Back and neck injuries

The goals of initial emergency care for spine injuries are to resuscitate, haemodynamically stabilise the patient and prevent secondary or further spinal injury.

Key principles

• Consider the degree of the spinal injury.
  • Is it complete or incomplete?
• Consider the four levels:
  • Neurological
  • Sensory
  • Motor
  • Skeletal
• Establish the mechanism and how it affects pattern of injury.
  • Flexion, rotation, extension and compression injuries will present with different patterns, both clinically and radiologically.

Assessment

• Use the Emergency Care Assessment and Treatment (ECAT) resources to assess and manage traumatic neck and back injuries.
  • Traumatic injury (adult)
  • Secondary survey (paediatric)
  • Secondary survey (adult)
• For all neck (cervical spine) and back (thoracolumbar spine) injuries, it is essential to establish the mechanism of injury.
• Maintain the cervical collar and apply spinal precautions.
  • If collar not fitted, refer to Use of foam collars for cervical spine immobilisation - Initial management principles (PDF) to fit one.
• If a spinal injury is suspected, perform a thorough neurological examination, including a detailed sensory exam (if the patient can comply), log roll and rectal examination and document your findings carefully. This may happen prior to radiology. Your findings may have important implications for management, transfer, medico-legal sequalae and patient prognosis.

Clinical decision rules

The following clinical decision tools can help you decide which patients require radiology to rule out a significant cervical spinal injury:

• NEXUS Criteria for C-Spine Imaging
• Canadian C-Spine Rule (suitable for alert, stable trauma patients)

Cervical spine injuries

Consider whether there are features to the patient or their history that require mandatory radiology or make clinical clearance impossible.

Thoracolumbar injuries

• If there is thoracolumbar fracture in trauma, consider the possibility of concurrent intra-abdominal or solid organ injury.
• Thoracic vertebral fractures are frequently missed on plain x-rays (will detect only 75%).
• Wedge or compression fractures are common in osteoporosis and may occur spontaneously. Remember, the elderly person with back pain has a much lower threshold for considering imaging.
• Consider the ‘columns’ when assessing if a fracture is stable versus unstable.
• If anterior margin is reduced by >50% and/or posterior ligament is injured, it may be a potentially unstable fracture requiring surgery. You are generally advised to progress to CT imaging for further assessment if >30% collapse. Otherwise, most wedge fractures are managed conservatively with symptomatic treatment, but the elderly may require admission for mobility or pain management.
• Chance fractures (disruption involving all three spinal columns) may be missed on CT without bony (saggital) reconstructions. The ‘typical’ flexion injury is associated with using a lap belt or falling from height and has a high rate of concurrent intra-abdominal pathology.

Spinal cord syndromes

Cauda equina syndrome

Though not a spinal cord syndrome, cauda equina syndrome is considered here because its location within the spinal canal subjects it to many of the same disease processes that cause myelopathy.

Cause

The syndrome is caused by the loss of functions of two or more of the 18 nerve roots constituting the cauda equina.

Symptoms

• Deficits usually affect both legs but are often asymmetric.
• Low back pain accompanied by pain radiating into one or both legs. Radicular pain reflects involvement of dorsal nerve roots and may have localising value.
• Weakness of plantar flexion of the feet with loss of ankle jerks occurs with mid-cauda equina lesions, involving S1, S2 roots. Involvement of progressively higher levels leads to corresponding weakness in other muscles.
• Bladder and rectal sphincter paralysis usually reflects involvement of S3-S5 nerve roots.
• Sensory loss of all sensory modalities occurs in the dermatomal distribution of the affected nerve roots.

Etiology

Many etiologies can cause a cauda equina syndrome, including intervertebral disc herniation, epidural abscess, epidural tumour, intradural extramedullary tumour, lumbar spine spondylosis, several inflammatory conditions, e.g. spinal arachnoiditis, chronic inflammatory demyelinating polyneuropathy and sarcoidosis; and some infections, e.g. cytomegalovirus, herpes simplex virus, herpes zoster virus, Epstein-Barr virus, Lyme disease, mycoplasma and tuberculosis.

