Diagnostic Imaging Pathways - Thoraco-Lumbar Spine Trauma
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This pathway provides guidance on the imaging of adult patients at risk of thoraco-lumbar spine injury following trauma.
Date reviewed: December 2018
Date of next review: December 2021
Published: July 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Teaching Points
Teaching Points
- Indications for imaging in thoracolumbar spine (TLS) trauma include:
- High-energy mechanism of injury
- Neurologic signs consistent with TLS injury
- Back pain or pain on palpation
- Concomitant c-spine injury
- Altered mental status
- Evidence of intoxication with ethanol or drugs
- High-energy mechanisms of injury include:
- Falls from significant height (> 10 feet or 3m)
- Motor vehicle crash with ejection or high-velocity
- Motor cycle crash
- Pedestrian vs motor vehicle
- Other high-velocity injuries
- CT is now the preferred initial imaging modality for TLS
- Plain radiographs may be used in younger patients to avoid radiation exposure, followed by MRI where required
- Targeted CT should be considered for imaging suspected injuries of the upper thorax, across the shoulder girdle or at the cervicothoracic junction as these may be missed on plain radiographs
- MRI is indicated for patients with neurologic deficits as well as when clinical suspicion is high despite a normal CT scan. MRI should be undertaken in consultation with a trauma specialist, including trauma surgeon, spinal surgeon or emergency medicine consultant
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Thoraco-Lumbar Spine (TLS) Injury
- Imaging is indicated for TLS injury with if any of the following are present: 1
- Back pain or TLS tenderness on examination
- Neurologic deficits referable to the TLS
- Concomitant cervical spine fracture
- Altered mental state or intoxication
- Distracting non-spinal injuries, or
- Known or suspected high-energy mechanisms
- There is a high incidence of spinal injuries at multiple levels in blunt trauma patients. CT evaluation of the whole spine should be considered in patients with known injury to the cervical spine, or any other region of the spine 1
- Noncontiguous fractures occur in 10-30% of patients with a spinal column fracture; they are generally associated with other severe injuries and high-energy mechanisms 2-5
- Of patients with c-spine fractures, up to 21.5% and 10% have concomitant thoracic and lumbar spine fractures respectively 2
- However, concomitant occult injuries are rare when isolated C-spine fractures are sustained from low velocity trauma 6
- It has been previously accepted practice to clinically clear the thoraco-lumbar spine in trauma patients with no spine tenderness, no altered mental status and no distracting painful injury. This method detects clinically significant TLS injuries with sensitivity 78.6-96.6% of and specificity 49.1-83.4% 7,8
- Mechanisms of injury that have been correlated with TLS fractures include falls greater than 10ft (3m), ejection from a motor vehicle, motorcycle crashes, high-velocity injuries and pedestrians struck by motor vehicles 1
- The mean collision speeds of patients sustaining thoracic and lumbar spine injuries has been reported as 40 km/h (compared with 17.3km/h mean speed of all motor vehicle accidents) 12
- Nonspinal traumatic injuries may be a distraction to the physical examination of the spine, but also a marker of the severity of mechanism 1
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Computed Tomography (CT)
- Multi-detector CT is the preferred imaging modality for TLS injury in trauma 1,13
- Older studies have reported sensitivities of 95-100% for thoracic and lumbar fractures and specificities of 97-100%. 14-22 Newer CT scanners have even higher resolution with faster acquisition time
- In comparison, plain radiographs may miss fractures. Reported sensitivities range from 33-75% with specificities of 72-100%. 14-21 The sensitivity of radiographs is generally lower for thoracic fractures compared with lumbar fractures
- CT has the advantage of being able to evaluate multiple injuries, such as visceral and vascular injuries in the abdomen and thorax. If trauma patients with multiple injuries are undergoing contrast-enhanced CT scanning as part of an evaluation for visceral injury, the spine can also be evaluated with no additional scan time, radiation, or patient movement 23
- Disadvantages include radiation exposure and cost. Intravenous contrast is not required for evaluation of bony structures but improves the evaluation of visceral injuries
- Infrequently injuries may be occult on CT but demonstrated on MRI. 24,25 If there is still clinical concern for a fracture despite normal CT, MRI should be considered
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Magnetic Resonance Imaging
- MRI is indicated to evaluate patients with neurologic deficits referable to a thoracolumbar spine injury, even if CT is unremarkable, and to further assess injuries on CT that are suggestive of neurologic involvement 1
- CT and MRI are complementary examinations
- MRI is useful to evaluate soft tissues that are not well visualised by CT including the spinal cord, ligamentous injuries, haematomas and disc involvement as well as facet joint involvement 24,25
- MRI does not involve exposure to ionising radiation
- Limitations:
- Longer acquisition time, not suitable for unstable patients
- Contraindicated in the presence of non-MRI compatible prostheses/implants
- May not be tolerated by claustrophobic patients
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Plain Radiography
- Plain radiographs may be performed instead of CT in select cases, particularly in younger patients where avoiding radiation is desired, and where cross-sectional imaging of the chest/abdomen is not otherwise indicated to evaluate other injuries
- Plain radiographs may miss a small proportion of significant injuries 1
- Because of this, normal radiographs should be followed by a screening MRI of the whole spine if there is persisting clinical concern
