years or older
 Dangerous mechanism of injury: fall from 1 m (3 ft) or five stairs; axial load to the head, such as diving
accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle
accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car
 Paresthesias in the extremities
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Condition Two: In patients with none of the high risk characteristics listed in Condition One above, assess for
any low-risk factor that allows for safe assessment of neck range of motion. The low-risk factors are as
follows:
 Simple rear end motor vehicle accident; excludes: pushed into oncoming traffic; hit by bus or large truck;
rollover; hit by high speed (>100 km/hour [>62 mph]) vehicle
 Sitting position in emergency department
 Ambulatory at any time
 Delayed onset of neck pain
 Absence of midline cervical spine tenderness
Patients who do not exhibit any of the low-risk factors listed here are NOT suitable for range of motion testing and must
be assessed with radiographs.
If a patient does exhibit any of the low-risk factors, perform range of motion testing, as described in Condition Three
below.
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Condition Three: Test active range of motion. Perform radiography in patients who are not able to rotate
their neck actively 45 degrees both left and right. Patients able to rotate their neck, regardless of pain, do not
require imaging.
In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying
clinically important cervical spine injuries
NEXUS versus Canadian C-spine rule — Both the NEXUS Low-risk Criteria and the Canadian C-spine rule are well
validated and sensitive, and either can be used to determine the need for cervical spine imaging. Nevertheless,
controversy persists about which of the two rules is more specific and more useful.
Plain x-rays versus CT
 It is reasonable to use plain radiographs to assess for cervical spinal column injury in patients without a severe
mechanism of injury or neurologic abnormalities, in whom adequate x-rays are likely to be obtainable, and in
whom CT imaging for other potential injuries is not planned
 Routine cervical spine radiographs for trauma must include anterior-posterior (AP), lateral, and odontoid (ie, openmouth) views at a minimum
 Adequate views are essential
 Depending upon the patient population, up to 72 percent of plain films may be inadequate to visualize the
complete cervical spine, necessitating performance of a CT
 Once a CT is performed, plain radiographs add no further clinically relevant information and should not be
obtained
 The C7 vertebra may be obscured in muscular or obese patients, as well as patients with spinal lesions that
cause paralysis of the muscles that depress the shoulders
o The shoulders can be lowered by pulling the patient's hands toward their feet, using slow steady traction
 A CT scan is obtained if visualization of the cervical spine remains inadequate despite these additional
maneuvers and views
Interpretation of plain radiographs
 If plain radiographs are used to assess the cervical spine, the clinician must be certain that the views obtained are
adequate and systematically examined
 On the lateral view, the entire cervical spine, from the base of the occiput to the top of the first thoracic vertebra
must be clearly visible
 On the odontoid view, the dens and both lateral masses must be clearly visible
 Inadequate views are not acceptable
 Once adequate views are obtained, examine each for alignment of the vertebrae; appearance, position, and
spacing between vertebrae; and appearance of the soft tissues
 ABC’s method for interpreting the three major views (lateral, odontoid, and anterior-posterior)