V 20TH ANNIVERSARY
12 December 1999
CE Refereed Peer Review
FOCAL POINT
★ Accurate clinical assessment and
immobilization of animals with
spinal trauma are important for
successful patient management.
KEY FACTS
■ Animals that are suspected of
having an unstable vertebral
segment should be rigidly
immobilized as quickly as
possible.
■ Clinical assessment should
be done cautiously to avoid
iatrogenic damage to the spinal
cord.
■ When a nervous system injury is
suspected, a complete neurologic
assessment is mandatory to
determine the location and
severity of nervous tissue
damage.
■ Because vertebral fractures
and subluxations can be subtle
and visually difficult to assess,
good-quality, well-positioned
radiographs are essential.
■ Methylprednisolone sodium
succinate should be administered
as soon as possible after an
animal has sustained spinal
injury.
Vol. 21, No.
Exogenous Spinal
Trauma: Clinical
Assessment and
Initial Management
Washington State University
Rodney S. Bagley, DVM Anthony J. Cambridge, BVMS
Michael L. Harrington, DVM, MS Rebecca L. Connors, LVT
Gena M. Silver, DVM, MS Michael P. Moore, DVM, MS
ABSTRACT: Spinal trauma is a common cause of spinal cord dysfunction in dogs and cats.
When the spine is subjected to exogenous injury, the resultant impact often causes vertebral
fracture or luxation. Because each spinal injury is unique, treatment guidelines must be indi-
vidualized. This article reviews clinical assessment and management of spinal trauma.
S
pinal trauma, a common cause of spinal cord dysfunction in dogs and
cats,1–8 can occur from exogenous or endogenous spinal injury. Interverte-
bral disk extrusion remains the most common endogenous cause, whereas
automobile-related injury is the most common exogenous cause. Falls, trauma
from falling objects, and projectile damage are also common. External impacts
often result in vertebral fracture, subluxation, or luxation. This articles focuses
on the clinical management and treatment of small animals with exogenous
spinal injuries that result in vertebral fracture or luxation.
PATHOPHYSIOLOGY
The pathophysiologic changes that occur in the spinal cord after external impact
have been reviewed.1–7 Briefly, there are two major injuries: the primary mechani-
cal injury and the resultant pathophysiologic sequelae or secondary injury. The
primary injury usually includes shearing and disruption of axonal processes, nerve
cell bodies, and supporting structures (e.g., glial cells, vascular elements), resulting
in physiologic or morphologic disruption of nervous impulses. Any change in the
vertebral canal diameter may cause spinal cord displacement, compression, and in-
creased intraspinal pressure. Nervous impulses in this area may be disrupted be-
cause of increasing pressure applied to the axons and nerves or from ischemia
caused by alteration in spinal cord blood flow or hemorrhage. These increased
pressures set in motion numerous pathophysiologic consequences, including is-
Compendium December 1999 20TH ANNIVERSARY Small Animal/Exotics

chemia, further hemorrhage, tional persons to help trans-

and edema.1–7 port the animal can mini-
Because gray matter nor- mize the chance of addition-
mally receives proportional- al injury.
ly higher blood flow than After the animal arrives
does white matter, ischemic- at the veterinary clinic, it
related damage often occurs should be rigidly immobi-
to gray matter first. Central lized to decrease the risk of
hemorrhagic necrosis is the further mechanical damage
pathologic consequence. All to the spinal cord.4 It is im-
these events lead to a self- portant to quickly obtain a
perpetuating process of complete history of the in-
damage to the spinal cord jury; significant information
that often is equally, if not Figure 1A includes whether the owner
more, detrimental than the witnessed the accident, how
initial mechanical injury; long ago it occurred, and
this is referred to as the sec- what movement the animal
ond injury theory.1–7 Putative was capable of immediately
mediators of this self-per- after the trauma. For exam-
petuating process include ple, was the dog able to walk?
excitatory neurotransmit- Has it been able to urinate on
ters, endorphins, catechola- its own?
