title: Clinical examination is insufficient to rule out thoracolumbar spine injuries.
abstract: OBJECTIVE
  The role of clinical examination in the diagnosis of thoracolumbar (TL) spine injuries is highly controversial. The aim of this study was to assess the sensitivity and specificity of a standardized clinical examination for diagnosing TL spine injuries after blunt trauma.
  
  
  METHODS
  This was a prospective observational study conducted at a level I trauma center from March 2008 to September 2008. After Institutional Review Board approval, all evaluable blunt trauma patients older than 15 years were evaluated by a senior resident or attending surgeon for TL spine deformity, tenderness to palpation, and neurologic deficits. Patients were followed through their hospital course to capture all TL spine injury diagnoses, all imaging performed, and any immobilization or stabilization procedures.
  
  
  RESULTS
  Of the 884 patients enrolled, 81 (9%) had a TL spine injury. More than half (55.6%) had two or more fractures with 30.9% having three or more. Isolated L-spine fractures occurred in 56.8%, T-spine fractures occurred in 34.6% only, and combination injuries sustained in 8.6%. The most commonly identified fractures were of the transverse process (67.9%) followed by the vertebral body (30.9%) and spinous process (12.3%). Among the 666 patients who were evaluable, 56 (8%) had a TL spine fracture. Of these, 29 (52%) had a negative clinical examination, of which 2 (7%) had clinically significant compression fractures. For evaluable patients who had localized pain or tenderness elicited on examination, although the finding triggered imaging appropriately, the site of pain correlated to the site of actual injury in only 61.5% of cases. The sensitivity and specificity of clinical examination for TL spine fractures were 48.2% and 84.9%, respectively, for all fractures and 78.6% and 83.4% for those that were clinically significant.
  
  
  CONCLUSIONS
  Clinical examination as a stand-alone screening tool for evaluation of the TL spine is inadequate. In this series, all the clinically significant missed fractures were diagnosed on computed tomography (CT) obtained for evaluation of the visceral torso. A combination of both clinical examination and CT screening based on mechanism will likely be required to ensure adequate sensitivity with an acceptable specificity for the diagnosis of clinically significant injuries of the TL spine. Further research is warranted, targeting the at-risk patient with a negative clinical examination, to determine what injury mechanisms warrant evaluation with a screening CT.
authors.affiliation: Division of Trauma Surgery and Surgical Critical Care, Los Angeles County Medical Center-University of Southern California, Los Angeles, California 90033, USA. kinaba@surgery.usc.edu
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: DuBose
authors.forename: Galinos
authors.initials: G
authors.lastname: Barmparas
authors.forename: Raffaella
authors.initials: R
authors.lastname: Barbarino
authors.forename: Sravanthi
authors.initials: S
authors.lastname: Reddy
authors.forename: Peep
authors.initials: P
authors.lastname: Talving
authors.forename: Lydia
authors.initials: L
authors.lastname: Lam
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003951:Diagnostic Errors / Q000517:prevention & control; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000175:diagnosis* / Q000000981:diagnostic imaging; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000175:diagnosis*; D055815:Young Adult