Spine Trauma

Media Review

CJEM 1999;1(1):72

Spine Trauma
Edited by A.M. Leaven, F.J. Easement, S.R. Garfin and J.E. Zigler. 660 pp. WB Saunders, 1998. ISBN 0-7216-2957-1

Clearance of the cervical spine remains a concept deeply embedded in emergency medicine, although it is fraught with practical and conceptual difficulties. Recent literature has expanded the concept to clearance of the entire spine - an even more formidable task for the practising emergency physician.

Despite the availability of excellent comprehensive texts on spinal radiology, references correlating radiological abnormalities with clinical presentation are sorely lacking. Terminology such as flexion tear drop, extension tear drop, atlantoaxial rotational deformity, and facet perch, although familiar to emergency physicians, may be incompletely or differently understood. Although the editors recognize that less than 10% of patients who suffer from spinal injuries develop neurological deficits, guidelines for the acute management of specific types of spinal trauma in both cord-injured and non-cord-injured patients are provided.

The text is divided into four sections: General Principles, Cervical Injuries, Thoracolumbar Injuries, and Postoperative Care and Complications. Each of the injury chapters is divided into anatomy, mechanism of injury, classification, radiology, clinical presentation and treatment. The majority of the book's 56 authors are orthopedic surgeons, which accounts for the emphasis on specific operative techniques. Despite this emphasis, the book is still useful to the practising emergency physician, but the level of discussion mandates an adequate preexisting knowledge of anatomy and spinal radiology.

The General Principles section contains several valuable chapters; however, the second chapter, "Initial management of the polytrauma patient," is distinctly dated in its recommendations for routine nasal intubation, as well as in its lack of discussion of rapid sequence intubation (RSI), advocacy of hyperventilation of head injured patients, and euvolemic volume resuscitations. In this chapter, no references more recent than 1988 were cited. The subsequent chapters on physical examination and spinal radiology are succinct and well written. The spinal radiology chapter provides an excellent overview of injury mechanisms and rational explanations for the liberal use of computed tomography and magnetic resonance imaging, while refraining from nebulous radiological definitions of stability.

The 10 chapters in Cervical Injuries are uniformly well written and exceptionally detailed. Each of the chapters is supplemented with high-quality radiographic studies of various injuries. I have never encountered a more comprehensive discussion of cervical trauma. The discussion of C2 fractures contains graphic descriptions of judicial knot placement and a formula to determine the drop distance necessary to ensure 100% mortality.

The 7 chapters devoted to thoracolumbar injuries are of equally high quality, although assertions such as "multiplanar CT must be used in all lumbar compression fractures to document an intact vertebral ring" may pose logistical difficulties for technologically challenged Canadian emergency physicians.

Fortuitously, after I finished reviewing this text, one of my colleagues sustained a sacral fracture while snowboarding. Not only could I provide a classification of sacral injuries, I was also able to quote the incidence of neurological injury. She was neither amused nor reassured.

Overall, this text is a valuable reference for the practising and experienced emergency physician with a good baseline knowledge of clinical and radiologic spinal trauma.

Ross Berringer, MD
St. Paul's Hospital
Vancouver, BC