Practice management guidelines for the screening of thoracolumbar spine fracture.
BACKGROUND
Fractures to the thoracolumbar spine (TLS) commonly occur because of major trauma mechanisms. In one series, 4.4% of all patients arriving at a Level I trauma center were diagnosed as having TLS fracture. Approximately 19% to 50% of these fractures in the TLS region will be associated with neurologic damage to the spinal cord. To date there are no randomized studies and only a few prospective studies specifically addressing the subject. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the diagnosis of TLS fractures.


METHODS
A computerized search of the National Library of Medicine and the National Institutes of Health MEDLINE database was undertaken using the PubMed Entrez (www.pubmed.gov) interface. The primary search strategy was developed to retrieve English language articles focusing on diagnostic examination of potential TLS injury published between 1995 and March 2005. Articles were screened based on the following questions. (1) Does a patient who is awake, nonintoxicated, without distracting injuries require radiographic workup or a clinical examination only? (2) Does a patient with a distracting injury, altered mental status, or pain require radiographic examination? (3) Does the obtunded patient require radiographic examination?


RESULTS
Sixty-nine articles were identified after the initial screening process, all of which dealt with blunt injury to the TLS, along with clinical, radiographic, fluoroscopic, and magnetic resonance imaging evaluation. From this group, 32 articles were selected. The reviewers identified 27 articles that dealt with the initial evaluation of TLS injury after trauma.


CONCLUSIONS
Computed tomography (CT) scan imaging of the bony spine has advanced with helical and currently multidetector images to allow reformatted axial collimation of images into two-dimensional and three-dimensional images. As a result, bony injuries to the TLS are commonly being identified. Most blunt trauma patients require CT to screen for other injuries. This has allowed the single admitting series of CT scans to also include screening for bony spine injuries. However, all of the publications fail to clearly define the criteria used to decide who gets radiographs or CT scans. No study has carefully conducted long-term follow-up on all of their trauma patients to identify all cases of TLS injury missed in the acute setting.
Diaz
Jose J
JJ
Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, 37212, USA. jose.diaz@vanderbilt.edu.
Cullinane
Daniel C
DC
Altman
Daniel T
DT
Bokhari
Faran
F
Cheng
Joseph S
JS
Como
John
J
Gunter
Oliver
O
Holevar
Michele
M
Jerome
Rebecca
R
Kurek
Stanley J
SJ
Lorenzo
Manuel
M
Mejia
Vicente
V
Miglietta
Maurizio
M
O'Neill
Patrick J
PJ
Rhee
Peter
P
Sing
Ronald
R
Streib
Erik
E
Vaslef
Steven
S
D003937:Diagnosis, Differential; D003952:Diagnostic Imaging; D019317:Evidence-Based Medicine; D006801:Humans; D015601:Injury Severity Score; D008159:Lumbar Vertebrae / Q000293:injuries*; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D016103:Spinal Fractures / Q000175:diagnosis*; D013904:Thoracic Vertebrae / Q000293:injuries*