mines, lipid peroxidation, During the initial evalua-
and free radicals released af- tion, the animal should re-
ter the initial insult. main in the same position as
Based on this informa- that on admission (usually
tion, two therapeutic con- lateral or sternal recumben-
siderations become para- Figure 1B cy). Excessive manipulation
mount when treating a should be avoided. If the
spinal injury with fracture Figure 1— (A) A dog with spinal trauma that has been immo- history strongly suggests spi-
or luxation. One is to pre- bilized using a backboard. (B) The head can also be taped if a nal trauma or if the animal
vent further mechanical cervical lesion is suspected. is struggling to move, it
damage to the spinal cord should be immediately re-
by stabilizing the vertebral column.4 The second con- strained and immobilized by being firmly taped to a
sideration is to stop or hinder the development of sec- rigid backboard or similar structure (Figure 1). A spinal
ondary pathophysiologic events that perpetuate the trauma board (8 to 10 inches wide by 4 to 5 feet long
magnitude of spinal damage. Much of current medical by 1 to 2 inches deep) works well; but any rigid, mov-
therapeutic efforts have been directed at counterbalanc- able surface can be used. Before securing the animal,
ing or neutralizing the effects of these by-products of the board should be weighed so that an accurate weight
trauma. of the animal can be recorded later. If thoracolumbar
vertebral trauma is suspected, the animal can be se-
CLINICAL ASSESSMENT cured to the board by placing tape over the scapular
Immobilization and femoral trochanter regions. If a cervical injury is
Owners often witness traumatic spinal injuries; how- suspected, the head should also be secured.
ever, some animals are found acutely dysfunctional
without a known traumatic history. When owners con- Physical, Neurologic, and Musculoskeletal
tact the veterinary office for advice on transporting an Because spinal injury frequently occurs in concert with
injured animal, they should be advised to be cautious multiorgan trauma, other life-threatening injuries should
because traumatized animals may become uncharacteris- be identified as quickly as possible. A standardized,
tically aggressive. Animals with spinal injuries should be stereotypical physical examination should be conducted9;
placed on a rigid, movable surface. If a board or other critical care physical diagnosis checklists may be useful.
rigid device is not available, the animal can be transport- Specific assessments include respiratory and heart rates,
ed in a blanket or slinglike apparatus. Recruiting addi- heart rhythm, degree of peripheral perfusion (capillary re-

SECOND INJURY THEORY ■ TRANSPORTATION ■ SPINAL TRAUMA BOARD

Small Animal/Exotics 20TH ANNIVERSARY
fill time, coolness of limbs),
ability to move voluntarily,
and level of consciousness.
The level of consciousness
significantly influences subse-
quent neurologic evaluation
(e.g., if the animal is poorly
responsive because of inade-
quate perfusion to the brain,
assessment of deep pain sen-
sation will be difficult).
When a nervous system in-
jury is suspected, a complete
neurologic assessment is man- Figure 2—A dog exhibiting the Schiff-Sherrington posture af- The presence or absence of
ter being hit by a car. Note the thoracic limb extension.
datory to determine the lo-
cation and severity of ner-
vous tissue damage. However, if the animal has an
unstable vertebral fracture, the normal manipulations
and standard neurologic examination may not be possi-
ble. The examination and diagnostic sequence as well
as mobilization method therefore need to be modified
to accommodate possible unstable vertebral fracture.
If the animal is mentally alert but unable to move,
immediate concerns should be directed toward the neu-
rologic and musculoskeletal systems. Observing the an-
imal’s posture can be helpful in determining whether a
neurologic abnormality exists. For example, Schiff-
Sherrington posture is characterized by thoracic limb
extension and an inability to move the pelvic limbs
normally (Figure 2).8,10 Spinal reflexes in the pelvic
limbs are usually normal. This results from a lesion in
the thoracolumbar spinal segments that interrupts the
ascending inhibitory impulses originating from border
cells in the lumbar gray matter and terminating on cells
responsible for extension of the thoracic limbs. The
thoracic limbs are otherwise neurologically normal. Al-
though Schiff-Sherrington posture usually occurs in an-
imals with severe spinal cord injuries, this posture alone
does not indicate that the spinal lesion is irreversible.
The presence or absence of deep pain sensation in the
pelvic limbs is a more important prognostic indicator.
