Selective Indications for Thoracic and Lumbar Radiography in Blunt Trauma,☆☆,

Presented at the Seventh Annual Scientific Assembly of the Eastern Association of the Surgery of Trauma in Freeport, Bahamas, January 1994.
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Abstract

Study objective: To determine indications for thoracolumbar radiography.

Design: Case series with prospective data collection. Setting: Level I trauma center. Participants: Blunt-trauma victims more than 12 years old who underwent routine thoracic and lumbar radigraphy according to institutional protocol. Patients were classified as group 1, not able to be evaluated clinically (Glasgow Coma Scale score of less than 13, intoxication, intubation, or cervical neurologic deficit); and group 2, able to be evaluated clinically. Results: Twenty-four of 319 patients sustained 25 thoracic or lumbar fractures. Seven of 136 group 1 patients and 17 of 183 group 2 patients had fractures. Eight of 17 patients with pain and 9 of 17 with tenderness had fractures (P =.001). No group 2 patients without pain, tenderness, thoracic or lumbar neurodeficit, or major distracting injury, including cervical fracture, had fractures. The negative predictive value of pain and tenderness was 95%. Five of 46 patients with spinal fractures at any level had multiple fractures. Conclusion: Blunt-trauma victims who cannot be evaluated clinically should undergo thoracolumbar radiography. Routine radiography may be unnecessary in asymptomatic patients who can be evaluated clinically and who do not have neurologic deficits or distracting injuries. Spinal fracture at any level mandates complete spinal radiography. [Terregino CA, Ross SE, Lipinski MF, Foreman J, Hughes R: Selective indications for thoracic and lumbar radiography in blunt trauma. Ann Emerg Med August 1995;26:126-129.]

Section snippets

INTRODUCTION

Trauma care mandates early recognition and appropriate management of injuries. Recent studies have recognized spinal injuries as significant missed injuries1, 2, 3, 4, and in many centers, including our own, thoracolumbar radiography of blunt-trauma patients has become routine.

Some authors have noted that cervical spine radiography may not be necessary in blunt-trauma victims who meet specific, well-defined criteria.5, 6, 7A recent retrospective review suggested that routine thoracolumbar

MATERIALS AND METHODS

All victims of blunt trauma older than 12 years who were triaged to the Southern New Jersey Regional Trauma Center on the basis of American College of Surgeons criteria9 for blunt trauma from March 11 to June 19, 1993, were in clu ded in this study. Patients were classified into two groups. Group 1 patients could not be evaluated clinically for signs and symptoms of spine injury because of a Glasgow Coma Scale (GCS) score of less than 13, an alcohol level of 100 mg/dL or more, cervical

RESULTS

The procedures used for this study followed standard institution policies for initial trauma evaluation, and data were collected in accordance with the state-mandated trauma registry. Therefore official approval was not required from our institutional review board. Three hundred nineteen blunt-trauma victims (216 males [68%] and 103 females [32%]) were enrolled in the study. Average patient age was 35 years (range, 12 to 92 years). The mechanisms of injury included 208 motor vehicle crashes

DISCUSSION

In the current medicoeconomic climate, the identification of indications for various diagnostic tests, including spinal radiography, has become important. Although many would view cervical spine radiography as mandatory in the evaluation of significant blunt trauma, the literature supports the clearance of the cervical spine by clinical means without the use of radiography in patients who meet the following specific criteria: alert, nonintoxicated, normal neurologic findings5, 7, and no loss of

CONCLUSION

Our preliminary findings suggest that thoracic and lumbar spine films should be mandatory in all blunt-trauma victims who cannot be evaluated clinically. In patients with GCS scores of 13 or more; no cervical neurologic deficit; no advanced airway adjunct; alcohol level of less than 100 mg/dL; and no pain, tenderness, thoracic or lumbar neurologic deficit, cervical fracture, or major distracting injury, thoracolumbar radiographs may be unnecessary. A spinal fracture at any level mandates

References (10)

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From the Department of Emergency Medicine* and the Division of Trauma, Cooper Hospital/University of Medicine,and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden§, Camden, New Jersey.

☆☆

Address for reprints: Carol A Terregino, MD, Department of Emergency Medicine, Cooper Hospital/University Medical Center, One Cooper Plaza, Camden, New Jersey 08103, 609-635-9765 Fax 609-225-0322

Reprint no. 47/1/65284

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