Thoracolumbar (TL) spine injuries (affecting the middle or lower back) are more common than cervical spine (affecting the neck and upper back) injuries after blunt trauma. Patients are considered at very low risk for TL spine injury if none of the following criteria are present: complaints of TL spine pain, TL spine tenderness on midline palpation, decreased level of consciousness, abnormal peripheral neurologic examination, distracting painful injury, or evidence of intoxication with ethanol or drugs.
All patients with TL spine injuries have at least one of the high-risk criteria. This suggests that use of all six screening criteria can identify virtually all blunt trauma patients with acute TL spine injuries, concludes William R. Mower, M.D., Ph.D., of the University of California, Los Angeles School of Medicine.
With support from the Agency for Healthcare Research and Quality (HS08239), Dr. Mower and his colleagues studied patients who underwent TL spine x-rays following blunt trauma. They determined injury status by the final faculty radiologist interpretation of all x-rays for a total of 2,404 patients. Radiologists identified TL spine injuries in 152 patients; all 152 patients were considered high-risk for TL spine injury because they met at least one of the high-risk criteria. Patients who exhibited none of the criteria were considered to have low risk for TL spine injury.
Overall, the criteria had a specificity of 3.9 percent and a positive predictive value of 6.6 percent. They did, however, have sensitive and negative predictive values of 100 percent, meaning that the criteria could reliably identify a subset of patients who did not have acute TL spine injury and for whom an x-ray would be unnecessary. Although these criteria identified all patients with TL injury, the positive predictive value and specificity of the criteria were disappointingly low, according to Dr. Mower. He concludes that further research is needed to identify criteria that maintain sensitivity but have improved specificity. Such criteria could then be employed in development of clinical guidelines for use of x-rays in blunt trauma patients suspected of TL spinal injury to avoid unnecessary spine imaging.
See "Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients," by James F. Holmes, M.D., Edward A. Pancek, M.D., Paul Q. Miller, B.Sc.H., and others, in the Journal of Emergency Medicine 24(1), pp. 1-7, 2003.
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