Voluntary movement indicates that some nervous im-
pulses are traversing the injured spinal area. It is impera-
tive, however, to differentiate voluntary from reflex
movements. Reflex movements occur when animals are
touched or physically stimulated, whereas voluntary
movements are made without external stimulation. Talk-
ing to the animal or calling its name may result in at-
tempts to move its limbs or wag its tail. Such stimulation
should be attempted only while the animal remains re-
strained. Until definitively proven otherwise, voluntary
movement should be assumed to be absent.
The animal should be in lateral recumbency when
SCHIFF-SHERRINGTON POSTURE ■ VOLUNTARY VERSUS REFLEX MOVEMENTS ■ SEVERITY OF INJURY
Compendium December 1999
the cranial nerves, spinal re-
flexes, and cutaneous trunci
reflexes are assessed and the
spine is palpated for hyper-
esthesia. Finding an area of
focal spinal hyperesthesia is
an important clue that spinal
injury may have occurred.
Deep Pain Sensation
The initial assessment
should conclude with analy-
sis of deep pain sensation.
deep pain sensation has ma-
jor ramifications for the
prognosis. Using a hemostat, a painful stimulus should
be applied to affected digits; testing for skin sensation
only will not confirm retention of deep pain sensation.
Deep pain sensation is intact if the animal reacts by vo-
calizing or turning toward the stimulus, often attempt-
ing to bite the examiner. However, simply pulling the
foot away from the stimulus does not indicate con-
scious recognition of deep pain. Misinterpretation of
this withdrawal reflex may lead to a falsely optimistic
prognosis.
To evaluate the animal’s opposite (down) side, a sec-
ond backboard can be placed on the upside of the ani-
mal and the animal flipped over and secured to the sec-
ond backboard. The same techniques should be
followed as those already described.
After spinal trauma has been established, the severi-
ty of injury needs to be determined before developing
a management strategy and discussing a realistic prog-
nosis with the owner. The severity of a spinal cord in-
jury is usually graded according to clinical findings
(Table I). Animals with less severe trauma (painful
only; mildly paretic) are more often managed without
surgical intervention.13 Animals with more severe neu-
rologic impairment (nonambulatory paretic or para-
lyzed) are usually considered for surgical stabilization.
It is important to recognize, however, that scientific
data supporting many current treatment recommen-
dations are lacking. Individual clinical experience with
the various treatments is often the overriding factor in
decision making. Anecdotal experiences, however, are
difficult to prove without case-controlled studies. Un-
fortunately, individual assessments based on clinical
experience and owner wishes remain the guiding
forces behind management decisions in animals with
spinal trauma.
Animals lacking deep pain sensation are less likely to
return to normal function.4 If animals with interverte-
Compendium December 1999
bral disk disease have de-
compressive surgery within
48 hours of losing deep pain
sensation, they have approxi-
mately a 50% or greater
chance of walking eventual-
ly.14 In contrast, we have found
that animals that lose deep
pain sensation after suffering
spinal trauma have consider-
ably less than a 50% chance
of recovery. If deep pain sen-
sation has been lost for 48
hours or longer, there is vir-
tually no chance of func-
tional recovery. Further-
more, if deep pain sensation
is absent in an animal with
100% or greater displace-
ment of the vertebral canal,
the prognosis for walking is
hopeless (Figure 3).
DIAGNOSTIC TESTING
If a vertebral injury is sus-
pected, survey radiographs of
the affected area should be
taken before continuing the
examination. Vertebral frac-
tures and subluxations can be
subtle and visually difficult to
assess. Thus good-quality,
well-positioned radiographs
are essential.11,12 Initial radio-
graphic assessment of obvi-
ous displacements of the ver-
tebrae can be done while the
animal is awake and immo-
bilized. Sedation may be nec-
essary in some animals; how-
ever, it may influence the
results of further neurologic
examination. Animals should
be sedated only after deter-
mining the extent and severi-
ty of the trauma.
