Spinal Trauma

Introduction to Spinal Trauma in the Canadian Context

Spinal trauma is a critical topic for MCCQE1 preparation, particularly given its prevalence and potential for severe outcomes in the Canadian healthcare system. This comprehensive guide will cover key aspects of spinal trauma, focusing on Canadian guidelines and practices to help you excel in your MCCQE1 exam.

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According to the Rick Hansen Institute, approximately 86,000 Canadians are living with spinal cord injury, with 4,300 new cases occurring each year. Understanding spinal trauma is crucial for Canadian medical practitioners.

Anatomy and Physiology Review

Before diving into the specifics of spinal trauma, let's review the key anatomical and physiological concepts relevant to the MCCQE1 exam:

The spinal column consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal.

Classification of Spinal Injuries

For MCCQE1 preparation, it's essential to understand the classification of spinal injuries:

Mechanism of injury:
- Flexion
- Extension
- Rotation
- Compression
- Distraction
Stability:
- Stable injuries
- Unstable injuries
Neurological status:
- Complete
- Incomplete
- ASIA Impairment Scale (AIS)

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The ASIA Impairment Scale is crucial for MCCQE1 exam preparation. Memorize the grades A through E for accurate classification of spinal cord injuries.

Initial Assessment and Management

Primary Survey (ABCDE)

Airway with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurological status)
Exposure/Environmental control

Secondary Survey

Detailed neurological examination
Log-rolling the patient
Palpation of the entire spine

Diagnostic Imaging in Spinal Trauma

Canadian guidelines for spinal trauma imaging:

Plain radiographs: Often the initial imaging modality
CT scan: Gold standard for bony injuries
MRI: Best for soft tissue injuries, cord compression, and ligamentous injuries

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The Canadian C-Spine Rule is widely used in emergency departments across Canada to determine the need for cervical spine imaging in alert and stable trauma patients.

Specific Spinal Injuries

Cervical Spine Injuries

Injury Type	Key Features	Management
Atlanto-occipital dislocation	Highly unstable, often fatal	Immediate stabilization, surgical fusion
Hangman's fracture (C2)	Bilateral C2 pars interarticularis fracture	External immobilization or surgical fixation
Clay-shoveler's fracture	Avulsion fracture of C6/C7 spinous process	Conservative management
Central cord syndrome	Upper extremity weakness > lower	Early surgical decompression if deficit persists

Thoracolumbar Spine Injuries

Chance fracture
Burst fracture
Compression fracture

Management Principles

Immobilization: Crucial in the pre-hospital and early hospital phase
Methylprednisolone: No longer routinely recommended in Canada for acute spinal cord injury
Surgical intervention: Based on injury type, stability, and neurological status
Rehabilitation: Early involvement of interdisciplinary team

Canadian Guidelines for Spinal Trauma Management

The following guidelines are specific to Canadian healthcare practices:

Acute Spinal Cord Injury: The Canadian Spine Society no longer recommends routine use of high-dose methylprednisolone.
Cervical Spine Clearance: The Canadian C-Spine Rule is preferred over NEXUS in Canadian emergency departments.
Thoracolumbar Injury Classification and Severity Score (TLICS): Widely used in Canada for guiding thoracolumbar injury management.
Early Rehabilitation: Canadian best practices emphasize early involvement of rehabilitation specialists in acute spinal cord injury management.

Key Points to Remember for MCCQE1

🍁 Memorize the Canadian C-Spine Rule for cervical spine clearance
🧠 Understand the ASIA Impairment Scale for spinal cord injury classification
🏥 Know the indications for surgical intervention in spinal trauma
🚑 Emphasize the importance of pre-hospital immobilization in Canadian EMS protocols
🩺 Be familiar with the CanMEDS roles in managing spinal trauma patients, especially as a Medical Expert and Collaborator

Sample Question

A 25-year-old man is brought to the emergency department after a motor vehicle collision. He complains of neck pain and numbness in both arms. On examination, he has weakness in both upper extremities (3/5 strength) but normal strength in the lower extremities. Which one of the following is the most likely diagnosis?

Explanation

The correct answer is:

C. Central cord syndrome

Central cord syndrome is characterized by greater weakness in the upper extremities compared to the lower extremities. This pattern is typically seen in hyperextension injuries of the cervical spine, particularly in patients with pre-existing cervical spondylosis. The presentation of neck pain, numbness in both arms, and weakness predominantly in the upper extremities is classic for central cord syndrome.

MCCQE1 Tip

Remember the pattern: "Central cord syndrome = arms > legs" for your MCCQE1 exam preparation.

References

Noonan, V. K., et al. (2012). Incidence and prevalence of spinal cord injury in Canada: A national perspective. Neuroepidemiology, 38(4), 219-226.
Fehlings, M. G., et al. (2017). A clinical practice guideline for the management of patients with acute spinal cord injury: Recommendations on the use of methylprednisolone sodium succinate. Global Spine Journal, 7(3_suppl), 203S-211S.
Stiell, I. G., et al. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA, 286(15), 1841-1848.
Vaccaro, A. R., et al. (2005). A new classification of thoracolumbar injuries: The importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine, 30(20), 2325-2333.
Canadian Medical Association. (2015). CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada.

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