Mason Raymond: So you’re an expert?

After Mason Raymond’s hit from Johnny Boychuk in game 6 of the Stanley Cup final, nobody could have been more surprised than I when he left the ice on his feet after what seemed like several minutes of face-down on-ice discussion with a Vancouver trainer. When a player goes down (and stays down) for that long, we’re used to seeing them stretchered off in full spinal immobilization.

The purpose of full spinal is to keep the spine still (amazing, I know). It involves being strapped to a hard plastic spine board with your head held completely still looking straight ahead (or straight up, as is the case once you’re laying flat on your back). There’s an algorithm used to decide who needs full spinal precautions – at its simplest it’s a question of whether there’s potential for a head, neck, or back injury. Is there neck pain? Spine board. Head injury? Spine board. Penetrating injury that could compromise the spine? Spine board. Too drunk to stand up and fell off the porch/bicycle/moped/roof of your brah’s SUV? Spine board.

So the question is why Raymond left the ice on his feet. There are actually several reasons this could have been completely appropriate, despite what Twitter’s many, many experts seem to believe. I kicked off a Twitter explosion the likes of which I hadn’t previously seen with two simple tweets:

Lots of criticism for skating Raymond off. Trainers aren’t stupid, guys. Guarantee they tried to get him on a spineboard and he refused.

And as if that weren’t enough expert-bait, I followed it up with:

So let’s give up the “Skating him off is malpractice!”. Were you there? Are you an expert? Cue Andy Sutton.

Now let’s back it up just a bit and take a look at the hit:

 

The first thing worth noticing is that Raymond doesn’t seem to lose consciousness. He’s also moving his arms and legs. Next, he and Canucks head trainer Mike Burnstein actually spend a full minute in discussion before Kesler and Higgins help Raymond up and off the ice. In an injury situation a minute is a really, really long time. Usually the way it goes is you get the equipment you need, get the patient on it, and get the patient out. You know what situation usually gets in the way of keeping things moving? Arguing. My suspicion is that Burnstein was doing his best to convince Raymond to get on a board, and ultimately couldn’t do it. That wasn’t malpractice, Vancouver’s trainers are experts, and I’ll gladly explain why.

The Algorithm

To be clear, there are two types of spinal clearance algorithms. The kind that determines if an injured person needs to be on a spine board at all (used in the field by EMS, athletic trainers, and other first responders) and the kind emergency physicians use to determine if someone with a spinal injury can come off of the spine board, and if they need imaging (x-rays). I’m talking about the first algorithm. Let’s walk through it.

1. The patient gets injured. The ambulance gets called.

2. Spinal exam: Do they have neck and/or back pain? This can be on movement or palpation.

3. Neuro exam: Are there any focal neurological deficits? Examples would be numbness, tingling, weakness/inability to move.

4. Mechanism of injury: Is it significant? “Significant” is different just about everywhere. Several state EMS formularies define it as such (and yes, most of these relate to motor vehicle crashes):

• Ejection from the vehicle
• Death in the same passenger compartment
• Fall greater than 15-20 feet (or some places use twice the patient’s height)
• Vehicle rollover
• Vehicle vs pedestrian
• High-speed collision
• Motorcycle crash
• Unconscious or altered level of consciousness following injury
• Penetrating injury to head, neck, torso

Common sense (and the more clever formularies) add axial loading to this list. An axial load is a force applied to the head that causes spinal compression (or loading). Think of someone jumping into a pool and hitting their head on the bottom. The Canadian Journal of Emergency Medicine did a nifty little study wherein they found that in non-car-crash incidents, you’re at greatest risk for a spinal fracture with axial loads, falls, diving accidents, and motorized non-car vehicles (ATVs, snowmobiles, etc – If anyone’s interested I have a great rant about why you should stay the hell away from those evil, evil, contraptions).

5. Impairment: Is the patient impaired (ie. by drugs/alcohol)?

6. Distracting injuries: Does the patient have any painful injuries that might distract from their spinal issue? For example, if your leg is hanging off, we’re probably not going to spend time discussing whether you need a spine board.

If you answered yes to any of those questions, the patient needs to be immobilized. Problematically, some people still refuse. Even more problematically, those people are often sober and intelligent.

Okay, so what do you do if someone needs to be put on a spine board and they refuse?

Well, contrary to what the Twitter experts believe, you don’t force them. You explain to them the consequences of their actions. You beg. You plead. You might bully a little bit. You might even threaten just a touch. Have I ever told someone that by refusing treatment they could die? You bet. Have I had a patient actually die as a result of refusing treatment? Almost. It’s hard to understand just how completely useless you feel trying to explain to an unwilling patient that you’re trying to help them. So let’s spend a moment in Mike Burnstein’s shoes, and in Mason Raymond’s skates.

