Unconscious patients with multiple injuries present a major diagnostic and therapeutic problem. The incidence of neurological deficit increases if diagnosis of a spinal injury is delayed or missed. Thoracolumbar fractures are commonly the result of high energy injuries and in an unconscious patient the risk of missing such fractures is increased considerably. There is little consensus on which blunt trauma patients warrant thoracolumbar spine films when no pain, tenderness, neurological deficit or cervical spine injuries are identified. We present a retrospective analysis of all patients who were admitted to the Major Injuries Unit at the Birmingham General Hospital and underwent radiological survey of the thoracolumbar spine. Of the 110 patients, all spinal fractures were detected in 94 patients with a Glasgow Coma Scale (GCS) > or = 11. Of the 16 with a GCS < or = 10, 9 patients had sustained injuries of their thoracolumbar spine 4 of which were not detected initially due to a decreased level of consciousness. The common features amongst the 4 patients with missed injuries were: (1) High velocity injury. (2) Decreased level of consciousness on admission. (3) Associated head injury. (4) Pelvis/lower extremity injury. We describe the four cases and identify a group of high risk patients for thoracolumbar fractures. Radiological examination of the thoracolumbar spine is essential in this group.