- Plain radiographs have a reported sensitivity of 33-75% for all thoracolumbar fractures, with specificities of 72-100%, compared with CT which has reported sensitivities of 95-100% and specificities of 97-100% 14-22
- The majority of fractures that are missed on plain radiographs are transverse or spinous process fractures, however there is a small proportion of unstable fractures that may be missed
- Importantly, plain radiographs are less sensitive for thoracic fractures than lumbar fractures. 15 In particular, vertebral body fractures may be missed in the upper thoracic region, across the shoulder girdle or at the cervicothoracic junction. Targeted CT should be considered if the injury is in this area
- Observational studies have suggested that plain radiographs are not required in patients in the absence of high-energy injury mechanism, back pain, neurological deficits, altered mental state or distracting injury 5,10,11
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Sixta S, Moore FO, Ditillo MF, Fox AD, Garcia AJ, Holena D, et al. Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. The journal of trauma and acute care surgery. 2012;73(5 Suppl 4):S326-32. (Guideline). View the reference
- Nelson DW, Martin MJ, Martin ND, Beekley A. Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. The journal of trauma and acute care surgery. 2013;75(1):135-9. (Level III evidence). View the reference
- Meldon SW, Moettus LN. Thoracolumbar spine fractures: clinical presentation and the effect of altered sensorium and major injury. J Trauma. 1995;39(6):1110-4. (Level III evidence). View the reference
- Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury. 2003;34(6):426-33. (Level III evidence). View the reference
- Anderson S, Biros MH, Reardon RF. Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients. Acad Emerg Med. 1996;3(9):832-9. (Level III evidence). View the reference
- Kelleher MS, Jr., Gao G, Rolen MF, Bokhari SA. Kelleher MS, Jr., Gao G, Rolen MF, Bokhari SA. Radiology. 2016;279(2):395-9. (Level II-III evidence). View the reference
- Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency medicine journal : EMJ. 2013;30(8):679-82. (Level II-III evidence). View the reference
- Inaba K, DuBose JJ, Barmparas G, Barbarino R, Reddy S, Talving P, et al. Clinical examination is insufficient to rule out thoracolumbar spine injuries. J Trauma. 2011;70(1):174-9. (Level II-III evidence). View the reference
- Inaba K, Nosanov L, Menaker J, Bosarge P, Williams L, Turay D, 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. The journal of trauma and acute care surgery. 2015;78(3):459-65; discussion 65-7. (Level II evidence). View the reference
- Frankel HL, Rozycki GS, Ochsner MG, Harviel JD, Champion HR. Indications for obtaining surveillance thoracic and lumbar spine radiographs. J Trauma. 1994;37(4):673-6. (Level III evidence). View the reference
- Holmes JF, Panacek EA, Miller PQ, Lapidis AD, Mower WR. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003;24(1):1-7. (Level II-III evidence). View the reference
- Muller CW, Otte D, Decker S, Stubig T, Panzica M, Krettek C, et al. Vertebral fractures in motor vehicle accidents - a medical and technical analysis of 33,015 injured front-seat occupants. Accid Anal Prev. 2014;66:15-9. (Level III evidence). View the reference
- American College of Radiology. ACR appropriateness criteria. Suspected spine trauma. 2012. (Guideline). View the reference
- Hauser CJ, Visvikis G, Hinrichs C, Eber CD, Cho K, Lavery RF, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma. 2003;55(2):228-34; discussion 34-5. (Level II evidence). View the reference
- Sheridan R, Peralta R, Rhea J, Ptak T, Novelline R. Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients. J Trauma. 2003;55(4):665-9. (Level II evidence). View the reference
- Wintermark M, Mouhsine E, Theumann N, Mordasini P, van Melle G, Leyvraz PF, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology. 2003;227(3):681-9. (Level II evidence). View the reference
- Herzog C, Ahle H, Mack MG, Maier B, Schwarz W, Zangos S, et al. Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy? Eur Radiol. 2004;14(10):1751-60. (Level II evidence). View the reference
- Mejia VA, Diaz JJJ, Guy J, Miller R, May AK, Guillamondegui O, et al. Plain films vs helical CT for thoracolumbar spine clearance. 2004;57(6):1376. (Level II evidence). View the reference
- Berry GE, Adams S, Harris MB, Boles CA, McKernan MG, Collinson F, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma. 2005;59(6):1410-3; discussion 3. (Level II evidence). View the reference
- Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? J Trauma. 2006;61(2):382-7. (Level II evidence). View the reference
- Smith MW, Reed JD, Facco R, Hlaing T, McGee A, Hicks BM, et al. The reliability of nonreconstructed computerized tomographic scans of the abdomen and pelvis in detecting thoracolumbar spine injuries in blunt trauma patients with altered mental status. J Bone Joint Surg Am. 2009;91(10):2342-9. (Level II-III evidence). View the reference
- Roos JE, Hilfiker P, Platz A, Desbiolles L, Boehm T, Marincek B, et al. MDCT in emergency radiology: is a standardized chest or abdominal protocol sufficient for evaluation of thoracic and lumbar spine trauma? AJR Am J Roentgenol. 2004;183(4):959-68. (Level II evidence). View the reference
- Inaba K, Munera F, McKenney M, Schulman C, de Moya M, Rivas L, et al. Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: a review of the literature. J Trauma. 2006;60(4):915-20. (Level II evidence). View the reference
- Winklhofer S, Thekkumthala-Sommer M, Schmidt D, Rufibach K, Werner CM, Wanner GA, et al. Magnetic resonance imaging frequently changes classification of acute traumatic thoracolumbar spine injuries. Skeletal Radiol. 2013;42(6):779-86. (Level II-III evidence). View the reference
- Pizones J, Izquierdo E, Alvarez P, Sanchez-Mariscal F, Zuniga L, Chimeno P, et al. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. Eur Spine J. 2011;20 Suppl 3:390-6. (Level II-III evidence). View the reference
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