In Raymond’s case, he’s just hit the boards ass-first in one of the most important hockey games he’ll ever be a part of. Maybe he’s in pain, maybe he isn’t. Spinal compression fractures are tricky little beasts – usually they’ll present with midline back pain, but they can also present with pain in a completely unrelated area (the lateral back, buttocks, hip, etc.) or no pain at all.  Since none of us are Mason Raymond, none of us know where or if he was hurting. There’s no way of knowing what his neuro exam was, but he was definitely moving his extremities after he went down. As far as mechanism goes, the video of the hit makes it look like there was probably an axial load from Boychuck driving him into the boards. Did Burnstein know that? Probably not. Did Raymond know that? If you’ve ever taken a hit (or been in a car wreck, or had any kind of sudden trauma) you know that even if you aren’t knocked out, you’re usually not able to immediately describe the mechanics of what happened. And let’s be honest – Raymond probably didn’t care what the mechanics were. More than likely he just wanted to get back up and keep playing.

Given Burnstein’s extensive training and experience, you have to assume he was trying to get Raymond on a board. Any assertion that he doesn’t know what he’s doing or committed malpractice makes about as much sense as trading Chara for Daigle (which is actually kind of a dumb example since that actually happened). To soothe the Twitter experts, why don’t we go ahead and define medical malpractice, just so it’s clear why Burnstein’s actions don’t qualify.

Malpractice: There’s more to it than you think.

Medical malpractice may vary from state to state, province to province, and country to country. I’m not a lawyer, so don’t expect any complex legalese here. This is just an overview of what’s involved. There are four requirements for a charge of medical malpractice:

• Duty to act: This is the care provider’s responsibilities within his job/training. In Burnstein’s case, as the head trainer he has a duty to respond to and treat injuries to players. His level of training allows him to recognize Raymond’s injury and then to direct that he be immobilized and transported to the hospital. That’s assuming Raymond consents to the indicated treatment (we’ll look at consent in a second – that’s significant in this case).
• Breach of duty: A breach occurs when the provider fails to provide the care that’s indicated (and permitted by his level of training). If you want to argue that Raymond needed immobilization (which it’s safe to say he probably did), then you may also want to argue that Burnstein committed a breach of duty. I’ll argue that he didn’t, under the assumption that Raymond wouldn’t consent to immobilization.
• Injury resulting from the breach: Failure to provide the indicated treatment causes injury to the patient. This is hard to argue either way in this case. Raymond broke his back when he hit the wall. There’s no way to say if skating off the ice made it worse.
• Damages: This refers to emotional distress or monetary loss – i.e. if someone didn’t receive the indicated treatment and as a result was unable to work. The damages must be as a direct result of the breach of duty. In this case you’d be hard-pressed to argue that there were any damages. Yes, Raymond will miss ice time, but his injury was from hitting the wall, not from skating off the ice. And as I just said, it’s impossible to know if skating off made it worse. Most significantly, damages don’t exist unless there’s a plaintiff to claim them. There can’t be malpractice unless Raymond makes a claim for it.

So is Burnstein guilty of medical malpractice? No. Clearly not. If you’re not convinced, then maybe a quick discussion of consent will help.

Consent: Wherein medical providers would rather not assault people.

In order to administer treatment to a patient, a health care provider must first obtain that patient’s informed consent (unless the patient is unable to provide consent and the treatment is absolutely required, in which case consent is implied). Informed consent consists of informing the patient of:

• Their diagnosis (to the best of the provider’s knowledge at that time) – In Raymond’s case, it would be as simple as Burnstein telling him that he could have a back injury.
• The treatment or procedure that’s indicated and its risks/benefits (spinal immobilization to prevent any movement in the spinal column).
• Any alternative treatments and its risks/benefits (not really applicable here).
• The risks/benefits of refusing the treatment (Risk: making it worse. Benefit: full spinal is uncomfortable).

If your patient doesn’t consent to the treatment and is in possession of their faculties (not drunk, not high, not a minor, not head injured, etc), and you treat them anyway, then you’ve just committed medical battery. That’s a real thing, and people get sued for it. It’s defined as violating a patient’s rights to direct their medical treatment, and involves the unauthorized touching of a patient. Health care providers are acutely aware of what they can and cannot do, and assessing a patient’s ability to make an informed decision is a skill that comes with time and experience. Any Twitter expert assertion that “They should have just made him get on the spine board!” is frankly ignorant. It’s never that simple. You can’t just make someone do something.

Trying to paint the Raymond incident in black and white strokes isn’t possible. There are a lot of factors involved, and screaming malpractice doesn’t make sense. Yes, Raymond broke his back. Yes, he should have been immobilized. The long and the short of it is that Burnstein knew that, and more than likely tried to make it happen. In the end he had to get Raymond off the ice and into treatment, and when he was transported to the hospital it was reportedly in full spinal immobilization.

