Matthew J. Martin
Chief of Surgery, 47th Combat Support Hospital, TF Vanguard, Tikrit, Iraq, 2005–2006
Chief of Trauma, Theater Consultant, General Surgery, 28th Combat Support Hospital, Baghdad, Iraq, 2007–2008
Commander, 655th Forward Surgical Team, FOB Ghazni, Afghanistan, 2010
Chief of Surgery, 758th Forward Surgical Team, FOB Farah, Afghanistan, 2013
Ryan Gocke
USSOCOM Surgical Support, 2015, 2016
“The expert surgeon is smarter than the algorithm.”
Charles Abernathy
BLUF Box (Bottom Line Up Front)
- 1.
There are limited spine surgery resources in a combat theater, so you are likely to be the spine surgeon.
- 2.
With combat spinal cord injuries, what is done is done, and there is little you can do acutely to improve or worsen.
- 3.
Therefore, do not worship at the altar of “spinal precautions”; do what you need to do to take care of the patient’s injuries.
- 4.
A quick and thorough neurologic exam is key to distinguishing between complete and incomplete spinal cord injuries.
- 5.
If there is any question about a spinal column or canal wound, wash it out and get tissue coverage.
- 6.
Irrigation, debridement, and broad coverage of antibiotics are the key to wound management success.
- 7.
There is little role for steroids in penetrating spine trauma and even less in a combat theater. Steroids should never be given for any penetrating SCI. Steroids are no longer recommended by most guidelines.
- 8.
Treat the spine injury like a brain injury – always avoid hypotension and hypoxia.
- 9.
Don’t forget the airway! Particularly with high cervical spine injuries, delayed decompensation is common, so anticipate and intubate (always before transfer).
- 10.
Run-of-the-mill blunt spine injuries happen in combat also – use CT scan liberally for blast and vehicular incidents.
You arrived in the theater of operations several weeks ago, and injured patients from your first mass casualty event are streaming into the emergency room (ER). With the exception of the uniforms and the fact that your ER is a tent, it looks a lot like a civilian trauma event. Multiple patients arrive bleeding and moaning, almost all of them on spine boards and with cervical collars in place. One patient has multiple fragment wounds to his chest, neck, and face and is having a hard time breathing. He is bleeding around his cervical collar, but no one wants to remove it or move the patient for fear of violating “spinal precautions.” Suddenly, the experienced triage physician arrives and wastes no time in removing the collar, sitting the patient upright, and assessing his neck wounds. Miraculously the patient survives with an intact spinal cord and neurologic function.
Before we begin a discussion of how to manage spine injuries in a combat setting, it is critical to understand their epidemiology and limitations of available therapies. Most will be penetrating or a combination of blunt and penetrating (blast) mechanisms. This means that most often the die has been cast long before they arrive at your facility, and either they have a neurologic injury or they don’t. What you do in terms of moving them or placing them in “spinal precautions” will have little to no impact for the vast majority. The patient with no motor deficit but a spine that is so unstable that removing their collar and turning their head will suddenly “pith” them and result in paralysis is so rare that it should not be a consideration when you are faced with real and present injuries. This may be somewhat heretical, but do not let spinal precautions prevent you from doing what you need to do to take care of the patient.
The other important consideration is that there are almost no spinal emergencies that you will encounter in the combat setting. Almost all other injuries should take precedent in both evaluation and management, unless the spinal cord injury is impeding the airway (cervical spine) or the hemodynamics (neurogenic shock). No emergent imaging of the spine is required prior to a laparotomy or other surgeries, and you can always just keep them immobilized until the spine can be safely assessed. Even if one of the rare spinal cord emergencies is encountered, such as a progressively worsening exam with a cord compression that requires surgical decompression, your job will be to stabilize and transfer the patient to a spine surgeon.
Assessing Spinal Cord Injuries
The vast majority of combat trauma is the result of explosions or gunshot wounds . Considering the fact that most of the thorax is protected by body armor, penetrating spine injuries in modern combat are quite uncommon. Most of the spine injuries tend to occur in civilians and soldiers from forces that do not routinely wear body armor. However, blasts and vehicular accidents also happen in combat zones, and these can result in the regular, run-of-the-mill spinal column and cord injuries that you see in civilian trauma . The main difference is that you usually will not have a spine surgeon available, so you will be the spine expert. You also may not even have a CT scanner available, so you may have to base your management on your physical examination and plain x-rays. Fortunately, anyone with an interest can provide 99% of the critical early management that is required.
