How to Determine the Severity of a Spinal Sprain Outline

Transcription

1 Spinal Trauma How to Determine the Severity of a Spinal Sprain Outline Instructor: Dr. Jeffrey A. Cronk, DC, CICE Director of Education, Spinal Kinetics. CICE, American Board of Independent Medical Examiners. In order to fully appreciate this hour, you should have full understanding of our hour on Mechanism of Injury, our hour and Trauma Terminology and our hour on Stress Radiology. A working dynamic model of subluxation: Trauma/ micro-trauma causes sub-failure to ligaments, joint capsules, and disks. This causes damage to collagen fibers and mechanoreceptors. The result is partial differentiation, disturbed kinesthesia, and loss of spatial and temporal integrity. The neuromuscular control unit has difficulty interpreting the corrupted mechanoreceptor signals. The muscle response pattern is corrupted, disturbing co-activation, recruitment of spinal muscles, range of motion, and kinematics. Pages: 1 of 6

2 Disturbed motor control results in abnormal loads, stresses, and strains leading to further sub-failure injury. Sub-failure injury produces inflammation and causes chronic pain, recurrences, and reduced functional capacity. The Spinal Sprain Policy Statement of the International Chiropractic Association: Inherent in most spinal sprain and strain injuries, there exists a biomechanical, neurological component of articular malposition referred to chiropractically as subluxation. Such subluxation, if not addressed and merely treated with soft tissue therapeutics and/or joint immobilization forms of care, may lead to joint fixation and/or instability and loss of motor unit integrity. It is the opinion of the International Chiropractors Association that in such injuries evidence of the chiropractic vertebral subluxation complex should be analyzed and, if present, be corrected by specific chiropractic articular adjustment before immobilization procedures are applied. Lack of such correction of articular misalignment (subluxation) may result in permanent impairment, for waiting more than an hour, much less days, may lead to joint fixation, motion impairment, neurological insult and/or hypermobility of the intervertebral motor unit. Adjustive reduction of the articular subluxation must be accomplished with due regard to soft tissue injury, attempt to enhance recovery and contribute to the prevention of future joint motion impairment, neurological impairment and deteriorative pathological consequences. Pages: 2 of 6

3 How do you determine the severity of a spinal sprain clinically? You do not have injury without mechanical deformation of the tissues. A subluxation is the result or a mechanical deformation; this is a spinal sprain. This is an important question as it guides every care decision you are going to be making with the patient---their diagnostics, their treatment plan, there active care, their supportive care, their education, their activity modification and their documentation in your file. It is going to determine the ease of the stress level that you have with the medical legal system. Most providers today have no idea of the severity (location ) of the patient s condition (Sprain/subluxation/spinal instability) and just begin dispensing treatment (directions to the know destination one size fits all)----they DETERMINE the severity of the condition by the treatment response---if it is poor it is obviously severe---if it is good it was not so severe. Lets look at the spinal sprain by revisiting the ligaments: A main Spinal Functional Motion Unit has ten ligaments. ALL PLL 2 Capsular 2 Intertertransverse Ligamentum Flavum Pages: 3 of 6

4 Interspinous Supraspinous Although ligaments are of water density and generally do not possess enough radiodensitiy to be visible on radiographs the articular relationships that intact ligaments provide can be evaluated on conventional radiographs. Loss of normal articular relationships implies loss of ligamentous support" Pg 145 "If there is a history of trauma and joint instability or hypermobility, or if either is clinically suspected or needs to be ruled out, lateral flexion and extension stress views should be obtained. These two films are then evaluated to identify joint hypermobility revealed by misalignment of the injured segment." pg Fundamentals of Musculoskeletal Imaging This is consistent with AMA guidelines. Spinal Ligaments are passive tensile restraints which limit displacement patterns (subluxation) of the individual vertebrae, while under physiological loads Loss of normal articular relationships implies loss of ligamentous support" Pg 145 Damaged ligaments cause the individual spinal motion units to abnormally translate or angulate. Motion of individual spine segments cannot be determined by physical examination but is evaluated with flexion extension roentgenograms pg. 379 AMA Guides When routine x- rays are normal and severe trauma is absent, motion segment alteration is rare; thus, flexion and extension x- rays are indicated only when the physician suspects motion segment alteration from history or findings on routine x- rays. pg. 379 AMA Guides The Sprain injury causes abnormal motion patterns on x-rays that is the key to both the location and severity. Pages: 4 of 6

5 Ratable levels: Spinal motion unit angulation and translations found on your patients flexion extension films. Meeting or exceeding these numbers would indicate a severe sprain. Numbers that exceed normal but are not ratable would indicate a more moderate sprain. n Translation is defined as anterior-posterior motion of one vertebra over another that is: n >3.5 mm in cervical spine n >2.5 mm in thoracic spine n >4.5 mm in lumbar spine n Angular motion difference of two adjacent segments: n >11 deg Cervical spine n >15 deg at L1-L2, L2-L3 & L3-L4 n >20 deg at L4-L5 n >25 deg at L5-S1 The AMA has determined what the measurements for severe spinal ligament damage are. When the damaged spinal motion units meet or exceeds these measurements they are determined to be ratable. A ratable spinal motion segment is termed by the AMA Alteration as Motion Segment Integrity (AOMSI). Pages: 5 of 6

6 The AMA calls this condition Alteration of Motion Segment Integrity. The finding is highly objective because it is a measurement. Mild Sprain: Vertebral offsets in the normal range Moderate Sprain: Vertebral offsets in the abnormal range Severe Sprain: Vertebral offsets in the ratable range It should be apparent at this point that in order to determine, clinically both the severity of the sprain and the spinal motion units which were most affected, you must do two things: 1. Take stress films of the trauma patient (flexion and extension, APOM Stress) x-rays, or stress x-rays of the area in question, i.e., Cervical or lumbar. 2. Accurately and reliably assess the location and the severity of the abnormal motion patterns. 3. It is a good idea to get an accurate and reliable inter-segmental motion analysis performed. Computerized Radiographic Mensuration Reads assist you with determining the location and severity of the ligamentous laxity that causes abnormal motion patterns. This is often clinically correlated to a spinal instability. It can also rule in or rule out severe sprain findings that are ratable (alteration of motion segment integrity). Pages: 6 of 6