Still not happy? The Globe and Mail had a few experts of their own opine on the incident, among them a spinal surgeon and a physiotherapist. You’ll notice that one of the physicians in the article states that “…the team should err on the side of caution and insist he be taken off on a stretcher” – didn’t I say something about this not being black and white? Again this comes down to one’s ability to convince/cajole/bully the patient into doing what’s appropriate. In Raymond’s case, it seems like it just didn’t work.

Raymond’s Injury

Raymond suffered a compression fracture of the L5 (lumbar aka lower back) vertebrae. Per Vancouver GM the fracture is through the belly of the vertebrae, which is to say the big fat round part in the front.

Here’s what’s broken.

These fractures can be managed through injection of special cement into the vertebrae, or surgery to immobilize the bone from the inside through the placement of plates or rods, although this is generally a last resort.  Most often this is treated with a back brace to immobilize the spine, pain medication, time, rest, and physical therapy. The brace generally used in injuries like Raymond’s is the TLSO (thoracic-lumbar-sacral orthosis) brace, which you can conveniently buy on Amazon (although you probably shouldn’t).  Raymond is expected to miss 3 to 4 months.

In case you have no idea what the Andy Sutton reference is all about, here you go. I will never, ever tire of this.  Ever.

– Jo

It’s just a numb leg. I can skate it off.

Time heals all wounds.  Actually, it’s time, physical therapy, medication, possibly surgery, and not pushing yourself for no reason.

In a show of truly spectacular self-defeatism, talented hockey players will often push themselves to come back before their body is ready.  How often do we hear about someone “Playing through it”?  And why are some injuries somehow more acceptable to play through than others?  Nobody would expect a player to suit up after an eye injury or a giant laceration (helloooooo Malarchuk), but this year we saw player after player limping through the playoffs on injuries that should have had them out for the duration.  Was Dany Heatley really contributing more by playing with a broken hand and a high ankle sprain than he would have by packing it in for the season?  Was that one point in the Western Conference finals worth the pain?  If you asked him he’d probably say yes.  How about Steven Stamkos – he hurt his shoulder in the Pittsburgh series, and played through to the Eastern Conference finals where he tallied seven points.  So absent of my sneaking suspicion that Stamkos is basically infinitely better than Heatley (sorry, Sharks fans), for him it probably was worth it.

Stamkos: He is tougher than you.

Daniel Alfredsson was the perfect example this year (and last) of playing with injuries that should have put him in the press box.  Ottawa Senators fans scratched their heads and wondered what was wrong as their captain’s point production dropped off towards the end of the 2009-10 season.  After the Sens were eliminated in the first round of the playoffs (as usual) by the Pens, Alfie admitted he’d been playing with a sports hernia since February (which isn’t really a hernia, but groin pain caused by any number of different injuries in the…  ahem…  area).  He still finished the season with 71 points, more or less on par with his usual production.

This year Alfie only played 54 games, and finished with 31 points – the fewest games and points he’s put up since he started with the Sens in 1995-96.  The problem this time was a back injury that he tried to fight through, and to which he finally conceded defeat in early February.  He admitted he’d been having weakness in his right leg, and today Ottawa GM Bryan Murray made the following statement:

“Daniel will have surgery on Friday.  He’s done a lot of rehab.  He felt to continue his career at the level he wants to, it’s the right thing to do.  It’s just to relieve a little pressure on the nerve that has taken away some of the strength in his leg and affected his skating and overall game, obviously…  It was a decision that he, during the latter part of the year and the off-season now, was hoping that he wouldn’t have to have.  I guess the fact the nerve is touching and being affected … in particular on the left side of his body … that he felt it was the right thing after much thought.”

Let’s go ahead and overlook the fact that all the interviews earlier this year said the problems were in the right leg, and discuss this injury, and the surgery that will (hopefully) fix it.

Theory: The stress of carrying around so much hair destroyed his spine.

The Injury

Although the interviews disagree on which leg was affected, the common thread is that Alfredsson has a lower back injury that’s causing one of his legs to be weak, tingly, and “heavy”.  Murray said today that there was pressure on a nerve that needed to be relieved.  The best way to understand why an injury in the back is affecting the leg is to learn a little something about the spine and dermatomes.

Whatatomes?

The nerves that make up the spinal cord exit the vertebrae through little canals called intervertebral foramina and proceed on to whatever part of the body they’re responsible for.  Those parts are very specific, and beautifully demonstrated by this fellow:

Best Halloween costume ever: A guy dressed up like dermatomes.

Each zone on the dermatome map represents the area that the specific listed nerve innervates.  So if you hurt L4 or L5, the top of your foot will suffer for it.

Your spine isn't this pretty. Sorry.