Survey radiographs pro-
vide a static record of the po-
sition of the vertebrae. In-
formation regarding how
extensive the displacement
of vertebrae was at the time
of injury and before radiog-
SURVEY RADIOGRAPHY ■ DEGREE OF DISPLACEMENT ■ DRUG THERAPY
20TH ANNIVERSARY Small Animal/Exotics
TABLE I raphy, however, may not be
Grading Scale for Assessing appreciated from a single im-
Treatment of Spinal Injuriesa age. Because of the strong
paraspinal musculature, ver-
Grade Condition tebrae can be displaced acute-
8 Normal ly at the time of injury and
7 Pain only subsequently pulled back to a
more normal position. This
6 Paresis (walking)
possibility should be consid-
5 Paresis (not walking) ered in patients with verte-
4 Paraplegia (urination and deep pain sensation bral trauma when clinical
intact) signs appear worse than that
3 Paraplegia (urination absent and deep pain suggested by radiography.
sensation intact) Disturbances to adjacent soft
2 Paraplegia (deep pain sensation absent <48 hr) tissue (e.g., paraspinal muscle
1 Paraplegia (deep pain sensation absent >48 hr) disruption, hematoma) may
provide radiographic clues to
aFrom
least to most severely injured. the location of injury. The
degree of displacement of the
vertebral canal on radiographs
is less important in determin-
ing prognosis than is the de-
gree of neurologic impair-
ment.
CORTICOSTEROID
THERAPY
Corticosteroid therapy is
an important adjunctive ther-
apy for humans and animals
with spinal trauma.15–24 Ideal-
ly, corticosteroids are admin-
istered as soon as possible
Figure 3A after a spinal injury, either
before or during radiographic
evaluation. A multicenter
study in humans also sug-
gested that methylpred-
nisolone sodium succinate
(MSS) administered up to 8
hours after spinal trauma was
beneficial. 16 Experimental
studies in small animals have
suggested that after spinal
trauma, the time frame in
which MSS is helpful may be
Figure 3B
less (possibly as little as 1
hour).15–24 This information
Figure 3—(A) Survey radiograph of a dog that lacks deep pain suggests that recommenda-
sensation in the pelvic limbs. There is greater than 100% dis- tions in human trials regard-
placement of the vertebral canal L3-4. (B) Sagittal T2-weight- ing the benefit of MSS may
ed magnetic resonance image of the same area. The spinal be too long, thus emphasiz-
cord has been severed at this location.
ing the need to administer
Small Animal/Exotics 20TH ANNIVERSARY Compendium December 1999

MSS to small animals as quickly for 4 to 6 weeks may be a satis-

as possible. Other corticoster- factory or equally beneficial
oids (e.g., dexamethasone)25 have treatment for animals with
not been proven effective treat- spinal trauma.32,33 External sup-
ment of experimental spinal port bandages or casts have also
trauma and have been associated been successful as nonsurgical
with significant complications in treatment of animals. 34 The
clinically affected animals with goals of external support should
spinal disease.26–28 be immobilization of the verte-
In studies in humans, a 30- bral segments above and below
mg/kg intravenous (IV) bolus the damaged area. This support
of MSS was administered ini- should be as rigid as possible to
tially, followed by 5.4-mg/kg/ ensure that minimal, and ideal-
hour IV for the next 23 hours ly no, motion of the vertebral
as a constant-rate infusion in an column occurs around the af-
attempt to keep high levels of fected area.
the drug in the injured cord for Figure 4A First, a soft bandage should
a longer period. This regimen, be extended above or below the
however, is labor intensive and thoracic limbs for thoracolum-
requires 24-hour monitoring of bar and cervical fractures, re-
the animal. An alternative but spectively. Cast padding cov-
experimentally unproved proto- ered by cling gauze and elastic
col is MSS as an initial bolus wrap works well as the initial
(time 0) at a dose of 30 mg/kg bandage. A plaster or fiberglass
IV, with additional doses of 15 cast can then be molded to the
mg/kg IV at 2 and 6 hours after shape of the spine and used for
the initial dose. rigid support; however, we pre-
If MSS is administered too fer using aluminum rods bent
quickly to an awakened ani- in a rectangular shape and con-
mal, vomiting often occurs. If Figure 4B toured to the curvature of the
MSS is given too rapidly to an spine (Figure 4). The ends of
animal under general anesthe- Figure 4—(A) A dog with an L-1 fracture that has had the rectangular configuration
sia, hypotension often is noted. an external spinal splint applied. The handles are helpful can then be bent outward and
when moving the dog. (B) A male dog with a T13-L1
In addition, a primary compli- used as handles that will assist
luxation that has had an external spinal splint applied. A
cation of MSS administration waterproof pad has also been applied to the ventral as- during manipulation, physical
to dogs with spinal injury is pect of the bandage to minimize the possibility of urine therapy, and walking. Additional
gastrointestinal ulceration.26–30 soaking the bandage. handles can be fashioned with
Acute death has also been not- the bandage to serve the same
ed experimentally with bolus purpose (Figure 5). The casting
injections of MSS; however, this is very rare in clinical material or aluminum rods should be secured to the soft
practice.31 Regardless, we advise administering IV MSS wrap with bandage material (e.g., white porous tape).
