Fractures are stable if further deformity is unlikely. They are unstable if a change in the fracture position is expected with mobilization.
Spinal cord injury is complete if there is no nerve function below the level of injury and if improvement or return of function is unlikely. Incomplete injuries have some nerve function below the injury level and may show improvement with treatment.

Evaluation

During the period of spinal shock (usually the first 48 hours after injury) there may be no spinal cord function. As shock wears off, some neurological recovery may occur with incomplete injuries. The ultimate prognosis cannot be accurately determined during the first several days.

X-ray examination

X-ray the entire spine in patients not mentally responsive enough to cooperate with the clinical examination. In patients who are awake:

Evaluate the cervical spine:

Take AP and lateral views of the thoracic and lumbar spine.

The most common areas of injury are C2, C5–6 and T12–L1. In patients with pain but normal X-rays, take flexion and extension lateral X-rays of the cervical spine.

X-ray interpretation
The bony spine is anatomically divided into three sections or columns (Figure 18.64).

Figure 18.64

Injuries are unstable if there is:

Treatment

Cervical spine

•	C1: The first cervical vertebra has ample room for the spinal cord and neurological injury is unusual: > Initially, place patients in skull traction (see page 17–4) to maintain the fracture position and to control discomfort > When stable, change to a Minerva cast or a rigid cervical collar Healing takes about 3 months
•	C2: Odontoid fractures at the junction of the vertebral body are unstable (Figure 18.65): > To reduce the fracture, place the patient in skull traction with slight hyperextension of the head > At 4–6 weeks, change to a Minerva cast or a halo vest
Figure 18.65
•	C2: Vertebral body: > Reduce the fracture by placing the neck in the neutral position and apply a Minerva cast or rigid collar > Avoid traction because it will distract this fracture
•	C3–7: Treat fractures, dislocations and fracture-dislocations (Figure 18.66) in skull traction followed, after 4–6 weeks, by a Minerva cast or halo vest. Healing time is 3–4 months, usually with a spontaneous fusion.
Figure 18.66

Facet dislocations or subluxations

Gradually increase the traction weight (5 kg/hour up to 20 kg) while monitoring neurological signs and taking frequent lateral X-rays. When the facet joints are unlocked, attempt to reduce the dislocation by gently rotating and extending the neck. If this is unsuccessful, allow it to remain dislocated and treat as above.

Neurological damage

Spinal cord injury above C5 causes paralysis of the respiratory muscles and patients usually die before reaching a medical care facility. At or below this level, treat similarly to patients without neurological deficit. However, begin care of the skin, bowel and bladder immediately.

Thoracolumbar spine

•	Place the patient at bed rest on a soft pad and move only by log roll. A paralytic ileus is common following lumbar fractures. Give the patient nothing by mouth until bowel sounds return. Regularly monitor and record the neurological status.
•	If there is no neurological damage, begin ambulation, when comfortable, using a brace or body cast (Figure 18.67). A sitting lateral X-ray will confirm fracture stability. The patient should not bend or lift for at least 3 months.
Figure 18.67

For incomplete neurological injury, treat as above but monitor the neurological status closely until recovery has stabilized.

With complete neurological disruption, begin the rehabilitation programme immediately to prevent potential complications.