Assessment
of the spine
Trauma
Always assume that the patient has a spinal column injury until you have
proved otherwise
It is of great importance to recognise the presence of a spinal injury
as early as possible after the injury has occurred. This will prevent further
injury to the spinal cord and nerve roots, and give the patient the best chance
of a good long-term outcome. Throughout assessment and resuscitation the spine
must be suitably immobilised. Initially this can be done with simple in-line
immobilisation. Advanced trauma and life support (ATLS) protocols can then be
used to resuscitate the patient in the normal way (see Chapter 4).
The
patient should be suitably immobilised at the site of the injury on a spine
board with a hard collar and with the whole of the spine immobilised. The head
should be attached to the board with tape and steadied with sand bags or some
similar device (see Fig. 33.4). The patient can then be safely transported to a
suitable hospital for further treatment.
There
are certain features in an injured patient which should alert the doctor that
there may be a spinal injury of some sort:
• evidence of neurological injury;
• multiple injury;
• head injury;
• facial injury;
• high-energy injury (e.g. fall from a height);
• seat-belt abdominal marking (may suggest lumbar injury).
Assessment of the spine in the unconscious
patient with multiple injuries is probably the most difficult. If there are
associated life-threatening injuries, it is probably best to carry on and treat
these first before the spine is fully assessed. For example, a patient with
severe intra-abdominal bleeding may require urgent surgery. It is still
mandatory that the spine is protected throughout management, for example moving
the patient on to the operating table. Further spinal assessment can then be
carried out later.
The
spine must always be examined clinically as part of the secondary survey. This
can be done easily when the back of the patient is examined. If this is not
done, severe injuries such as an open spinal injury may be overlooked for some
hours.
In
the conscious patient without other severe injuries spinal injury can usually be
excluded by the combination of absent pain and a normal clinical examination of
the spinal column with a normal neurological examination.
In
the conscious patient biplanar X-rays of the symptomatic part of the spine are
adequate, and in the cervical spine open mouth view of the odontoid peg should
be included. In the unconscious patient assessment of the spinal column is much
more difficult because clinical signs are often absent. In the thoracic and
lumbar spine full anteroposterior (AP) and lateral X-rays of the spine are
required to exclude an injury to the spinal column. In the cervical spine
unstable injuries of the neck are easily overlooked, and full AP lateral and
odontoid peg views will still overlook about 5 per cent of injuries. One
option is to carry out real-time fiexion and extension X-rays of the cervical
spine using an image intensifier. If there is any evidence of instability at any
point the investigation is stopped. An alternative is to carry out magnetic
resonance imaging (MRI) scans on all these patients but this is time consuming
and difficult in the patient with multiple injuries.
The
extent of an injury may not be apparent initially, and further imaging in the
form of computerised tomography (CT) or MRI scanning may be required. For
example, in the unconscious the upper and lower cervical spine may be very
difficult to assess. Most of these patients will require a CT scan of the brain
to exclude a space-occupying lesion, and it is convenient to carry out a few CT
cuts at the occipitocervical junction and at the cervicothoracic junction to
exclude a significant injury, particularly if the cervicothoracic junction has
not been visualised on plain films. Similarly, the upper thoracic spine is a very
difficult area to visualise on plain films and if there is suspicion of injury,
CT scan should be used to assess the area. CT scan will show any disruption of
the ring of the vertebra suggesting an unstable injury, and will allow
assessment of canal compromise and of subluxation or dislocation of the
vertebrae.
MRI
scanning is very sensitive, but is better for assessment of soft-tissue injury
and less sensitive for assessing bone injury. Where there is no fracture it can
be useful for establishing the presence of a soft-tissue injury, it is useful
for
assessing spinal cord and nerve root compression as well as the extent
of spinal cord injury, and it can be helpful in making a long-term prognosis
about spinal cord recovery.
If
an unstable injury is demonstrated, spinal immobilisation should continue
until such time as the spine can be stabilised, or until healing has occurred.
Nontrauma
As in assessment of any part of the skeleton first principles should be
followed, or clinical signs will be missed.
• Take a history — 90 per cent of diagnoses can be made at this
point.
• Look at the spine standing and lying.
• Palpate the spine.
• Examine the neurological system.
• Examine the peripheral vascular system.
• Watch the spine moving.
The
history should include past medical history of importance (e.g. injury or
previous similar symptoms) and family history (e.g. for scoliosis). Important
parts of the history are:
• pain (site, nature, duration, pain scale, effects);
• disability (sitting, standing, walking, lifting, dressing, travel,
social activities, sleep, sex life);
• physical impairment;
• work loss.
