A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?

Focused Assessment with Sonography in Trauma

A 38-year-old man comes to the physician for a follow-up examination. He has quadriparesis as a result of a burst fracture of the cervical spine that occurred after a fall from his roof 1 month ago. He has urinary and bowel incontinence. He appears malnourished. His temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 104/60 mm Hg. Examination shows spasticity in all extremities. Muscle strength is decreased in proximal and distal muscle groups bilaterally. Deep tendon reflexes are 4+ bilaterally. Plantar reflex shows extensor response bilaterally. Sensation to pinprick and temperature is absent below the neck. Sensation to vibration, position, and light touch is normal bilaterally. Rectal tone is decreased. There is a 1-cm area of erythema over the sacrum. Which of the following is the most likely cause of this patient's symptoms?

Damage to the anterior spinal artery

Hemi-transection of the spinal cord

Cavitation within the spinal cord

Injury to gray matter of the spinal cord

Occlusion of the posterior spinal artery

A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most consistent with his presentation?

Left-sided Brown-Sequard (hemisection)

Right-sided Brown-Sequard (hemisection)

A 22-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained driver. After extrication, he had severe neck pain and was unable to move his arms and legs. On arrival, he is lethargic and cannot provide a history. Hospital records show that eight months ago, he underwent an open reduction and internal fixation of the right humerus. His neck is immobilized in a cervical collar. Intravenous fluids are being administered. His pulse is 64/min, respirations are 8/min and irregular, and blood pressure is 104/64 mm Hg. Examination shows multiple bruises over the chest, abdomen, and extremities. There is flaccid paralysis and absent reflexes in all extremities. Sensory examination shows decreased sensation below the shoulders. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. There is swelling of the right ankle and right knee. Squeezing of the glans penis does not produce anal sphincter contraction. A focused assessment with sonography for trauma shows no abnormalities. He is intubated and mechanically ventilated. Which of the following is the most appropriate next step in management?

Intravenous dexamethasone therapy

A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?

Flaccid paralysis at the level of the lesion

A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

Computed tomography (CT) scan of cervical spine, hips, and lumbar area

AP and lateral radiographs of hips

Lateral radiograph (x-ray) of hips

Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area

Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area

A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

External fixation of the pelvis

Spinal trauma for USMLE Step 3: High-Yield Surgery Lessons

Initial Assessment - Stabilize & Scrutinize

ATLS Protocol: Begin with Airway (with C-spine protection), Breathing, Circulation, Disability, Exposure.
Spinal Immobilization: Maintain rigid cervical collar and log-roll patient to prevent secondary injury.
C-Spine Clearance:

Shock States: | Feature | Spinal Shock | Neurogenic Shock | | :--- | :--- | :--- | | Mechanism | Cord concussion | Loss of sympathetic tone | | Duration | Days to weeks | < 72 hours | | Reflexes | Flaccid paralysis, loss of reflexes | Variable | | Hemodynamics | N/A (not a true shock state) | Hypotension, Bradycardia (↓HR) |> ⭐ Exam Favorite: Neurogenic shock is unique! It presents with hypotension AND bradycardia due to unopposed vagal tone, unlike the tachycardia seen in hypovolemic shock.

Spinal Cord Syndromes - A Mixed Bag

Spinal Cord Tracts and Syndromes

Syndrome	Mechanism	Key Deficits
Anterior Cord	Flexion / ASA Occlusion	↓ Motor, Pain, & Temp below lesion. Proprioception intact.
Central Cord	Hyperextension	Upper > Lower limb motor weakness. "Cape-like" distribution.
Brown-Séquard	Hemisection / Penetration	Ipsilateral: ↓ Motor, Proprioception. Contralateral: ↓ Pain, Temp.
Posterior Cord	Rare (e.g., Tabes Dorsalis)	↓ Proprioception & Vibration.
Cauda Equina	L2+ Root Compression	⚠️ Saddle anesthesia, bowel/bladder dysfunction, LMN signs.

Imaging & Grading - Picture The Damage

Imaging Modalities:
- CT scan is the initial workhorse for assessing bony fractures and alignment.
- MRI is superior for evaluating the spinal cord, ligaments, intervertebral discs, and hematomas.
Stability Assessment:
- Denis 3-Column Model: An injury involving ≥2 columns is considered mechanically unstable.
Functional Grading:
- ASIA Impairment Scale grades the severity of neurologic deficit.

⭐ The absence of all NEXUS criteria (e.g., no midline tenderness, normal alertness) allows for clinical clearance of the cervical spine without imaging.

Denis 3-Column Model of the Spine

Named Fractures - The Usual Suspects

Jefferson Fracture: C1 burst from axial load; fractures of anterior/posterior arches.
Hangman's Fracture: Traumatic spondylolisthesis of C2 (pars interarticularis) from hyperextension.
Odontoid (Dens) Fracture:
- Type I: Tip avulsion (stable).
- Type II: Base fracture (unstable).
- Type III: Extends into C2 body.
Chance Fracture: Flexion-distraction (seatbelt) injury; horizontal vertebral fracture.
Teardrop Fracture: Flexion/extension injury; anteroinferior fragment; highly unstable.

⭐ Odontoid Type II fractures are the most common type and are notoriously unstable with a high risk of non-union.

Complications - The Long Haul

Autonomic Dysreflexia: (Lesions above T6) Potentially fatal hypertensive crisis from noxious stimuli (e.g., full bladder).
Thromboembolism (DVT/PE): Requires routine prophylaxis with anticoagulants and/or mechanical compression.
Pressure Ulcers: Prevention is key; requires frequent repositioning and meticulous skin inspection.
Respiratory Compromise: Injury at C3-5 paralyzes the diaphragm, often necessitating long-term ventilation.
Rehabilitation: A multidisciplinary team is vital for long-term functional improvement.

⭐ The most common trigger for autonomic dysreflexia is bladder distention due to a blocked urinary catheter.

Always prioritize airway management with a modified jaw thrust to protect the cervical spine.

Differentiate neurogenic shock (hypotension, bradycardia) from spinal shock (transient reflex loss).

Use NEXUS criteria or Canadian C-Spine Rule to clinically clear the C-spine.

Anterior cord syndrome spares proprioception; Central cord syndrome causes greater upper extremity weakness.

Brown-Séquard syndrome is hemisection: ipsilateral motor/proprioception loss, contralateral pain/temperature loss.

CT is the best initial imaging for bony injury; MRI is superior for cord and soft tissue evaluation.

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Spinal trauma