Clinical examination alone is insufficient to detect a significant fracture of the thoracolumbar spine and should be combined with CT imaging, according to a study published in the August issue of The Journal of Joint and Bone Surgery British volume.
Murali Venkatesan, Leicester Royal Infirmary, Leicester, UK, and others wrote that while guidelines for the assessment of the cervical spine after a blunt injury have been established, the assessment of the thoracolumbar spine after a blunt injury is less clear. They wrote: “It is accepted practice to image the thoracolumbar spine in patients with symptoms and signs of spinal injury or neurological deficit. However, the value of these signs in drowsy or intoxicated patients, or those with other painful injuries, remains controversial and is extrapolated from studies of the cervical spine.”
They added that there was evidence that reformatted CT scans were a better alternative to the traditional approach of taking two plain radiographs and wrote: “We therefore set out to establish whether CT scans of the viscera could be used to detect clinically unrecognised fractures of the thoracolumbar vertebrae.”
In their retrospective review of 303 CT scans of the torso, Venkatesan et al specifically looked at patients (aged >15 years) with a fracture of the thoracolumbar spine. They found that 51 patients had evidence of a thoracolumbar fracture on the CT scan. Of these, only 17 (33%) would have been suspected as having a thoracolumbar fracture on the basis of their clinical examination and only 20.6% of patients with a stable fracture (29 overall) would have been identified as having a possible fracture. The authors added: “Of the 22 unstable fractures, only 11 (50%) were anticipated and had positive recorded findings on examination.”
According to the authors, the most important message of their study is that “an absence of clinical signs does not exclude serious injury to the thoracolumbar spine.” They added that previous studies have shown that there is a risk of missing injuries in patients with a low Glasgow Coma Scale because physical signs are difficult to assess and the resulting physical examination may be inadequate in such patients, but said: “Interestingly, in our series, 23 of 34 patients (67%) of the patients with negative clinical signs were alert, awake, and able to co-operative with clinical examination. This suggests that thoracolumbar fractures are often silent even in patients who appear alert and reliable.”
Venkatesan suggested that one reason for low sensitivity of clinical examinations for possible thoracolumbar fractures may be a “lack of thoroughness and consistency of examination.” They wrote: “Evaluation of the spine may be delegated to a junior member of the trauma team and may be perceived as ‘routine’ rather than critical.”
Concluding, the authors reported that a “high index of suspicion and standardised method of assessing the thoracolumbar spine are mandatory” if the problem of the diagnosis of vertebral fractures being missed or delayed in 0.5–24% of patients who have incurred a blunt injury is to be addressed. They also wrote: “We have shown that clinical examination alone is insufficient to detect significant fractures of the thoracolumbar spine and that it has to be combined with imaging to reduce the risk of missed injury.”
Senior author of the study, Philip Sell (Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham, UK) told Spinal News International that he was pleased he and his co-authors’s paper has been published “at a time when road traffic accidents and trauma are the focus of the Bone and Joint Decade initiative”. He added: “The key message of our paper is that if there is a suspicion of intra-abdominal visceral trauma on clinical grounds, then it is probable that there is also a thoracolumbar fracture. If a fracture is detected on CT it is very helpful to have a detailed bone quality CT of the injured spine to avoid return to scanning later, and at that point involve the appropriate spinal specialist if they are not already aware of the case.”