Many
of these parameters are very difficult to assess in the spine. Pain is a very
subjective sensation, and it is difficult to grade the amount of pain which a
patient is experiencing. Methods of assessing the amount and quality of the pain
include the anatomical pattern of the pain, the use of pain scales such as the
visual analogue scale, and pain descriptions such as the short-form McGill pain
questionnaire.
In
assessing the pain and disability which a patient is experiencing it is
important to include an assessment of how much distress and illness behaviour
the patient is experiencing. This is because the type of treatment chosen may
be very different for the patient with significant distress, and because the
outcomes of treatment are very different. For example, the outcome of surgery
for back pain in those with distress is very much worse than in those who are
not distressed. Physical signs which suggest that the patient may be
exhibiting abnormal illness behaviour include the following.
Symptoms
include:
• whole leg pain;
• tailbone pain;
• whole leg numbness;
• whole leg giving way;
• never free of pain;
• intolerance of treatments;
• emergency admission to hospital.
Signs include
• superficial widespread non anatomical tenderness;
• lumbar pain on axial loading of the spine;
• lumbar pain on simulated rotation of the spine;
• straight leg raising which improves with distraction;
• regional sensory disturbance;
• regional motor weakness;
• jerky movements on motor assessment with giving way.
Litigation
is an important confounding factor in the treatment of individuals with spinal
pain. There is no doubt that the response to treatment is less good in those who
are litigating, perhaps because there is little incentive for them to recover.
However, there is also good evidence that few patients experience a significant
improvement in their symptoms after settlement of the claim.
Physical
impairment can be measured and lumbar spine measurements of impairment include
those of the American Medical Association and the American Academy of
Orthopaedic
Surgeons. We have more experience with the use of the Oswestry Disability Index,
a 10-question self-administered score of back pain and associated disability
which is reliable and reproducible. This combined with a pain score is in
regular use in our institutions and allows easy scoring of pain and disability
and comparison of pretreatment and post-treatment pain and disability.
Examination
technique
Make the patient feel relaxed. Watch how the patient moves and walks,
and watch how the patient dresses and undresses. Look at the spine. Is there a
deformity or muscle spasm, does the patient have a scoliosis? Are there any
associated features such as birth marks or a leg length discrepancy which might
suggest a congenital disorder? Examine the range of movement of the spine in the
cervical, thoracic and lumbar spine with the patient standing up if possible.
The range of spinal movement is difficult to assess accurately, but flexion and
extension can be measured with a goniometer if necessary. Deformities should
also be assessed for their mobility. It is usually easiest to have the patient
lie prone to palpate the spine. This avoids putting the patient off balance, and
also allows the muscles to relax. Look to see whether the deformity corrects,
for example with a sciatic scoliosis, as opposed to a structural scoliosis which
will not correct completely. Palpate the spine to see whether there is a step
suggesting a spondylolithesis. Remember to look for evidence of inappropriate
signs (axial loading and simulated rotation).
With
the patient prone the ankle reflexes can be assessed and posterior sensation
examined. The femoral stretch test (hip extension with the knee flexed) can be
carried out to see whether there is femoral nerve pain. The patient is then
asked to lie supine. An assessment of muscle bulk can be made, and measurements
made as required. A thorough neurological examination can be carried out
including a sciatic stretch test (see Fig. 33.5 and
Table 33.1).
Remember
to examine the abdominal reflexes where there is any possibility of an upper
motor neuron lesion. Hip and knee pathology frequently mimics back pain and
these joints
This
sounds like a lengthy examination, but with plenty of practice it should be
possible to carry out the examination reasonably rapidly (e.g. 5—10 minutes).
Does the patient have back pain as the primary problem, does the patient have
Investigations
Where malignancy or
infection is a possibility haematological investigation is useful [full blood
count (FBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP),
bone biochemistry].
MRI scanning has revolutionised the diagnosis and
In
many parts of the world MRI scanning is not readily available. Plain X-rays will
have more use in screening for conditions such as tumours or infection.
Compressive lesions can be investigated with CT scanning arid, if necessary, CT
myelography can be carried out. Myelography alone may still have its place, for
example in a compressive lesion in a patient with a metal implant in the spine.
Bone scanning is a useful screening test where, for example, a bone tumour is
suspected, but MRI scanning has largely replaced this as an investigation.
For
assessment of back pain and nerve root pain provocative tests arc widely used.
Discography can help to assess