The Focused Spine Assessment (FSA)

There are five commonly used protocols for ruling out possible spine injuries in the field: the Canadian C-spine Rule (CCR), the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria (NEXUS), the modified Nexus criteria, the State of Maine criteria (also based on the NEXUS criteria), and the Wilderness Medical Society (WMS) algorithm (a combination of the CCR and NEXUS). All are backed by solid research, in common use, and summarized below; click on an image to enlarge it.

Here's a quick summary of the differences: The CCR primarily focuses on ruling out the potential for a cervical spine injury by looking closely at the mechanism of injury. The NEXUS, modified NEXUS, State of Maine protocols, and the WMS guidelines assume a spine injury and focus on ruling it out via signs and symptoms. The difference between the NEXUS and modified NEXUS  is the NEXUS study focuses on the cervical spine while the modified NEXUS has been adapted for the entire spine. The original NEXUS criteria does not include assessing the patient's spine pain, the modified NEXUS does and, as such, is more conservative than the NEXUS. The State of Maine criteria adds paraspinal tenderness to the mix, while the WMS guideline is a combination of the CCR and modified NEXUS. The term focused spine assessment (FSA) is somewhat generic and may refer to any of the above protocols.

• Regardless of which FSA you use, only begin after completing your the Scene Survey, Primary Survey, and  Secondary Survey—all three triangles of the Patient Assessment System—and only if your patient is RELIABLE. A reliable patient has a normal pain response and is awake, alert, and cooperative with no distracting pain or sympathetic ASR.
• Unreliable patients are assumed to be spine-injured and must be evacuated for further assessment and potential imaging.
• Patients who pass the FSA do not need to be evacuated for a potential spinal injury.
• Patients who fail the FSA may have a spine injury and  should be evacuated for physician assessment and potential imaging, ideally within 6-24 hrs; those who have motor or sensory impairment may also have a spinal cord injury. Treat as per a spine injury: Click here to read a detailed article about managing potentially spine-injured patients in wilderness and remote locations.
• Remember to document the results of your FSA in the patient’s SOAP note.
• Details of WMTC's FSA can be found in our print or digital handbooks, complete with illustrations.
  

Want more information on this and other wilderness medicine topics? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.