Back: Acute Spinal Injuries

Spinal column injury classification and imaging. For head-injury imaging decisions, see Head Injury & Concussion; for facial/rib/sternal fracture management, see head, spine & chest fractures.

Imaging

Plain X-ray has almost no utility for spinal fracture (misses >50% of cervical spine fractures). CT is the standard first-line investigation. MRI is useful for cord, disc and ligament assessment, and preferred in children where radiation matters.

Severe neck pain with a normal CT: if the patient has no neurological symptoms, GCS 15 with a normal neurological exam, no significant distracting injury, and a CT reported as normal by a consultant radiologist — no further investigation or action is necessary. (Ligamentous injury without bony malalignment is the theoretical concern, but the above criteria are reassuring.)

Pre-hospital immobilisation

Routine spinal immobilisation (backboard, cervical collar, sandbags/straps, log-rolling) before hospital is widely practised on the assumption it prevents further cord damage, but the evidence base for this is thin. A Cochrane review found no randomised controlled trials of spinal immobilisation strategies in trauma patients at all — “the effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. “Immobilisation itself is not risk-free: tissue pressure and discomfort, difficulty swallowing, and — because cervical immobilisation can contribute to airway compromise — serious breathing problems, in a group where airway obstruction is already a major cause of preventable death. This doesn’t change current pre-hospital practice on its own, but it’s why selective immobilisation protocols (rather than reflexive full immobilisation of every trauma presentation) have gained traction.

Specific fracture patterns

• Spinous process fracture — trivial; can be very painful but does not explain a neuro deficit; not unstable.
• Wedge/compression fracture — stable, painful, almost always neurologically intact. Follow-up X-ray recommended (watch for vertebral collapse → kyphosis); bracing helps pain and reminds the patient to be careful, but does not itself stabilise the injury.
• Burst fracture — unstable; needs neurosurgical opinion and possibly surgical stabilisation.
• Central cord syndrome — pre-existing canal stenosis + hyperextension injury; upper-limb pain ± weakness with legs relatively spared.

Sacrum / coccyx

Pain on sitting and moving from sitting to standing.

• Coccygeal fracture — conservative: analgesia, sit on a rubber ring; heals over a few weeks.
• Sacral fracture — higher-energy trauma, can compromise sacral nerve roots. Actively ask about saddle anaesthesia and incontinence; consider rectal/perineal sensation examination.

Driving

No driving while symptoms are unresolved; otherwise follow the Austroads medical standards for licensing.