The spine is made up of 33 separate bones, known as vertebrae, extending from the base of the skull to the coccyx (tailbone). Each vertebra surrounds and protects the spinal cord (nerve tissue). Fractures or dislocations to the vertebral bones may result in injury to the spinal cord. The direct mechanical injury from the traumatic impact can compress or sever the nerve tissue. This is followed by secondary injury caused by ongoing bleeding into the spinal cord as well as continued swelling at the injured site and surrounding area.
The possibility of spinal injury must be considered in the overall management of all trauma victims. The risk of worsening the spinal injury in the prehospital period is probably less than previously thought, yet to minimise the extent of the secondary injury, caution must be taken when moving a victim with a suspected spinal injury.
Spinal injuries can occur in the following regions of the spine:
The cervical spine is most vulnerable to injury, which must be suspected in any victim with injuries above the shoulders. More than half of spinal injuries occur in the cervical region.
Suspected spinal injuries of the neck, particularly if the victim is unconscious, pose a dilemma for the rescuer because correct principles of airway management often cause some movement of the cervical spine.
The most common causes of spinal cord injury are:
The symptoms and signs of a spinal injury depend on two factors: firstly, the location of the injury and secondly, the extent of the injury – whether there is just bone injury or associated spinal cord injury, and whether the spinal cord injury is partial or complete. It will be difficult to elicit symptoms and signs in victims with an altered conscious state.
The priorities of management of a suspected spinal injury are:
An awareness of potential spinal injury and careful victim handling, with attention to spinal alignment, is the key to harm minimisation.
Ask the victim to remain still but do not physically restrain if unco-operative. Those with significant spinal pain will likely have muscle spasm which acts to splint their injury. Keep victim comfortable until help arrives.
If it is necessary to move the victim from danger (e.g., out of the water, off a road), care must be taken to support the injured area and minimise movement of the spine in any direction. Ideally, only first aid providers or health care professionals trained in the management of spinal injuries, aided by specific equipment, should move the victim.
Airway management takes precedence over any suspected spinal injury. It is acceptable to gently move the head into a neutral position to obtain a clear airway. If the victim is breathing but remains unconscious, it is preferable that they be placed in the recovery position.
The victim should be handled gently with no twisting. Aim to maintain spinal alignment of the head and neck with the torso, both during the turn and afterwards. In victims needing airway opening, use manoeuvres which are least likely to result in movement of the cervical spine. Jaw thrust and chin lift should be tried before head tilt.
Rigid backboards placed under the victim can be used by first aiders should it be necessary to move the victim. The benefits of stabilising the head will be limited unless the motion of the trunk is also controlled effectively during transport. Victims should not be left on rigid spinal boards. Healthy subjects left on spine boards develop pain in the neck, back of the head, shoulder blades and lower back. The same areas are at risk of pressure necrosis. Conscious victims may attempt to move around in an effort to improve comfort, potentially worsening their injury.
The log roll is a manoeuvre performed by a trained team, to roll a victim from a supine position onto their side, and then flat again, so as to examine the back and/or to place or remove a spine board.
After road traffic accidents, conscious infants should be left in their rigid seat or capsule until assessed by ambulance personnel. If possible, remove the infant seat or capsule from the car with the infant/child in it. Children under eight years of age may require padding under their shoulders (approximately 2.5cm) for neutral spinal alignment.