It is important to realize that recovery of neurological function after any spinal cord injury in any setting is not very good. Nevertheless, the distinction of complete and incomplete cord injury should be made as patients with incomplete injuries may derive some benefit from operative intervention such as decompressive laminectomy or removal of bone fragments that are compressing the spinal cord. However, as a relatively strict rule, spinal column injuries should not be treated in a down range setting unless there is evidence of progression of neurologic deficits. Documentation is critical to assess any changes in neurologic function. Physical examination skills are still the most important factor in the evaluation, so you should have a good basic spinal exam committed to memory. A “complete” injury is an injury pattern in which there is absolutely no function below the level of the injury. An “incomplete” injury is one in which there is any function below the level of injury. Sacral root sparing , which may allow some residual anal sphincter function or sensation or slight movement of a great toe, is an indication that the injury is incomplete and carries a better prognosis for some recovery. Furthermore, the presence or absence of spinal shock should be assessed by way of assessing the bulbocavernosus reflex.
Non-penetrating trauma is more likely to produce an incomplete injury. High-energy penetrating trauma will more commonly produce “complete” injuries. Since distinguishing between complete and incomplete spinal cord injuries is a critical task, it is important that trauma providers learn to perform a rapid yet thorough neurologic exam. The performance of such an exam is frequently overlooked in busy trauma bays. There are many different ways to do such an exam, but the main points are that in addition to global neurologic disability (Glasgow Coma Scale and pupil exam), the secondary survey of the patient should include strength testing in upper and lower extremity muscle groups and a rectal exam for tone and sensation (Fig. 27.1). Not every muscle group in the upper and lower extremities must be tested if there are no focal injuries on the extremities. For example, if the patient can flex his deltoids (C5) and extend and spread his fingers (finger flexion and intrinsic muscles of the hand, C8/T1), chances are good that everything in-between is intact. Similarly, lower extremity muscle groups can be quickly and easily tested (knee extension, L2/3, and great toe extension, L5, or ankle dorsiflexion, S1/S2) with the assumption that everything in-between is intact in the absence of any other symptoms or obvious injuries. Both upper and lower extremities and both right and left sides should be tested, as certain syndromes may cause “skip” patterns or have unilateral deficits (e.g., central cord syndrome, Brown-Sequard).
Fig. 27.1
Extent of muscle paralysis associated with different levels of spinal cord injury. Injuries above C7 will typically result in quadriplegia, while injuries below C7 will result in paraplegia
For patients who complain of a neurologic deficit or have been noted to have paralysis, this testing can become more challenging. Both knowledge of which muscle group is fired by each spinal cord level and more thorough checking for neurologic function distal to the apparent spinal cord level (including rectal exam) can help identify patients with incomplete injuries who may benefit from more urgent operative intervention. In addition, such an exam may help identify the possible injury location in order to better immobilize and prevent iatrogenic extension of the neurologic deficit. Remember that if spinal shock is present, you cannot determine whether the injury is complete or incomplete. Spinal shock variably persists, and serial examinations should be completed when feasible to assess evidence of spinal cord recovery.
Your exam should establish several key factors about any spinal cord injury and which any receiving spine surgeon will want to know. Both the motor and the sensory level (Fig. 27.2) of the injury should be identified and documented. The presence or absence of spinal shock should be established as described below. Finally, the injury should be assessed as complete or incomplete (in the absence of spinal shock). With communication of these simple facts combined with the anatomic imaging findings (CT scan), the consulting spine surgeon can make immediate recommendations and develop the majority of the treatment plan. The evaluation and scoring sheet developed by the American Spinal Injury Association (ASIA) provides all the information you need about performing and documenting the motor and sensory exam (Fig. 27.3).
Fig. 27.2
Sensory dermatomal map and the key sensory levels with anatomic landmarks. The lowest level with intact sensation to light touch and pinprick should be identified and documented (Reproduced with permission from American Spinal Injury Association)
