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 should be examined. Remember that spinal stenosis is often contused with intermittent claudication, and the peripheral pulses must be examined. Finally abdominal examination should exclude intra-abdominal pathology as a cause of back pain (e.g. aneurysm) (Table 33.2).

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 nerve root pain, or is there a combination? Are there inappropriate signs suggesting illness behaviour?

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  treatment of patients with spinal problems. Plain X-rays still have their place, for example in the assessment of deformity or trauma, but for most other conditions MRI scanning is a very sensitive investigation. In some respects it is oversensi­tive and has to be used carefully. MRI scanning does not replace clinical assessment and should be used either to confirm a diagnosis in order to plan treatment or to exclude a lesion, for example spinal dysraphism in a patient with scoliosis. The false-positive rate for abnormalities is very high, especially for conditions such as disc degeneration hut even, for example, for disc prolapse. MRI scanning allows assessment of the discs and     spinal column, the spinal cord and nerve roots as well as the structures immediately adjacent to the spine such as the psoas muscles. It allows assessment of neurological compression and of other abnormalities within the spinal canal.

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 whether spinal pain arises from a disc, and facet blocks can be used to assess pain in the facets, but also to treat facet pain. Nerve root blocks with local anaesthetic can help to assess whether a particular nerve root is responsible for pain, for example in a patient with multiple-level stenosis whether spinal pain arises from a disc, and facet blocks can be used to assess pain in the facets, but also to treat facet pain. Nerve root blocks with local anaesthetic can help to assess whether a particular nerve root is responsible for pain, for example in a patient with multiple-level stenosis.