Thoracic and Lumbar
ASSESSMENT OF A THORACIC SPINE INJURY
When assessing a possible spinal cord injury, it is extemely important to take note of the patients position when you reach them. Do not try to move the patient before you have done an initial assessment. Start by checking ABC's, then move into a HOPS format for further, off-field evaluation.
ABC's:
If you see an athlete go down with a suspected spinal injury, always make sure to check their level of consciousness. Check to see if the athlete's airway is clear, they are breathing normally and have a normal pulse. If the athlete is having issues with any of these, activate EMS immediately, and begin CPR is necessary.
SPINEBOARDING:
If a spinal injury is suspected, the athlete will most likely have to be spineboarded. It is important to move swiftly, and be organized when action needs to be taken. Keep the athlete calm, and remind them to not move. Hold c-spine until the cervical collar is in place. The following link goes into more detail about spineboarding an athlete.
HISTORY:
Once the athlete has had a thorough on-field assessment, and there is no severe spinal injury suspected, get them off the playing surface and begin a more detailed off-field assessment starting with the athete's history. If you do not know the athete, ask their NAME, AGE, HISTORY OF INJURY, MEDICATIONS, ETC. Once those questions are done, move into questions about the injury. Asking things like WHAT HAPPENED, WHAT DOES THE PAIN FEEL LIKE, POINT TO WHERE YOUR PAIN IS, DID YOU FEEL/HEAR ANYTHING, HAS IT GOTTEN ANY BETTER SINCE WE HAVE COME OFF THE FIELD, WHICH MOVEMENTS MAKE IT BETTER/WORSE, HAS THIS HAPPENED BEFORE, WHAT HAVE YOU DONE FOR TREATMENT
OBSERVATION:
Remove clothing or padding covering the area so bare skin is showing, but making sure to protect the athlete's modesty. Inspect the are for DISCOLORATION, SCARS, DEFORMITY, BLEEDING, SWELLING, POSTURAL ABNORMALITIES. Look at their QUALITY OF MOVEMENT, RANGE OF MOTION, HOW THEY HOLD THEIR POSTURE, ANY OTHER CONGENITAL POSTURAL DEFECTS (scoliosis, kyphosis).
PALPATION:
Palpate the area looking for DEFORMITY, CREPITUS, TEMPERATURE CHANGES, POINT TENDERNESS AND SWELLING. Make sure to locate specific landmarks like SPINOUS PROCCESSES, INTERVERTEBRAL DISCS, COSTOTHORACIC JOINTS, ERECTOR MUSCLES, OTHER MUSCLES THAT RUN THROUGH THE AREA OR ATTACH/INSERT.
SPECIAL TESTS:
These tests include range of motion tests, manual muscle tests, and specific tests for certain injuries. Generally range of motion is tested first, then manual muscle testing, sometimes co-insiding with special tests. Many of these tests cannot isolate just the thoracic spine, so keep in mind that they test the strength and range of motion of both the thoracic and lumbar spine.
RANGE OF MOTION TESTING:
FLEXION: Begin with having the patient flex the spine and asking if it causes them discomfort, or if they feel any catching or popping sensations. Have them extend back up. Next, locate C7 and L1, and place a tape measure running between the two landmarks. Record that number. Have the patient flex forward and measure the distance between the two landmarks again. Subtract the two numbers. The average change should be about 10 cm.
EXTENSION: Begin with having the patient extend their spine as far as possible. Make sure to ask them to describe if anything is painful, or any pops, clicks, or shifts are felt. Have the patient return to normal posture. Next, measure the distance between C7 and L1, then have the patient extend and measure again. Subtract the the two numbers, and keep track of their progress. There is no normative value for thoracic extension.
LATERAL FLEXION: Have the patient stand on a flat surface, and you as the examiner must stabilize the hips. Have the patient laterally flex to the uninjured side (if any) and note how far they appeared to go. Then have them laterally flex to the injured side and compare. Again, ask the patient to describe the quality of the movement. Next have the patient stand in a neutral position, with their hands at their sides. Have them laterally flex, and measure the distance between the tip of their middle finger to the floor. Compare this measurement to the opposite side. Look for symmetry and smoothness of the movement.
ROTATION: Have the patient stand erect, and stabilize their pelvis to eliminate extra movement not coming from the spine. Have the patient rotate to the uninjured side and note how far they go. Then have them return to neutral, and rotate to the injured side. Again have them describe the quality of the movement and range of motion. There is no real quanititative way to measure this movement.
RHOMBOIDS: There are many different ways to measure the strength of the rhomboids. One way is to have the patient lay prone, with their elbow extended and shoulder abducted to 90 degrees. Then have them horizontally abduct that arm against gravity. Apply resistance on the upper arm, while placing the other hand on the rhomboid. Use the grading scale, then compare bilaterally.
LOWER TRAPEZIUS: Patient is lying prone with arm abducted to about 135 degrees, with thumb up. Apply resistance to the patients forearm, and place one hand on the muscle itself.
UPPER ABDOMINALS: Have the patient lie supine with legs fully extended. A grade 5 is described as being to do a curl up with hands behind the head through the hip flexion phase. A grade 4 is when they can curl up with their arms folded across their chest through the hip flexion phase. A grade 3 includes being able to curl up with their arms at their side, but unable to get to the hip flexion phase.
LOWER ABDOMINALS: Have the patient lie supine, with arms folded across their chest. Raise the patient’s legs to 90 degrees of hip flexion, then release. The patient is to slowly lower legs to the table to complete the test. A 5 is described as being able to keep the low back flat on the table through the whole movement. A 4 is described as being able to keep the low back flat until about 30 degrees off the table. A 3 is described as being able to keep the low back flat while lowering the legs to 60 degrees off the table.
MANUAL MUSCLE TESTING:
Remember the scale goes from 5 being the strongest to 0 being the weakest. A 5 is achieved when the patient can hold the injured limb against gravity and resistance for 5 seconds. A 4 is achieved when the patient can hold the injured limb against gravity and resistance for at least 3 seconds. A 3 is achieved when the patient can hold the injured limb against gravity and no resistance. A 2 is achieved when the patient can move the limb in a gravity eliminated position. A 1 is achieved when a visible or palpable contraction is seen but there is no movement. A 0 is achieved when the patient has no contraction in the area.