Thoraco-Lumbar Spine Injury (Suspected)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients at risk of thoraco-lumbar spine injury following trauma.

Lead Researcher: Sian Chin

Experts & Contributors: Scott Davies, Stephen Dunjey, Ferry Dharsono, Sudhakar Rao

Date reviewed: December 2018

Date Published: July 2019

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  • Indications for imaging in thoracolumbar spine (TLS) trauma include:
    • High-energy mechanism of injury
    • Neurologic signs consistent with TLS injury
    • Back pain or pain on palpation
    • Concomitant c-spine injury
    • Altered mental status
    • Evidence of intoxication with ethanol or drugs
  • High-energy mechanisms of injury include:
    • Falls from significant height (> 10 feet or 3m)
    • Motor vehicle crash with ejection or high-velocity
    • Motor cycle crash
    • Pedestrian vs motor vehicle
    • Other high-velocity injuries
  • CT is now the preferred initial imaging modality for TLS
  • Plain radiographs may be used in younger patients to avoid radiation exposure, followed by MRI where required
    • Targeted CT should be considered for imaging suspected injuries of the upper thorax, across the shoulder girdle or at the cervicothoracic junction as these may be missed on plain radiographs
  • MRI is indicated for patients with neurologic deficits as well as when clinical suspicion is high despite a normal CT scan. MRI should be undertaken in consultation with a trauma specialist, including trauma surgeon, spinal surgeon or emergency medicine consultant

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Sixta S, Moore FO, Ditillo MF, Fox AD, Garcia AJ, Holena D, et al. Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. The journal of trauma and acute care surgery. 2012;73(5 Suppl 4):S326-32. (Guideline). View the reference
  2. Nelson DW, Martin MJ, Martin ND, Beekley A. Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. The journal of trauma and acute care surgery. 2013;75(1):135-9. (Level III evidence). View the reference
  3. Meldon SW, Moettus LN. Thoracolumbar spine fractures: clinical presentation and the effect of altered sensorium and major injury. J Trauma. 1995;39(6):1110-4. (Level III evidence). View the reference
  4. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury. 2003;34(6):426-33. (Level III evidence). View the reference
  5. Anderson S, Biros MH, Reardon RF. Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients. Acad Emerg Med. 1996;3(9):832-9. (Level III evidence). View the reference
  6. Kelleher MS, Jr., Gao G, Rolen MF, Bokhari SA. Kelleher MS, Jr., Gao G, Rolen MF, Bokhari SA. Radiology. 2016;279(2):395-9. (Level II-III evidence). View the reference
  7. Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency medicine journal : EMJ. 2013;30(8):679-82. (Level II-III evidence). View the reference
  8. Inaba K, DuBose JJ, Barmparas G, Barbarino R, Reddy S, Talving P, et al. Clinical examination is insufficient to rule out thoracolumbar spine injuries. J Trauma. 2011;70(1):174-9. (Level II-III evidence). View the reference
  9. Inaba K, Nosanov L, Menaker J, Bosarge P, Williams L, Turay D, et al. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. The journal of trauma and acute care surgery. 2015;78(3):459-65; discussion 65-7. (Level II evidence). View the reference
  10. Frankel HL, Rozycki GS, Ochsner MG, Harviel JD, Champion HR. Indications for obtaining surveillance thoracic and lumbar spine radiographs. J Trauma. 1994;37(4):673-6. (Level III evidence). View the reference
  11. Holmes JF, Panacek EA, Miller PQ, Lapidis AD, Mower WR. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003;24(1):1-7. (Level II-III evidence). View the reference
  12. Muller CW, Otte D, Decker S, Stubig T, Panzica M, Krettek C, et al. Vertebral fractures in motor vehicle accidents - a medical and technical analysis of 33,015 injured front-seat occupants. Accid Anal Prev. 2014;66:15-9. (Level III evidence). View the reference
  13. American College of Radiology. ACR appropriateness criteria. Suspected spine trauma. 2012. (Guideline). View the reference
  14. Hauser CJ, Visvikis G, Hinrichs C, Eber CD, Cho K, Lavery RF, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma. 2003;55(2):228-34; discussion 34-5. (Level II evidence). View the reference
  15. Sheridan R, Peralta R, Rhea J, Ptak T, Novelline R. Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients. J Trauma. 2003;55(4):665-9. (Level II evidence). View the reference
  16. Wintermark M, Mouhsine E, Theumann N, Mordasini P, van Melle G, Leyvraz PF, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology. 2003;227(3):681-9. (Level II evidence). View the reference
  17. Herzog C, Ahle H, Mack MG, Maier B, Schwarz W, Zangos S, et al. Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy? Eur Radiol. 2004;14(10):1751-60. (Level II evidence). View the reference
  18. Mejia VA, Diaz JJJ, Guy J, Miller R, May AK, Guillamondegui O, et al. Plain films vs helical CT for thoracolumbar spine clearance. 2004;57(6):1376. (Level II evidence). View the reference
  19. Berry GE, Adams S, Harris MB, Boles CA, McKernan MG, Collinson F, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma. 2005;59(6):1410-3; discussion 3. (Level II evidence). View the reference
  20. Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? J Trauma. 2006;61(2):382-7. (Level II evidence). View the reference
  21. Smith MW, Reed JD, Facco R, Hlaing T, McGee A, Hicks BM, et al. The reliability of nonreconstructed computerized tomographic scans of the abdomen and pelvis in detecting thoracolumbar spine injuries in blunt trauma patients with altered mental status. J Bone Joint Surg Am. 2009;91(10):2342-9. (Level II-III evidence). View the reference
  22. Roos JE, Hilfiker P, Platz A, Desbiolles L, Boehm T, Marincek B, et al. MDCT in emergency radiology: is a standardized chest or abdominal protocol sufficient for evaluation of thoracic and lumbar spine trauma? AJR Am J Roentgenol. 2004;183(4):959-68. (Level II evidence). View the reference
  23. Inaba K, Munera F, McKenney M, Schulman C, de Moya M, Rivas L, et al. Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: a review of the literature. J Trauma. 2006;60(4):915-20. (Level II evidence). View the reference
  24. Winklhofer S, Thekkumthala-Sommer M, Schmidt D, Rufibach K, Werner CM, Wanner GA, et al. Magnetic resonance imaging frequently changes classification of acute traumatic thoracolumbar spine injuries. Skeletal Radiol. 2013;42(6):779-86. (Level II-III evidence). View the reference
  25. Pizones J, Izquierdo E, Alvarez P, Sanchez-Mariscal F, Zuniga L, Chimeno P, et al. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. Eur Spine J. 2011;20 Suppl 3:390-6. (Level II-III evidence). View the reference

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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