Recognizing Spinal Cord Injuries in the Field
Spinal cord injuries (SCIs) represent some of the most consequential injuries an EMT will encounter. Proper assessment and management in the prehospital setting can mean the difference between a patient who recovers neurological function and one who suffers permanent paralysis. Understanding the anatomy of the spinal column, recognizing high-risk mechanisms of injury, and performing a systematic neurological assessment are essential skills for every EMS provider.
The spinal column consists of 33 vertebrae divided into five regions: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (fused). The cervical spine is the most vulnerable to injury due to its mobility and the weight of the head it supports. The thoracolumbar junction (T12-L1) is another common injury site because it represents the transition between the relatively rigid thoracic spine and the more flexible lumbar spine.
Mechanism of Injury Evaluation
Certain mechanisms of injury should raise immediate suspicion for spinal injury. These include motor vehicle collisions (especially at speeds over 30 mph or with rollover), falls from heights greater than three times the patient's height, diving accidents, axial loading injuries, and any blunt trauma above the clavicles. Penetrating trauma near the spine should also be evaluated carefully, though isolated penetrating injuries rarely cause unstable spinal fractures.
When evaluating mechanism, consider the forces involved. Hyperflexion injuries commonly affect the cervical spine in head-on collisions. Hyperextension injuries occur when the head is forced backward, as in rear-end collisions. Compression injuries result from axial loading, such as diving into shallow water. Rotation injuries combine flexion or extension with twisting forces and tend to be more unstable.
Neurological Assessment
A focused neurological exam in the field should assess motor function, sensory function, and reflexes. Ask the patient to wiggle their fingers and toes, squeeze your hands, and push against your hands with their feet. Test sensation by lightly touching the patient's extremities and asking if they can feel it. Document any deficits and the time they were noted.
Key findings that suggest spinal cord injury include numbness or tingling in the extremities, weakness or paralysis, loss of bowel or bladder control, priapism in male patients, and neurogenic shock (hypotension with bradycardia and warm, dry skin below the level of injury). Incomplete spinal cord injuries may present with deficits on only one side or in only certain dermatomes.
Spinal Motion Restriction Protocols
Modern EMS practice has shifted from routine spinal immobilization to selective spinal motion restriction (SMR). The NEXUS criteria and Canadian C-Spine Rule help guide decisions about which patients require SMR. Patients who are alert, not intoxicated, have no midline tenderness, no focal neurological deficits, and no distracting injuries may not require full SMR. When SMR is indicated, use a cervical collar and secure the patient to a long backboard or vacuum mattress, maintaining neutral alignment throughout.