Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXIII: Wounds and Injuries of the Spinal Column and Cord

Mechanical Integrity of the Vertebral Column

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

The vertebral column is composed of three structural columns (Table 15). Loss of integrity of two of the three columns results in instability of the spine. Instability is common following closed mechanical injury of the vertebral column, but is not usually the case with gunshot or fragment wounds of the vertebral column. Instability of the vertebral column is documented on the late radiograph by demonstrating 3.5 mm or greater displacement translation of one vertebral element on another, or by an interspinous, sagittal vertebral column angulation of 11° or more on the lateral view. Should questions exist regarding neck stability, lateral extension and flexion radiographs should be obtained under the direct supervision of a medical officer. Computerized tomography is effective in demonstrating spinal instability, but will not be available in forward hospitals.

Because instability may not be immediately confirmed following trauma, any patient who complains of a sense of instability (holds his head with his hands), has unexplained vertebral column pain, has tenderness to percussion along the vertebral column, or has neurological injury without evidence of skeletal injury should be suspected of an injury to the spine. Similarly, any trauma victim who is unconscious or confused, or has evidence of trauma above the clavicles, should be managed as though cervical spinal injury were present.

Injury of vertebral supporting structures (Table 15), with or without bony involvement, makes the spinal cord vulnerable to secondary injury. Proper emergency stabilization of the spine during extrication and transfer of the victim is crucial in order to prevent neurological complications in this group of patients. Ligamentous injuries, in contrast to bony injuries, frequently do not heal without surgical stabilization. Typically, bony injuries of the spine heal in 12 weeks, the recommended period for protecting spine fractures. After three months, flexion-extension X-rays should be obtained to assess stability. Evidence of instability or progressive loss of alignment are indications for operative stabilization.

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