title: Thoracolumbar fracture in blunt trauma: is clinical exam enough for awake patients?
abstract: BACKGROUND
  Physical examination is widely used to screen trauma patients for thoracolumbar fracture (TLFx). Retrospective data suggests that patients with altered sensorium may not manifest symptoms after TLFx. This study was designed to prospectively test the sensitivity of physical examination for detection of TLFx in patients with altered mentation.
  
  
  METHODS
  Prospective data collection in a large urban Level I trauma center from April 2002 to December 2003. During the study period, thoracolumbar radiography was performed on patients with signs or symptoms of TLFx, and also on patients with significant blunt trauma and any alteration in mentation, including drowsiness or apparent intoxication. All patients were classified as reliable if Glasgow coma score was >13 and the treating physician judged them capable of accurately reporting pain, and those who did not met both these conditions were deemed unreliable. Patients with normal mentation and no signs or symptoms were excluded. Injuries, mental status, symptoms, physical examination, and X-ray film results were recorded.
  
  
  RESULTS
  There were 3,028 blunt trauma patients evaluated during the study period. Thoracolumbar radiography was performed on 537 patients. Of these, 442 patients were deemed reliable, and 166 had no signs or symptoms of TLFx. Of these asymptomatic patients, 10 were found to have TLFx. Of these 10 reliable patients with TLFx despite negative examination, none required surgery, but four required a brace.
  
  
  CONCLUSIONS
  Thoracolumbar fractures are often clinically silent in blunt trauma patients with altered sensorium, even when they appear able to reliably report pain. X-ray screening of these patients is appropriate to prevent missed injury.
authors.affiliation: Division of Trauma, Washington Hospital Center, Washington, DC 20010, USA. jack.a.sava@medstar.net
authors.forename: Jack
authors.initials: J
authors.lastname: Sava
authors.forename: Michael D
authors.initials: MD
authors.lastname: Williams
authors.forename: Susan
authors.initials: S
authors.lastname: Kennedy
authors.forename: Dennis
authors.initials: D
authors.lastname: Wang
mesh_terms: D000293:Adolescent; D000328:Adult; D000435:Alcoholic Intoxication / Q000150:complications; D003072:Cognition Disorders / Q000150:complications; D003951:Diagnostic Errors / Q000517:prevention & control; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011859:Radiography; D012680:Sensitivity and Specificity; D016103:Spinal Fractures / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D013904:Thoracic Vertebrae; D014851:Wakefulness; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging