Early care of patients suffering from a spinal cord injury can have a significant impact on long term outcomes. Providers should focus on minimising handling, maintaining immobilisation and preventing any further damage.

Secondary Survey

History

Taking an adequate history from the patient, bystanders, or emergency personnel of the events surrounding the injury can assist with predicting other damage that may have occurred.⁽¹⁷⁾ Emphasis should be placed on understanding the mechanism, initial level of consciousness and any concurrent injuries noted. Note any history of drugs or alcohol prior to and at the time of injury.

Use the AMPLE acronym to assist with gathering pertinent information^{(17, 18)}:

Allergies
Medication
Past medical history including tetanus status
Last meal
Events leading to injury

Head-to-toe examination

A thorough examination of motor, sensory, and reflex capacity is crucial, and systems should be assessed independently and systematically. A head-to-toe assessment is an established approach to assessing neurological function. Where transfer to a MTS or the Victorian Spinal Cord Service at the Austin is imminent, a full ASIA assessment can be delayed while preparing the patient for transfer if the SPEED assessment has been completed.

Motor: Muscle groups should be assessed. It is often difficult to test some segments due to traumatic injuries, therefore, upper limbs are often most easily assessed. Strength rated 1/5 to 5/5 should be documented in addition to any deficits of left or right responses.

Sensory: Sensation should be assessed systematically with initial tests using light touch. If no response, then increase to sharp stimulation. The trigeminal nerve, exiting above the spinal cord, is a useful reference point for assessing primary SCI where intact facial sensation is expected.

Reflexes: Reflex responses should be obtained by usual assessment practice.

Head and face

This examination should be conducted with the patient remaining supine.

Inspect the face and scalp. Look for any lacerations and bruising as well as mastoid or periorbital bruising, which is indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull.

Assess the ears for any signs of cerebrospinal fluid leak, bleeding, or blood behind the tympanic membrane.

Check the nose for any deformities, bleeding, nasal septal haematoma, cerebrospinal fluid leak.

Look in the mouth for any lacerations to the gums, lips, tongue, or palate. Note any swelling, which may indicate inhalation injury. Inspect the teeth, noting if any are loose, fractured, or missing.

Test eye movements, pupillary reflexes, vision, and hearing.

Palpate the bony margins of the orbit, maxilla, nose, and jaw.

Inspect the jaw for any pain or trismus.

Neck

NEXUS criteria

All potential major trauma patients suspected of having a cervical spine injury will arrive in the Emergency Department with a soft collar applied by ambulance crew. Assessment and imaging will occur while the patient has the soft collar in-situ. Clinical examination using the NEXUS low-risk criteria should be performed, however, this can only occur four hours after the last administration of narcotics.
The NEXUS low-risk criteria constitute a decision tool for use in the initial assessment of conscious patients to indicate those at very low risk of cervical spine injury following blunt trauma who may not need radiographic imaging.
Patients are considered to be at extremely low risk of cervical spine injury if ALL of the following criteria are fulfilled:

No midline cervical spine tenderness
No focal neurologic deficit
No evidence of intoxication
No painful distracting injury
No altered mental status

If all of the above criteria are satisfied, clinical examination may then proceed. If there is no evidence of any bruising, deformity, or tenderness on examination, and if a full range of active movement can be performed without pain (including 45-degree rotation to the left and right), the cervical spine can be cleared without radiographic imaging and the cervical collar removed.
Should the patient exhibit any of the criteria, however, clinical examination is unreliable, and radiographic assessment of the cervical spine is advised.

For further details on the NEXUS criteria, refer to Appendix 2.

NEXUS criteria

1. Midline cervical spine tenderness

Present if the patient indicates the existence of neck pain on palpation of the posterior midline neck region from the nuchal ridge to the third thoracic prominence, or palpation of any cervical spinous process.

2. Focal neurologic deficit

Motor or sensory examination indicates the presence of a focal neurologic deficit eg. segmental weakness, numbness, or paraesthesia.

