title: Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study.
abstract: BACKGROUND
  Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury.
  
  
  METHODS
  Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested.
  
  
  RESULTS
  Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery.
  
  
  CONCLUSIONS
  Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries.
  
  
  METHODS
  Diagnostic test, level III.
authors.affiliation: From the Division of Trauma and Surgical Critical Care, University of Southern California (K.I., L.N., D.S.) Los Angeles; Department of Surgery, Loma Linda University (D.T.), Loma Linda; Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego (L.K.), La Jolla; and Trauma Service, Santa Barbara Cottage Hospital (S.K.), Santa Barbara, California; Department of Surgery, R Adams Cowley Shock Trauma Center (J.M.), University of Maryland School of Medicine, Baltimore, Maryland; Division of Trauma, Burns and Surgical Critical Care, University of Alabama at Birmingham (P.B.), Birmingham, Alabama; Department of Trauma, East Texas Medical Center (L.W.), Tyler; and Department of Surgery, University of Texas Southwestern-Austin (J.C.), Austin, Texas; Department of Surgery, Crozer-Chester Medical Center (R.C.), Upland; and Division of Acute Care Surgery, Thomas Jefferson University (A.B.), Philadelphia, Pennsylvania; Division of Trauma, Massachusetts General Hospital (M.D.), Harvard Medical School, Boston, Massachusetts; Broward General Medical Center (M.B.), Florida International University, Miami, Florida; and Division of Trauma and Surgical Critical Care, Lutheran Medical Center (M.G.), Brooklyn, New York.
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Lauren
authors.initials: L
authors.lastname: Nosanov
authors.forename: Jay
authors.initials: J
authors.lastname: Menaker
authors.forename: Patrick
authors.initials: P
authors.lastname: Bosarge
authors.forename: Lashonda
authors.initials: L
authors.lastname: Williams
authors.forename: David
authors.initials: D
authors.lastname: Turay
authors.forename: Riad
authors.initials: R
authors.lastname: Cachecho
authors.forename: Marc
authors.initials: M
authors.lastname: de Moya
authors.forename: Marko
authors.initials: M
authors.lastname: Bukur
authors.forename: Jordan
authors.initials: J
authors.lastname: Carl
authors.forename: Leslie
authors.initials: L
authors.lastname: Kobayashi
authors.forename: Stephen
authors.initials: S
authors.lastname: Kaminski
authors.forename: Alec
authors.initials: A
authors.lastname: Beekley
authors.forename: Mario
authors.initials: M
authors.lastname: Gomez
authors.forename: Dimitra
authors.initials: D
authors.lastname: Skiada
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003661:Decision Support Techniques; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D011446:Prospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000175:diagnosis*; D013904:Thoracic Vertebrae / Q000293:injuries*; D014193:Trauma Centers; D014481:United States; D014949:Wounds, Nonpenetrating / Q000175:diagnosis*