Management

Investigations

• Expedite radiological assessment and imaging.
• Choice of investigations is influenced by age, mechanism and suspicion of injury as well as local resources at time of assessment.
• If you find one spinal fracture, look for the second!
• Plain films will provide an inadequate view in up to 35% of patients, even with Swimmer’s views.
• Cervical spine CT often replaces plain films. It should be the first investigation of choice for patients:
  • who are over 65 years
  • who are obese
  • where there is an indication for CT head
  • with significant pre-existing spinal pathology and some other considered situations.
• MRI is the investigation of choice for ligamentous injuries, spinal cord injury or oedema. However, MRI is not always effective for detecting certain types of fractures, e.g. Jefferson fracture and pedicle fracture.

Maintaining cervical spine precautions

We advocate the adoption of foam cervical collars in the initial management of injured people requiring cervical spine precautions being transported by NSW Ambulance and presenting to NSW Health facilities.

Use of foam collars for cervical spine immobilisation: Initial management principles

In recent years there has been increasing discussion around the use of spinal immobilisation, both pre- and in hospital, particularly use of the rigid cervical collar.

There is evidence that rigid collars can lead to significant complications and morbidity when used to secure the cervical spine.

These complications include:

• pressure areas of the scalp and neck
• increased pain adversely affecting compliance with immobilisation strategies designed to protect patients from further harm
• impaired jugular venous return and rises in intracranial pressure, both in head-injured and healthy people
• impaired respiratory effort and forced expiratory volume, particularly in older patients with chest injury or comorbid respiratory conditions, predisposing these patients to aspiration
• increased complexity of airway management
• increased extrication time and delay to definitive treatment.

Evidence indicates we are unable to completely immobilise the cervical spine in any collar and there is no data to support that any additional movement of an injured cervical spine causes more damage.

After consultation with specialist clinicians across NSW and consideration of the available evidence, we have concluded that the risks of immobilisation with rigid collars outweigh the chance of benefit.

See State Spinal Cord Injury Service resources

Autonomic dysreflexia

Autonomic dysreflexia is a medical emergency that can occur in people with spinal cord injury at or above the sixth thoracic (T6) level. It is a sudden and severe rise in blood pressure resulting from overactivity of an isolated sympathetic nervous system below the lesion, triggered by a nociceptive stimulus that can result in intracranial haemorrhage, fits, arrhythmias, hypertensive encephalopathy and even death. This potentially life-threatening condition requires immediate and decisive action.

Treatment of autonomic dysreflexia for adults and adolescents with spinal cord injuries
Use the guide, treatment algorithm and training videos to understand autonomic dysreflexia and manage patients with this condition.
Source: Agency for Clinical Innovation

Background

Epidemiology and patterns of injury

• Male:female ratio 4:1.
• Two peaks of injury, young adults and those >65 years.
• Falls >2m and motor vehicle accidents are the most common causes.
• Remember the three-column model; stability requires that two of the three columns of the cervical spine remain intact. This will delineate stable versus unstable injuries.
• C2 is the most commonly fractured vertebra.
• C5-6 or C6-7 are the most common dislocations.
• Spinal cord syndromes.

Spinal cord injury

Spinal shock (not to be confused with neurogenic shock) is a transient state used to describe dysfunction of neurones following a spinal concussion, i.e. there is no demonstrable injury to the spinal cord on MRI. It occurs within a few minutes of injury and lasts days to weeks but is associated with a good prognosis and potential for full recovery. It refers to a flaccid areflexia, rather than the loss of sympathetic vascular tone which accompanies neurogenic shock. Spinal shock and neurogenic shock may occur together. However, the terms have different pathophysiology and should not be used interchangeably.

Hypotension and spinal injury: in the trauma scenario, a hypotensive patient is presumed to be hypovolaemic until proven otherwise. While other forms of shock must be considered in the background (e.g. neurogenic), always remember that hypotension + trauma = hypovolaemia, even if a patient has a concurrent spinal cord injury.

Resources

• Acute low back pain clinical tool
  Source: Agency for Clinical Innovation
• Anatomy and localisation of spinal cord disorders
  Source: UpToDate
• Radiology assistant: Cervical injury
  A comprehensive overview of cervical spine injuries.
  Source: Adam Flanders, Department of Radiology and Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia
• State Spinal Cord Injury Service resources
  Source: Agency for Clinical Innovation

Patient information

• Acute low back pain consumer information

Change log

Date	Section updated	Change
March 2026	All	Minor revisions of text. Updated links to new resources. Removed obsolete resource links.