- Management of life-threatening injuries takes priority over management of spinal injuries.
- In the multiple-trauma setting, spinal injury should be assumed to be present pending appropriate assessment.
- Spinal injuries must be considered unstable until they are evaluated thoroughly.
- Vertebral injuries must be assessed in terms of the potential to create early neurologic injury or late deformity.
- Spinal cord injury is minimized or prevented by limiting the secondary ischemic phase and maintaining appropriate spinal immobilization.
- Complete spinal cord injuries have no potential for functional recovery. Incomplete injuries have recovery potential, which must be maximized.
- Considerations in rehabilitation must be initiated at the outset.
Severely injured patients frequently require ICU admission preoperatively and more commonly postoperatively for monitoring and assessing for change that may require intervention, including surgery. It is estimated that approximately 20% of patients sustaining multiple injuries have associated spinal column trauma that may be the prime reason for ICU admission. More commonly, ICU admission is necessitated by the more immediately life-threatening injuries, and the spinal injury then could be missed or management delayed, leading to significant morbidity or even death. The intensivist plays an important role in determining outcome in these injuries by having a high index of suspicion based on awareness of the mechanisms of spinal injuries and their clinical features. This chapter reviews (1) the mechanism, classification, and clinical picture of spinal injuries and (2) the principles of management of vertebral and spinal neurologic injuries to enable the intensivist to optimize ICU management and recognize the need for early orthopedic and/or neurosurgical consultation.
It is extremely important in the management of multiply injured patients that longer-term rehabilitation considerations not be forgotten because this may result in serious chronic disability. The possibility of cervical spine injury must be considered in anyone who has suffered significant injuries to the face or head, especially those who are unconscious from trauma.1 However, patients who are at risk on the basis of preexisting abnormalities of the cervical spine (e.g., ankylosing spondylitis and congenital anomalies) may suffer serious neck injury as a result of what might appear to be trivial trauma. Knowledge of the mechanism of injury is helpful in considering the possibility of spinal injury (e.g., fractures at the thoracolumbar junction associated with falls from a height).
The vertebral column consists of three components (Fig. 94-1)2:
The anterior column, consisting of the anterior two-thirds of the vertebral body, disk, and annulus and the anterior longitudinal ligament
The middle column, consisting of the posterior one-third of the vertebral body, disk, and annulus and the posterior longitudinal ligament
The posterior column, consisting of the pedicles, laminae, facets, capsule, and the interspinous and supraspinous ligaments
The anterior, middle, and posterior columns are illustrated. SSL, supraspinous ligament; ISL, interspinous ligament; LF, ligamentum flavum; C, capsule; PLL, posterior longitudinal ligament; AF, annulus fibrosis; ...