SPINAL INJURIES IN SNOW SPORTS


Spinal injuries are a rare but potentially devastating consequence of participation in many activities - snow sports included. Whilst one must never forget to manage life threatening airway, breathing and/or circulation problems first, the important thing with spinal injuries is to always consider whether the spine may have been damaged and - if it possibly has - treat the casualty appropriately to prevent any further injury.

I have divided this topic into two pages - this one covers the anatomy of the spine, the mechanisms associated with spinal injuries, when to suspect their presence and how to manage them in the pre-hospital environment. The second page specifically looks at the incidence and pattern of spinal injuries seen as a result of snow sports. This is basically an evidence-based review of the literature with a few of my own thoughts thrown in for good measure!

 

Spinal anatomy


The vertebral column is the central supporting pillar of the body and extends from the base of the skull to the tip of the coccyx bone (near your bum). Its function is to support the weight of the head and trunk - which is then transferred to the hips and lower limbs - and to protect the delicate spinal cord. The vertebral column is made up of individual bones called vertebrae, separated by the intervertebral discs which are made up of softer, squidgy soft of stuff (anatomy was never my forté...).

 

The vertebrae are arranged in five distinct groups. From top to bottom these are

► Cervical vertebrae (7 in total)
► Thoracic vertebrae (12 in total)
► Lumbar vertebrae (5 in total)
► Sacral vertebrae (5 - which are fused together to form the sacrum)
► Coccygeal vertebrae (4; of which the bottom three are usually fused together too)

 


The cervical cord runs through the centre of each vertebrae and carries within it the nerves that transmit both sensation and function (movement) to and from the various areas of the body. The higher the damage to the spinal cord, the more extensive the resulting injury. For example, if the spinal cord is damaged high up in the neck, this can affect all function below this point and leave someone both paralysed from the neck down and with no sensation below the neck. Damage lower in the sacral spine may result in very little functional loss at all. Added to this, the higher up the vertebral column you go, generally speaking the weaker the bones are. For these reasons, it is injuries to the neck and upper back that cause the most concern - as these are the sort of injuries that can result in devastating consequences.
 

Types of spinal injury


The easiest way to visualise spinal injuries is to think of the spinal column as a series of bricks, one on top of another with a wee soft disc in between each block (representing the discs). In the middle of each block and disc is a central hole, through which the spinal cord passes. The discs, being soft, allow the spine to be flexible so it can bend forwards (flexion), backwards (extension) and side wards (lateral flexion) as well as twist from side to side (rotation). The bricks also vary in strength - those in the cervical spine are small and relatively delicate - so less force is needed to break them. The lumbar bones, which need to support more of the body's weight, are big and strong and a lot of force is needed to damage them. The thoracic bones are in the middle - the lower ones are tougher than the upper ones.

The two main mechanisms of injury seen on the slopes are

► Flexion/hyper-extension  - where the head bends forwards and then extends back (like whiplash)
► Compression - where the bones are pushed down onto one another

These lead to different types of injury to the bones as shown below

Flexion/hyperextension injury

As the forces push forwards and backwards, pressure is applied to the front and/or back of the spinal bones potentially causing damage in these areas

Compression Injury

In these injuries, direct compression forces downwards literally squash the bones, resulting in a loss of height seen on x-ray. This x-ray also shows a chip fracture at the front of the lumbar vertebrae (green arrow)

 



 

Mechanisms of spinal injury


Spinal injuries should be assumed to be present until proven otherwise on the ski slopes when any of the following are involved:

  • Unconscious patient
  • Patient with multiple trauma
  • Significant injuries above the level of the clavicle (collar bone)
  • Incident involving a fall from > 10 feet (or twice the height of the patient)
  • Any sporting accident when there the impact forces are (or seem to be) high

 

Symptoms and signs of a spinal injury


It is important to remember that a spinal injury is not ruled out if the casualty can move and feel all their limbs. If the mechanism involved high impact forces, assume the worst and treat them as if their spine may be damaged. The following some of the usual symptoms that someone with a spinal injury will complain about (but don't be fooled by a lack of symptoms if the mechanism of injury was significantly forceful):-

  • Pain anywhere from the neck to the bottom. Remember that spinal pain can be covered up by a more painful injury elsewhere)
  • Loss of function (e.g. can't move a leg)
  • Loss or alteration of sensation anywhere on the body (such as pins and needles)
  • In the unconscious patient there maybe:

                  - Signs of spinal shock (slow pulse and low blood pressure)
                  - Generalised 'floppiness' in all the limbs
                  - Penile erection
                  - Loss of bowel or bladder control
 

Initial first aid for spinal injuries


The best way to learn first aid for any injury is to attend a recognised and certificated first aid course in your area. These may be run by first aid societies like the Red Cross or St John's Ambulance or by other organisations (including ski patrol associations). The following is not intended to replace attendance at such a course and is only a very brief overview of what to do if there is any possibility of a spinal injury having been sustained:

  1. Safety - The most immediate consideration in any accident scenario is always to consider your own safety - don't dive straight in, get injured yourself and create more
  2. Attend to the ABC's - Ideally with cervical spine control maintained. Do not let concerns about a possible spinal injury compromise the management of an actual airway, breathing or circulation problem.
  3. Keep the patient still - Whenever possible though, keep the whole spine as still as possible - don't move or allow the casualty to move themselves unless they will die or be significantly injured if they stay in the position they are in (e.g. from falling rocks etc). The neck in particular must be kept absolutely still and the best way to do this is to get someone to hold the head steady on either side - click on the thumbnail and you'll see, anyone can do it!
  4. Once the professional services arrive, the casualty will be fitted with a rigid cervical collar and very carefully manoeuvred and then immobilised onto some form of spinal transportation system - this may be a vacuum mattress, a rigid spinal board or a scoop stretcher (see below).


   
Patient immobilised on a rigid spinal board


     
The next page on spinal injuries will concentrate on spinal injuries on the ski slopes and look specifically at the published evidence regarding their incidence and specific features - click here for page 2.