Selected topics: Emergency radiology
Thoracic and lumbar spine radiographs for walking trauma patients—is it necessary?

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Abstract

Numerous patients ambulating independently arrive in the Emergency Department complaining of back pain after being involved in a motor vehicle crash (MVC). We examined the yield of routine screening radiographs of the lumbar and thoracic spine in these patients. A retrospective review was carried out of the records of 3173 patients who were involved in a MVC during a 1-year period and presented to a single medical center. Radiographs of the lumbar spine, thoracic spine, or both were obtained in all patients complaining of back pain. Of 3173 ambulating MVC trauma patients, 35% (1110 patients) complained of thoracic or lumbar back pain. None of the lumbar and thoracic spine radiographs that were obtained in these patients was positive for a fracture or dislocation. The current study suggests that the yield of the routine use of spinal radiographs is very low in patients ambulating independently and complaining of back pain after a MVC.

Introduction

Numerous patients arrive every year in the Emergency Department (ED) after being involved in motor vehicle crashes (MVC). Most of them were involved in low energy accidents. Although most of these patients are ambulating independently, the assessment of patients complaining of post-traumatic back pain in the ED, in some centers involves routine radiographs of the thoracic or lumbar spine.

The literature clearly defines the indication for obtaining radiographs to assess cervical spinal injuries (1, 2, 3). Some recommend that for asymptomatic patients who are alert and oriented, without other distracting injuries and without obvious head or neck injury, no cervical spine radiographs are indicated (1). By adopting this approach, the number of cervical spine X-rays in trauma can be reduced by more than 30%. The incidence of cervical spine radiographs in the United States is about 800,000 per annum with a cost of $180,000,000 US (1). A reduction of 30% would be highly significant.

In contrast to the cervical spine, no reports were found dealing with the indications for obtaining radiographs of the lumbar and thoracic spine in the setting of low energy MVC. There are few reports dealing with the indication for obtaining radiographs of the lumbar and thoracic spine in blunt trauma patients (4, 5, 6, 7). Frankel et al. suggest the following indications: back pain or tenderness, ejection from motorcycle/motor vehicle crash ≥ 50 mph, falls ≥ 10 feet, Glasgow Coma Scale (GCS) score ≤ 8, and neurologic deficit (4). All these risk factors except back pain and tenderness are the result of high energy trauma.

Stephen and Laila retrospectively reviewed 145 patients with thoracic and lumbar fractures and found that all patients with clear sensorium, with no neurologic deficit, and no other major injuries complained of back pain or had midline back tenderness (5). They concluded that in patients with clear sensorium, with no neurologic deficit, and no other major injuries, routine screening radiographs of the lumbar and thoracic spine are not indicated (in the absence of clinical evidence of injury).

The objective of the current study was to assess the incidence of fracture or dislocations, diagnosed by routine X-rays of the thoracic or lumbar spine, in ambulating MVC patients complaining of post-traumatic back pain.

Section snippets

Patients and methods

A retrospective review was carried out of the records of 3173 patients who were involved in a MVC during a 1-year period, who presented to a single medical center. All patients arriving at the ED were ambulating independently.

The data were collected with the aid of a computer coding system and included the age of the patients, the chief complaints, and X-rays that were taken. Data regarding the mechanism of injury and physical findings on examination could not be obtained by the computer coding

Results

Of 3173 ambulating MVC trauma patients, 69.5% complained of either back or cervical pain, 35% of the patients complained of back pain and 42.5% complained of neck pain. Table 1 summarizes the distribution of complaints in all 3173 patients.

None of the lumbar or thoracic spine radiographs that were obtained for the 1110 patients who complained of post-traumatic back pain in this study was positive for a fracture or dislocation.

Discussion

Acute post-traumatic back pain is extremely common in patients who were involved in a MVC. This cohort comprised 35% of all ambulating trauma patients in this study. No clear guidelines are defined for the use of imaging studies in this setting in the hospital where this study was carried out.

In 1110 patients who complained of back pain and entered the ED walking, routine radiographs of the painful spinal region were obtained, regardless of the physical findings on examination. None of these

References (7)

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Selected Topics: Emergency Radiology is coordinated by Jack Keene, md, of Emergency Treatment Associates, Rhinebeck, New York

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