over a period of approximately 5 to 10 minutes. In animals with a cranial cervical fracture, the ban-
dage should be extended upward and over the animal’s
NONSURGICAL TREATMENT head to the level of the eyes (Figure 5). Holes can be
Treatment of spinal trauma can be separated into sur- cut in the bandage to allow the ears to protrude nor-
gical and nonsurgical categories, although combined mally. If external support is applied after surgery, the
modalities may be appropriate. Whether to use either bandage material immediately overlying the incision
or both of these treatments depends on numerous fac- can be cut open to allow visual inspection of the inci-
tors, including anecdotal experiences of the examiner sion. With lower lumbar and lumbosacral fractures, es-
and such nonmedical factors as owner finances. pecially in male dogs, the penis or vulva should not be
In general, major indications for surgery are reduction bandaged. To prevent males from urinating on the ban-
of spinal instability and alleviation of spinal cord com- dage, a plastic shield cut from a used IV fluid bag or
pression. In some instances, however, cage confinement waterproof pads can be ventrally secured to the ban-

METHYLPREDNISOLONE SODIUM SUCCINATE ■ EXTERNAL SUPPORT ■ BANDAGING

Compendium December 1999 20TH ANNIVERSARY
Figure 5—A dog with a C-2 fracture was wrapped in a sup-
port bandage with handles.
dage, a plastic shield cut from a used IV fluid bag or
waterproof pads can be ventrally secured to the ban-
dage (Figure 4). If more protection against moisture
damage is needed, a trash bag or suitable barrier can be
placed over the bandage with the ends tucked into it.
After completing the bandaging, the animal should
be closely monitored for complications. For example,
the layers of bandaging may cause an increase in the an-
imal’s body temperature, especially if the ambient envi-
ronment is warm. Thus the animal’s body temperature
should be monitored often. In addition, if the bandage
is too tight around the thorax or cervical area, mechani-
cal respiratory problems may develop.
External supports and bandaging should remain in
place for 4 to 6 weeks or until healing is complete. The
bandaging should be changed as needed, especially if
the skin becomes irritated. Loose-fitting bandaging also
should be replaced.
Follow-up evaluations should be scheduled as nec-
essary but ideally at 3 and 6 weeks after injury. How-
ever, more frequent visits may be required if external
support bandaging needs to be changed. Radiograph-
ic reassessments of fracture healing can determine
when cage confinement or external support can be
terminated. Gradual return to exercise should be ini-
tiated when healing is complete. During weeks 1 to 2
of returning to exercise, short (10 to 15 minutes)
leash-controlled walks should be initiated one to
three times a day on surfaces with good footing. If
leash walks are tolerated, the duration and number of
walks during the day can be increased over the next 2
to 4 weeks. If the animal tolerates this exercise, it
should be allowed free activity in enclosed activity ar-
eas (e.g., a fenced backyard).
BANDAGING COMPLICATIONS ■ FOLLOW-UP EVALUATIONS ■ RETURN TO EXERCISE
Small Animal/Exotics
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Compendium December 1999
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About the Authors
Drs. Bagley, Harrington, Silver, Cambridge, and Moore
and Ms. Connors are associated with the Department of
Clinical Sciences, Washington State University, College
of Veterinary Medicine, Pullman, Washington. Drs. Bagley
(Neurology and Internal Medicine), Harrington (Neurolo-
gy), and Moore are Diplomates of the American College
of Veterinary Internal Medicine. Dr. Silver is a resident in
neurology and neurosurgery. Dr. Cambridge is a resident
in surgery. Ms. Connors is a neurology veterinary techni-
cian.