This document provides guidelines for the surgical management of spine trauma. It discusses various spinal injuries including cervical, thoracic and sacral injuries. It provides options for treatment including immobilization, reduction, decompression and fusion. Guidelines are given for radiographic assessment, hemodynamic management, pharmacological therapy and prevention of further injury through safety measures.

1. Spine Trauma: Surgical Management Professor of Neurological Surgery Oakland University William Beaumont School of Medicine Chief of Neurotrauma and Critical Care Beaumont Health System; Royal Oak, MI Director of Michigan Head and Spine Institute, PC Daniel B. Michael M.D., Ph.D. [email_address]

4. Spinal Cord Injury: Demographics 2-5/100,000 M:F 1-5/1 2nd-3rd decade

6. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries Neurosurgery (Supplement) March 2002 50:3 Hadley MN Walters BC Grabb PA Oyesiku NM Przybylski GJ Resnick DK Ryken TC

8. Cervical Spine Immobilization Before Admission to the Hospital Standard : none Guideline : none Option : all potential patients should be immobilized at scene with rigid collar & backboard with straps

9. Transportation of Patients with Acute Cervical Spine Injuries Standard : none Guideline : none Option : “Expeditious and careful” transport to “nearest capable definitive care medical facility”

10. Clinical Assessment After Acute Cervical Spine Injuries Standard Neuro & Functional  none Guideline Neuro  none Functional  use Functional Independence Measure (FIM) Option Neuro  American Spinal Injury Association (ASIA) standards Functional  Modified Barthel Index

13. Dermatomes

19. Management of Acute Spinal Cord Injuries in an Intensive Care Unit or Other Monitored Setting Standard : none Guideline : none Option : Management in ICU with cardiac, hemodynamic & respiratory monitoring

20. Blood Pressure Management after Acute Spinal Cord Injuries Standard : none Guideline : none Option : avoid SBP<90mm Hg; maintain MAP 85- 90 mm Hg for 1st 7 days post injury

21. Pharmacological Therapy after Acute Spinal Cord Injuries Standard : none Guideline : none Option : 24 or 48 hour methylprednisolone protocol per NASCIS II & III or GM-1 ganglioside treatment “ ...most controversial of the Guidelines.”- M.L.J. Apuzzo

23. Deep Venous Thrombosis and Thromboembolism in Patients with Cervical Spinal Cord Injuries Standard : use prophylaxis with LMW heparin, roto beds, adjusted dose heparin, or low dose heparin with compression stockings Guideline : low dose heparin alone or oral anticoagulation not recommended Option : monitor with Doppler u/s, impedance plesmethography or venogram, Prophylax for 3 months post injury, consider cava filters in non responders or non anticoagulation candidates

24. Nutritional Support after Spinal Cord Injury Standard : none Guideline : none Option : provide support based on indirect calorimetry

25. Management of Pediatric Cervical Spine and Spinal Cord Injuries Diagnostic Standard : none Guideline -If child conversant, use adult radiographic criteria -If not, obtain AP & Lateral x-rays Option - <9y obtain x-rays - >9y use adult criteria - Supplement with CT, flex-ex, or MRI

26. Management of Pediatric Cervical Spine and Spinal Cord Injuries Standard : none Guideline : none Option : -Account for head-spine size difference in children < 8y when immobilizing -Closed reduction and halo immobilization for C2 injuries < 7y -Consider surgery for ligamentous injuries Treatment

29. Occipital Condyle Fractures Standard : none Guideline : CT for dx Option : Diagnosis may be aided by &/or MRI external mobilization

31. Isolated Fracture of the Axis in Adults Standard : none Guideline : consider surgery in Type II, >50 y Option : Initial treatment of Type I, II, III with external immobilization; Consider surgery if >5mm displacement, comminution or inability to stabilize in external device Odontoid

32. Odontoid Fracture Due to GSW

33. Traumatic spondylolisthesis of the axis (Hangman’s Fracture) Standard : none Guideline : none Option : Initial treatment with external immobilization in most cases; Consider surgery if severe angulation, c2-3 disc disruption or inability to stabilize in external device Isolated Fracture of the Axis in Adults

34. Isolated Fracture of the Axis in Adults Standard : none Guideline : none Option : external immobilization Miscellaneous Fractures of the Axis Body

38. Cervical Spine Stability White & Punjabi

39. Cervical Spine Stability White & Punjabi

40. Unilateral Facet Fracture

41. Cervical Flexion-Distraction Injuries

42. Cervical Flexion-Distraction Injuries

44. Cervical Axial Loading Injuries

46. Management of Vertebral Artery Injury after Non-penetrating Cervical Trauma Standard : none Guideline : none Option : -Angiography or MRI in complete cord injuries, fx thru f. transversarium, facet dislocation or vertebral sublux -IV anticoagulation if evidence of posterior circulation stroke -Observe or anticoagulate if evidence of ischemia -Observe if no evidence of stroke or ischemia

47. Thoracic Spine Stability White & Punjabi

48. A 40 y/o unlimited hydroplane driver injured at the 2003 Detroit Gold Cup race. Injuries: concussion, thoracic compression fxs and left ankle fx.

49. T2-3 Fracture, Complete paraplegia

50. T2-3 Fracture, Complete paraplegia

51. Unstable T4-5 complete - MVA

52. Motorcycle Accident T3-4 100% Sublux (complete)

53. T3-4 100% Sublux (complete) Nine days post injury

54. Snowmobile Injury

55. L2-3 complete-assault rifle injury (AK-47) 2000

56. L2-3 complete-assault rifle injury (AK-47) 2003

57. Sacral Injuries

58. Prevention: ThinkFirst