Spine Exam (HB)
One of the tools that we can use to assist with transport is to attempt to clear the spine.
Suppose we just assume that there is an injury to the cord. In that case, we need to protect it by stabilizing the whole spinal column as if it was a long bone—securing the joints above (the neck) and below (the pelvis). This means carrying the patient out, which requires a significant amount of resources and can delay evacuation significantly.
In the backcountry, we should always try to improve our patient’s condition and use diagnostic tools to help us feel safe about walking the patient out. Overall this is safer for the patient and the rescuers and usually results in a quicker extraction. The following example illustrates a real risk when you take away a patient’s ability to move: http://archive.boston.com/news/local/new_hampshire/articles/2006/08/24/injured_woman_drowns_under_rescue_boat/.
Performing a spine exam allows us to determine if a patient is safe to walk out or if we should take the precautions for protecting the spine.
The exam requires a few things. The patient must be awake and capable of providing us feedback and following directions. This means we must resolve distracting injuries, and the patient cannot be intoxicated. Most importantly, there needs to be a positive mechanism for spine injury—don’t just do this test “because.”
Also, this exam does not have to be done immediately. We can take some time to resolve distracting injuries, allow the patient some time to detox if needed, or allow ASR to resolve.
We will check a few things. We want to ensure that the column is free from damage and that the patient has intact motor and sensory functions. Sensory nerves carry signals to the brain. Two main types can differentiate between sharp and dull pressures. Motor nerves carry signals from the brain to the extremities. We need to ensure that the spine has structural integrity and that the bidirectional communication of the peripheral nervous system is intact.
It is important to note that we do not have to put our patient flat on their back for this exam. We can perform the test in any location or orientation that we find the patient assuming we can manage the testing criteria.
We will complete the entire exam. And we can do the exam again later if we feel the need or have concerns that develop.
Spinal Column Exam
We need to palpate every single vertebra in the spinal column. We are checking the spinal processes (the three bony prominences that come off each vertebra). Using the tip of your fingers, firmly press on every prominence. If the patient complains of any point tenderness (which is similar to a match burning the skin at that point), consider that a positive finding.
What if the patient is lying flat on their back? It is impossible to check the middle of the thoracic spine and the lumbar spine without moving the patient. While it is not extremely dangerous, we want to minimize movement until we are sure of a clear (or low-risk spine).
All processes on bones are attachment points for muscles and connective tissue. In the thoracic spine, the processes on the spine are the medial attachment for the latissimus dorsi (the largest back muscle). The lumbar spinal processes serve as attachments for the iliopsoas. Suppose we can get the patient to activate these muscles. In that case, they will be pulling on every thoracic and lumbar vertebra—they will not be able to do this without pain if there is damage to the column.
To activate the thoracic spine, have the patient lay with arms at their side and attempt to abduct (move away) from their body against resistance. Then have them attempt to abduct their arms (move toward) their body under resistance.
To activate the lumbar spine:
- Have the patient lay with legs together and attempt to move their legs apart against resistance.
- Have them attempt to close their legs under resistance.
- Have them try to pick their leg straight up while you apply resistance at their thigh; repeat on the other leg.
Suppose they can activate their spine on both of those tests. In that case, you should have a high degree of confidence that there is no damage to the column, but you should still roll the patient on their side and manually palpate.
Motor Exam
For the motor exam, we need to check all four extremities. We are checking to make sure the patient can perform a couple of gross movements against resistance. The patient’s response should be equal on both sides (assuming they do not have a pre-existing injury).
Have the patient spread their fingers on both hands. Put your hands over theirs surrounding their index finger to ring finger. Gently squeeze, attempting to collapse their fingers together. Ask the patient to resist. If they cannot resist the collapse or you note significant weakness that is not part of their history, consider that to be a positive finding.
Put the patient in a relaxed position (or ask them to get into one). Place your hands on the balls of their feet and ask them to “step on the gas” while providing gentle resistance. Next, place your hands on their big toes and ask them to try and touch their toe to their knee (this is, of course, impossible–otherwise, it would be an unstable injury–we are checking for the activation of the big toe), again while providing slight resistance. You should expect equal force from both feet for both tests. If they cannot press down or pull up, or there is significant weakness, consider that a positive finding. A positive finding here automatically makes the patient high-risk.
Sensory Exam
The sensory exam requires the use of a tool that can provide both a sharp and dull sensation. A pine needle or a cotton swab cut in half is perfect. Do not use a knife. A pen is not appropriate either (the tip is not sharp enough).
You must first establish a baseline so that you and the patient are on the same page. Explain to them what you are going to do: “I’m going to test your ability to tell between a sharp and dull sensation. First, I’m going to demonstrate on your forehead, and then I will have you close your eyes and will perform the test on your hands and feet.”
With their eyes open, poke them gently with the sharp side of the tool on the side of their forehead. You don’t need to drive it in—we are just trying to get the sensory nerves to report the contact. We use the forehead because we don’t want to preprogram the answer for the patient. We ask them what they felt “sharp or dull” and which side “left or right.” Repeat the test but use the dull side of the tool. Then repeat both sharp and soft on the other side of the forehead.
Once the patient indicates understanding and appropriately responds to the sensation and can identify the side, we will ask them to close their eyes. RANDOMLY pick a side and type (sharp/dull) and test the patient. Again randomly pick and repeat the test. Your goal is to test sharp and dull on all four extremities.
The location we test is as close to the hand’s pinky side as possible and as close to the little toe as possible. The reason we test these areas has to do with the way the peripheral nerves run. When they leave the spinal cord, they run down the body in a line to wherever they terminate. They do not wrap circumferentially around the limbs. This also allows us to make slight adjustments to the test if we need. For example, if the patient is wearing boots, we can test on the outside of the leg just above the top of the boot—this would be the same “line” that provides nerves to the little toe. Or, if the patient has an amputation, we can test above the amputation.
Note down any inability to discriminate sharp or dull or determine which side of the body the test was performed on. Come back and retest anything missed. If the tests fail again, consider that a positive finding. A positive finding here automatically makes the patient high-risk.