You have 24 vertebrae, plus 9 more that are fused to form the sacrum and coccyx (which make up the back wall of your pelvis).  The vertebrae are lettered and numbered according to where they are.  From the top, you’ve got

• Cervical (neck) C1-C7
• Thoracic (midback) T1-T12
• Lumbar (lower back) L1-L5
• Sacral (S1-S5 – fused) and coccygeal (also fused, don’t have a fancy letter, but have the distinction of being the oft-whacked tailbone).

The spinal nerves are named for the associated vertebra.  Those among you who are clever (or smartasses) have probably already noticed that although you have seven cervical vertebrae, there are eight cervical spinal nerves.  Feel free to impress girls at (nerdy) parties with the following bit of spine trivia: The spinal nerves exit the vertebral column above the associated vertebral bone until nerve C8 – the first one to exit below the bone (specifically vetebra C7) – cleverly paving the way for an extra nerve.

Bored yet?

The vertebrae are cushioned by discs, which are tough cartilage rings around a jelly-like center.  It’s a great design – they’re shock absorbers, allow for movement, and hold things together.  Unfortunately, they can also get badly out of place and cause awful symptoms.

When good discs go bad…

Injury or aging can cause discs to go to new and exciting places (that you’d rather they didn’t visit).  You can have a disc bulge – where the outer cartilage ring sticks out (usually posteriorly) from between the vertebrae and can put pressure on spinal nerves (or the spine itself).  A bulge can become a herniation, where the outer cartilage ring loses integrity completely and the jelly-like inside protrudes.  These injuries are best seen on MRI, like so:

Spot the disc bulges!

 

These are disc bulges at L3 and L5 – very common places for this type of injury.  This particular injury was the result of lifting a fat drunk kid out of a deep ditch in the rain after he drove mommy’s Lexus off the road.  But I’m totally over it.  Obviously.  I actually got lucky – I’ve been able to stay functional with exercise, responsible NSAID use, and being smart about lifting – let the fire department do it!  Kidding.  Sort of.  Not really.

If you look at the information available, it should be clear to you at this point that Alfredsson most likely has a disc bulge or herniation that’s pressing on one of his lumbar nerve roots.  He tried rehabbing the injury for a long time, and in fact there’s good data to show that non-surgical treatments are usually very effective for this sort of injury.  Pain control, steroids to relieve inflammation and physical therapy can bring relief in the majority of patients.  The exception is patients who have symptoms exceeding 6 weeks despite appropriate treatments, specifically those with neurologic deficits – Weakness, sensory deficit (numbness), and tingling.  This is Alfredsson’s picture.  Obviously he tried far longer than 6 weeks to avoid surgery, which was smart.  He also made loud noises after the all-star break about wanting to come back and play out the end of a dismal season, which was dumb.  There was no point, and there would have been a risk of worsening the injury.

FYI…

According to the World Health Organization, spinal manipulation (chiropractics) in the setting of a disc herniation is contraindicated.

The Surgical Fix

If Alfie does indeed have a herniation that’s pressing on a spinal nerve root, the likelihood is that he’ll be having a discectomy of some sort.  The operation is exactly what it sounds like – part of the disc is removed.  First a laminectomy is performed, where a tiny portion of the lamina (part of the vertebra) is removed to allow access to the disc and nerves.  The actual disc surgery can be done as an open procedure (cut the back open, remove part of the disc), percutaneously (through a small incision in the skin – less effective than open), or as microdiscectomy – where the surgeon operates using a special microscope allowing for more precise cuts and thus less damage to surrounding tissues.    A retractor holds the nerve roots out of the way while a device called a rongeur (what’s labeled here as ‘grasping device’ removes the offending disc tissue.  This should relieve the pressure on the nerve, allowing a return of strength and relief of pain.  The material that’s removed in surgery will eventually fill itself in with new disc material.

 

Discectomy Overview

A study out of Dartmouth cleverly called SPORT (Spine Patient Outcomes Research Trial) showed that patients with lumbar herniations showed significantly more improvement in pain and functionality with discectomy than patients who used non-surgical interventions.  Remember – these are the people with symptoms that persisted longer than six weeks with neurological problems and failure of non-surgical treatment.

After the surgery patients are encouraged to get up and walk as soon as possible, and physical therapy is started two weeks post-op.  It consists of stretching, strength training, and all the usual torture PTs put patients through (I love PTs, but they’re giant bullies – just ask one).

 

What we learned…

 

Alfredsson took from February until June to decide that he needed back surgery.  Although I admire his attempts to keep from being operated on, the research shows that if he was still having symptoms after 6 weeks he would have been better off just having the discectomy.  Did his hesitation stem in large part from his clear (and often-stated) desire to come back and play at the end of the season?  Probably.  With any luck, he’ll be looking at about a 6-week recovery, which puts him back in action at the end of July.  This should have him good to go for training camp on what is widely seen as likely his last season with the Sens.

 

– Jo