Original Contributions| Volume 57, ISSUE 3, P279-289, September 2019

Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department



      Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear.


      The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases.


      Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning.


      Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury.


      In certain lower-risk blunt trauma patients < 65 years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65 years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Disease Control and Prevention
        Injury Center. Data and Statistics (WISQARS).
        (Available at:)
        Date: 2018
        Date accessed: February 24, 2018
        • Hoffman J.R.
        • Mower W.R.
        • Wolfson A.B.
        • Todd K.H.
        • Zucker M.I.
        Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
        N Engl J Med. 2000; 343: 94-99
        • Stiell I.G.
        • Wells G.A.
        • Vandemheen K.L.
        • et al.
        The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients.
        JAMA. 2001; 286: 1841-1848
        • Inaba K.
        • DuBose J.J.
        • Barmparas G.
        • et al.
        Clinical examination is insufficient to rule out thoracolumbar spine injuries.
        J Trauma. 2011; 70: 174-179
        • Sava J.
        • Williams M.D.
        • Kennedy S.
        • Wang D.
        Thoracolumbar fracture in blunt trauma: is clinical exam enough for awake patients?.
        J Trauma. 2006; 61: 168-171
        • Gill D.S.
        • Mitra B.
        • Reeves F.
        • et al.
        Can initial clinical assessment exclude thoracolumbar vertebral injury?.
        Emerg Med J. 2013; 30: 679-682
        • Sixta S.
        • Moore F.O.
        • Ditillo M.F.
        • et al.
        Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline.
        J Trauma Acute Care Surg. 2012; 75: S326-S332
        • Friedman J.H.
        A recursive partitioning decision rule for nonparametric classification.
        J IEEE Trans Comput. 1977; 26: 404-408
        • Stiell I.G.
        • Wells G.A.
        Methodologic standards for the development of clinical decision rules in emergency medicine.
        Ann Emerg Med. 1999; 33: 437-447
        • Therneau A.
        • Atkinson B.
        • Ripley B.
        rpart: Recursive Partitioning and Regression Trees. R package version 4.1-13.
        R Foundation for Statistical Computing, Vienna, Austria2018
        • R Core Team. R
        A language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2017 (Available at:) (Accessed January 2018)
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap).
        J Biomed Inform. 2009; 42: 377-381
        • Long B.
        • April M.D.
        • Summers S.
        • Koyfam A.
        Whole body CT versus selective radiological imaging strategy in trauma: an evidence-based clinical review.
        Am J Emerg Med. 2017; 35: 1356-1362
        • Katsuura Y.
        • Osborn J.M.
        • Cason G.W.
        The epidemiology of thoracolumbar trauma: a meta-analysi.
        J Orthop. 2016; 13: 383-388
        • Samuels L.E.
        • Kerstein M.D.
        ‘Routine’ radiologic evaluation of the thoracolumbar spine in blunt trauma patients: a reappraisal.
        J Trauma. 1993; 34: 85-89
        • Durham R.M.
        • Luchtefeld W.B.
        • Wibbenmeyer L.
        • Maxwell P.
        • Shapiro M.J.
        • Mazuski J.E.
        Evaluation of the thoracic and lumbar spine after blunt trauma.
        Am J Surg. 1995; 170: 681-684
        • Stanislas M.J.
        • Latham J.M.
        • Porter K.M.
        • Alpar E.K.
        • Stirling A.J.
        A high risk group for thoracolumbar fractures.
        Injury. 1998; 29: 15-18
        • Hsu J.M.
        • Joseph T.
        • Ellis A.M.
        Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging.
        Injury. 2003; 34: 426-433
        • Inaba K.
        • Nosanov L.
        • Menaker J.
        • et al.
        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.
        J Trauma Acute Care Surg. 2015; 78: 459-467
        • Holmes J.F.
        • Panacek E.A.
        • Miller P.Q.
        • Lapidis A.D.
        • Mower W.R.
        Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients.
        J Emerg Med. 2003; 24: 1-7
        • Rodriguez R.M.
        • Langdorf M.I.
        • Nishijima D.
        • et al.
        Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT).
        PLoS Med. 2015; 12: e1001883
        • LeMier M.
        • Cummings P.
        • West T.A.
        Accuracy of external cause of injury codes reported in Washington State hospital discharge records.
        Inj Prev. 2011; 7: 334-338
        • McKenzie K.
        • Enraght-Moony E.L.
        • Waller G.
        • Walker S.M.
        • Harrison J.E.
        • McClure R.J.
        Causes of injuries resulting in hospitalization in Australia: assessing coder agreement on external causes.
        Inj Prev. 2009; 15: 188-196