Selective Indications for Thoracic and Lumbar Radiography in Blunt Trauma☆,☆☆,★
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)
Cervical radiographic evaluation of alert patients following blunt trauma
Ann Emerg Med
(1984)- et al.
Clinical predictors of unstable cervical spinal injury in multiply injured patients
Injury
(1992) - et al.
Etiology and clinical course of missed spine fractures
J Trauma
(1987) - et al.
Delayed identification of skeletal injury in multisystem trauma: The "missed" fracture
J Trauma
(1989) - et al.
The tertiary trauma survey: A prospective study of missed injury
J Trauma
(1990)
Cited by (41)
Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging
2019, Journal of Emergency MedicineCitation Excerpt :Lastly, because most criterion standards included the index test, incorporation bias likely falsely raised the SN and SP of the index (42). Ten studies examined injury mechanisms as predictors of TL-spine fractures (1,2,27,28,31,43–47). Injury incidents included falls, motor vehicle crashes, pedestrian struck, bicyclist accidents, motorcycle accidents, assaults, and “high-risk mechanisms,” as defined by individual studies.
The epidemiology of thoracolumbar trauma: A meta-analysis
2016, Journal of OrthopaedicsCitation Excerpt :The rate of spinal cord injury was 26.5% (95% CI 15.8%, 37.2%) in patients who had sustained a thoracolumbar fracture. Five studies9,10,12,18,19 were included (531 patients) for the analysis of the rate of non-contiguous cervical spine fractures in patients who had thoracolumbar spine fractures. The heterogeneity was measured as I2 = 44 indicating moderate heterogeneity.
Advances made in the treatment of thoracolumbar fractures: Current trends and future directions
2013, InjuryCitation Excerpt :It has also been suggested that the presence of a palpable step and back bruising has a high specificity for thoracolumbar injury.1 Furthermore, in up to 11% of polytrauma patients, cervical injury may be associated with concomitant thoracolumbar injuries.14 This implies that the presence of a fracture at any level necessitates evaluation of the entire spine.
A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain
2008, Journal of Clinical EpidemiologyCitation Excerpt :Clinician judgment, based on a positive or equivocal clinical exam (LR+ = 2.9, LR− = 0.00 [32]), was significant in one of the two studies that evaluated it. The presence of a structural deformity (LR+ = 21.6, 46.4 [31,35]) significantly increased the probability of a fracture when present, but when absent, did not lower the suspicion of fracture. Clinical guidelines for the management of low back pain advocate the use of red flags to raise the index of suspicion concerning serious spinal pathology.
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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.
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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
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Reprint no. 47/1/65284