3. Intoxication

The patient is considered to be intoxicated if:

the patient or an observer reports a recent history of intoxication or consumption of intoxicating substances
evidence exists of intoxication on physical examination eg. odor of alcoholic beverage, ataxia, slurred speech, dysmetria, other cerebellar signs or any behavior suggestive of intoxication
tests of bodily fluids are positive for drugs or alcohol which affect mental alertness

4. Painful distracting injury

Any non-spinal-related condition causing sufficient pain to distract the patient from a possible cervical spine injury. Suggestions include:

any long bone fracture
a visceral injury requiring surgical consultation
extensive laceration, crush, or degloving injury
considerable burns
any other injury producing functional impairment
any other injury thought to impair the patient’s ability to appreciate cervical spine pain

5. Altered mental status

An altered state of mental alertness can be demonstrated by:

GCS < 15
disorientation to time, place, person or event
inability to recall 3 objects at 5 minutes
delayed or inappropriate response to stimulus

Clinical spinal clearance
If all of the NEXUS criteria are negative, there is no evidence of bruising or deformity, and if a full range of active neck movement (including 45xc2xb0 rotation to the left and right) can be performed without pain, the cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. Documentation must be made on the electronic Spinal Assessment and Clearance Form.
Cervical spine imaging
Should the patient exhibit any signs of cervical spine tenderness, focal neurologic deficit, evidence of intoxication, painful distracting injury, or altered mental status, however, clinical examination is unreliable and radiographic assessment of the cervical spine is advised.

Cervical Multi-Segmental CT

MRI may be required if CT images are abnormal or if abnormal neurology is present

Adapted from The Alfred Spinal Clearance Management Protocol (November 2009). Developed by Helen Ackland. Accessed August 25 2014, available from http://www.alfredhealth.org.au/Assets/Files/SpinalClearanceManagementProtocol_External.pdf

Neck Examination

To ensure adequate access, have another colleague maintain manual in-line stabilization while the collar is removed for palpation and throughout the examination.

Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness, or deformity. The point of maximum tenderness should be noted.

Check the soft tissues for bruising, pain, and tenderness.

Complete the neck examination by observing the neck veins for distension and palpating the trachea and the carotid pulse. Note any tracheal deviation or crepitus.

The patient will need to be log-rolled to complete the full examination. This can be combined with the back examination.

Chest

Inspect the chest, observing movements. Look for any bruising, lacerations, penetrating injury, or tenderness.

Palpate for clavicle or rib tenderness. Look for bilateral chest expansion.

Auscultate the lung fields; note any percussion, lack of breath sounds or adventitious sounds.

Check the heart sounds: apex beat and the presence and quality of heart sounds.

Abdomen

Inspect the abdomen. Look for any distension or swelling, bruising, lacerations, or penetrating injuries.

Palpate for areas of tenderness, especially over the liver, spleen, kidneys, and bladder.

Check the pelvis.

Limbs

Inspect all the limbs and joints. Note any bruising or lacerations and muscle, nerve, or tendon damage. Look for any deformities, penetrating injuries, or open fractures.

Palpate for bony and soft-tissue tenderness and check joint movements, stability, and muscular power.

Note any inequalities with limb response to stimulation and document these findings.

Examine the sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Assess distal perfusion for capillary refill, pulse, and warmth.

Refer to Appendix 1: American Spinal Association: International Standards for Neurological Classification of Spinal Cord Injury

Back

Log roll the patient. Maintain in-line stabilization throughout. Inspect the entire length of the back and buttocks noting any bruising, lacerations or injuries.

Palpate the spine for any tenderness or steps between the vertebrae. Include a cervical examination at this stage. Many patients with SCI have vertebral injury at more than one level. Do not sit the patient up.

Digital examination should be performed in suspected SCI. Note any loss of tone or sensation.

Buttocks and perineum

Look for any soft-tissue injury such as bruising or lacerations.

Genitalia

Inspect for soft-tissue injury such as bruising or lacerations.

Note any priapism that may indicate spinal injury.

Major Trauma Guidelines & Education – Victorian State Trauma System