Risk factors for thoracolumbar fracture (TLF) and occurrence of back pain/tenderness detection (BPTD) in TLF patients have not been fully evaluated. Of 4142 blunt trauma patients directly admitted to a level I trauma center, 183 (4.4%) had a TLF. Risk factors for TLF (p < or = 0.05) were major non-TLF injuries (Abbreviated Injury Scale score > or = 3) and a fall mechanism of injury. Of 110 with TLF, Glasgow Coma Scale score (GCS) of 13 to 15, and no myelopathy, 34 (30.9%) had no BPTD; 7 of 34 (20.6%) required operative spinal stabilization. BPTD was lacking in 63% of patients with GCS scores of 13 to 14 compared to 22% of patients with GCS scores of 15 (p = 0.001). BPTD was decreased when major non-TLF injuries were present (63 vs. 91%) in the GCS score of 15 group (0.003), but similar in GCS score of 13 to 14 patients. In patients with GCS scores of 13 to 15, decreased BPTD is simultaneously related to both cognitive dysfunction and major injuries (p = 0.005). In conclusion, major injuries and falls are risks for TLF and cognitive deficit and major injury impedes BPTD in TLF. Thoracolumbar x-ray films should be carefully considered in patients with altered mentation or major injury.