Protocol 3 - Focused Spine Assessment

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. Repeat examinations may be necessary.

1.	Assess for mechanism of spine injury. If 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.
2.	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: a. 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. b. Patient must be free of significant spine pain and tenderness consistent with a spinal injury. c. 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 contain built-in redundancy.
3.	If a spine injury has not been ruled out, the patient must be fully immobilized except in the following case. In a wilderness context, with a reliable patient who has normal motor/sensory function, if spine pain and tenderness can be isolated to the lumbar area, the patient’s head may be left free. Likewise, if the injury involves only the c-spine, the hips may be left free for patient comfort.
4.	Arrange evacuation.