Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting

GOAL

The Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery CPG delivers updated, accurate guidance to the deployed provider in order to afford the best care to patients who suffer a spinal column or spinal cord injury. This requires constant re-evaluation of the literature, both military and civilian, in addition to reviewing the lessons learned from past and present deployments. Review of these sources drives evidenced-based changes in treatment and triage algorithms, while providing updates on injury classification and current mechanisms of injury.

The authors provide key recommendations for each section.1 It should be noted that while there may be strong evidence in the civilian literature for managing certain aspects of trauma, not all of these recommendations translate into a combat-trauma setting and so the account for the resource restricted environment of the deployed setting.

BACKGROUND

Injury to the spinal column or spinal cord occurs in approximately 5.5% of evacuated battle casualties and are among the most disabling conditions wounded service members face.2,3 Spine injuries in theater occur through a variety of battle-related and nonbattle related mechanisms.2,4,5 In a review of the Joint Theater Trauma Registry (now the DoD Trauma Registry) from 2001-2009, Blair reported the characteristics of 598 American service members who sustained spine injuries during Operation Iraqi Freedom and Operation Enduring Freedom.2 In this population, 502 (84%) patients experienced 1,834 battle-related spine injuries. The remaining 96 (16%) service members sustained 267 nonbattle-related injuries.2 From a mechanistic perspective, most battle injuries occur from explosions (66.7%) or gunshot wounds (17%) while nonbattle injuries most frequently result from motor vehicle accidents (54%) or falls (30.2%).2 Additionally, patients with battle related spine injuries have significantly higher Injury Severity Scores (ISS), present more frequently with noncontiguous spinal fractures and are more likely to require operative intervention.2,5 Despite these differences, the rate and severity of underlying spinal cord injury appears similar between groups. Blair reported an 18.1% incidence of spinal cord injury in patients with battle-related injuries compared to a 13.5% incidence in the nonbattle-related group. Of patients with neurologic deficits, approximately 45% from each group presented with a complete deficit.2 In a separate review of the same 598 records, Blair reported 66% of injuries occurred due to blunt trauma, while 28% resulted from penetrating injuries and 5% experienced a combined blunt and penetrating mechanism.4 Patients sustaining penetrating injury were more likely to experience spinal cord injury than those with blunt force mechanisms (38% vs. 10% p<.0001).4

The timing and location of surgical intervention has also been a point of debate both in civilian and military settings.6-10 The scarcity of data defining the optimal setting for surgical intervention when the injury occurs in a combat zone adds further challenges. The goal of decompressing and stabilizing the spine/spinal cord injury must be weighed by operational and logistical considerations in addition to the ability of the deployed spine surgeon.

In general, spine trauma patients may be placed into one of 3 clinical categories:

1. Patients with complete spinal cord injury.
2. Patients with an incomplete spinal cord injury
3. Patients with a spine fracture but normal neurological function.

In regards to the timing of surgery, an incomplete injury from a non-penetrating mechanism is often the most challenging in the decision-making process as these patients are the ones most likely to benefit from early surgical intervention in terms of neurological recovery.5,9