Protocol 4 - Spine Assessment & Clearance
In an urban context, all patients that are involved in a traumatic event that may have caused a spine injury are treated as though they are spine injured. In a wilderness context, clearing a potential spine injury when there is a positive mechanism for such an injury requires careful evaluation that focuses on patient reliability, nervous system function, and spinal column stability. Adequate time must be allowed for the evaluation.
Neutral alignment should be restored and maintained using non-rigid tools during extrication unless such a maneuver is met with resistance, increased pain, or a new or worsening neurologic deficit. Although no studies have specifically evaluated an optimal generic position for the injured spine, clinical evidence (derived from imaging and patient care experience with traction, manipulation, and operative reduction) would strongly suggest that neutral alignment is preferred.
The C-Spine Rule algorithm starts out with determining if there are any high-risk factors involved (positive MOI) and following the diagram based on findings, before performing a spine assessment.
Positive (Significant) Mechanisms of Injury:
• Fall w/ Loss of Consciousness
• Fall from Greater than 3 Feet
• Evidence of trauma from High-Velocity Impact
• Landing Head-First (compression)
• Landing on the Buttocks/heels (axial loading)
• A Fall onto a Rock or other Hard Surface
Remember: This is just a guidance tool to help you decide, with reliable certainty, whether or not the patient most likely has a spinal column injury. Injuries to the cervical spine (C-Spine) may cause trouble breathing, which could be life-threatening. Always perform a full, thorough spine assessment on all patients with a suspected spinal column injury.
Focused Spine Assessment
Assess for the mechanism of spine injury. If a positive or uncertain mechanism exists, protect the spine by whatever method is available. This could include but is not limited to hand stabilizing in the in-line position.
Do a thorough evaluation including a history and physical examination. To rule out a spine injury the patient must meet all of the following criteria:
The patient must be reliable. The patient must be cooperative, sober, and alert, and must be free of other distracting injuries significant enough to mask the pain and tenderness of the spine injury.
The patient must be free of significant spine pain and tenderness consistent with a spinal injury.
The patient must have normal motor/sensory function in all four extremities:
• Finger, hand, or wrist motion (check both hands).
• Ankle or great toe motion (check both feet).
• Normal sensation to pain and light touch in all four extremities.
• If reduced function in one particular extremity can be attributed with certainty to a condition unrelated to a potential spine injury (wrist fracture, for example), that deficit alone will not preclude ruling out a spine injury, because the motor/sensory assessment contains built-in redundancy.
If the spine cannot be cleared, spine injury remains on the problem list and must be appropriately managed and followed up as part of patient care and evacuation. This may include stabilization and carry, assisted self-extrication, or other means of reducing the risk of further injury pending medical evaluation and treatment.
If the patient with the suspected spinal column injury is reliable (alert & oriented, sober, not distracted), there is no stated pain/tenderness on the spine, and normal CSMs in all four extremities, a decision to discontinue spinal immobilization can be made. This also means the patient has good distal pulses, no numbness, tingling, or unusual (psychological) sensations, and a normal range of motion.
