Fractures of the thoracolumbar spine in major trauma patientsBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7170.1442 (Published 21 November 1998) Cite this as: BMJ 1998;317:1442
Thoracolumbar spine fractures may be present in major trauma patients without symptoms
Although much attention has been paid to improving the diagnosis of cervical spine injuries over the past few years, fractures of the thoracolumbar spine have received comparatively little attention. Several reports have indicated that back pain and bony tenderness may be absent in some patients with fractures of the thoracolumbar spine which may lead to a delay in diagnosis.13 and an increased risk of neurological damage.4
We report the cases of six patients with multiple trauma and fractures of the thoracolumbar spine in whom back pain and bony tenderness were absent, radiography of the thoracolumbar spine was not requested, and the diagnosis was delayed or missed. Our experience suggests that in the United Kingdom many doctors in trauma specialties are unaware that back pain and tenderness may be absent in cases of spinal fracture.
These cases were identified by the South West region major trauma outcome study. A total of six hospitals in Bristol, Gloucestershire, and Somerset collected data on all major trauma cases occurring in patients under 40 years of age and selected cases for peer review. Altogether 594 patients were entered into the study between 1994 and 1997, and 58 (10%) had fractures of the thoracolumbar spine.
Case 1—A driver who was not wearing a safety belt was ejected from a vehicle. His score on the Glasgow coma scale was 15 on arrival at the accident and emergency department. Avulsion fractures of C2 and C3 bodies were noted without neurological deficit. Additionally, an open fracture of the radius and ulna and fractures of the pelvic ring were diagnosed. The patient was “log rolled” (a procedure in which patients are rolled on to their side by a number of staff with minimal movement of the spine) to allow examination of his back. His responses were recorded as non-tender over the thoracolumbar spine and so radiographs were not taken. He made a steady recovery. He continued to complain of back pain after discharge. Radiographs taken three months after injury showed a healing wedge fracture of T12 with a clinically obvious kyphosis but no involvement of the spinal cord.
Case 2—A young car driver who collided with a tree was brought to accident and emergency in haemorrhagic shock. He complained of abdominal pain. Diagnostic peritoneal lavage revealed fresh blood, indicating the need for emergency laparotomy. His level of consciousness was slightly reduced (Glasgow score 13) and his spine was non-tender on “log roll.” He had an emergency laparotomy and splenectomy. Four months later, because of persistent back pain, radiography of the thoracolumbar spine was done. A burst fracture of T12 without involvement of the spinal cord was identified in the radiographs.
Case 3— A cyclist was hit by a car. She was fully alert and conscious (Glasgow score 15) in accident and emergency. Fractures of the pelvic ring, femur and tibia, and facial injuries were diagnosed. Back pain and spinal tenderness were absent. Computed tomography of the pelvis and abdomen was performed later and showed unexpected burst fractures of T7 and L1 requiring fixation. Bladder and bowel dysfunction and perineal sensory loss were present on discharge.
Case 4— This man was hit by a falling object which broke the helmet he was wearing and fractured his left third, fourth, and fifth ribs, and clavicle. His level of consciousness was slightly reduced (Glasgow score 13) when seen in accident and emergency. He denied back pain and spinal tenderness. Following a slight deterioration in consciousness he was intubated and ventilated for computed tomography of the brain; a small frontal contusion was identified. He was found to be paraplegic with priapism when sedation was withdrawn. He was extubated in the intensive care unit. Magnetic resonance imaging identified fractures at T8 and T9 with compression of the spinal cord.
Case 5— A motorcyclist collided with a car. She was in early haemorrhagic shock but fully conscious and oriented (Glasgow score 15) in accident and emergency. Facial fractures were noted. There was no spinal tenderness, bruising, or deformity when she was “log rolled.” She underwent emergency laparotomy and splenectomy for a ruptured spleen. She had low back pain before discharge. Some weeks later, radiographs showed severe burst fractures of T8 and T9 with retropulsion and canal narrowing. The patient had visible kyphosis but was neurologically intact apart from minor sensory loss on the left side.
Case 6—A young man fell 7 metres. He was fully alert and oriented (Glasgow score 15) on arrival at accident and emergency. He had multiple lacerations to his head and neck and multiple tendon lacerations on both wrists; the right radial artery was severed. There was no spinal pain or tenderness on “log roll.” He underwent definitive tendon and wound repair under general anaesthesia and was admitted to the intensive care unit. When extubated two days later, he denied back pain but radiographs showed a crush fracture of L2 with retropulsion and 80%canal compromise which required fixation. There were no neurological sequelae.
We identified six cases of major trauma in patients without back pain or spinal tenderness in which the diagnosis of fracture of the thoracolumbar spine was delayed or missed and so radiography was not done. Failure to recognise that patients with these fractures may be asymptomatic in some circumstances caused the delay in diagnosis. All six patients had other painful injuries, and three had a slightly reduced level of consciousness.
Clinical examination in patients with a reduction in consciousness may be unreliable.47Even slight reductions in the level of consciousness—for example, a reduction in the Glasgow score to 14 or 13 or the amount of impairment caused by alcohol intoxication—have been shown to make clinical examination of the spine unreliable in trauma patients 1 2 ; these two reviews concluded that pain or tenderness may be absent in thoracolumbar spine fractures not only when there is an altered level of consciousness but also if another painful, or distracting, injury was present. Cooper et al reviewed 183 cases of fractures of the thoracolumbar spine.1 The absence of back pain and bony tenderness was strongly associated with both mild cognitive impairment (Glasgow score 13 or 14) and the presence of other major injury. Meldon and Moettus reached the same conclusion in a review of 145 such fractures.2They noted that all 27 (19%) patients in whom back pain and tenderness were absent had either an altered level of consciousness, neurological deficit, or concomitant major injury.2
The concept that a painful injury elsewhere in the body may obscure symptoms and signs of spinal fracture was recognised as a cause of delayed diagnosis of fractures of the cervical spine in 19927; an association between multiple injuries and the missed diagnosis of fractures of the spine was noted earlier.4 Fractures of the thoracolumbar spine are associated with serious chest injuries.1Patients who have fallen from more than 3 metres or been involved in motorcycle accidents are at particularly high risk. 1 8
Fractures of the thoracolumbar spine occur in around 9% of cases of multiple trauma and are associated with a 32-38% incidence of neurological deficit,4 yet there is little agreement on the indications for radiography. TheAdvanced Trauma Life Support Manual for Physicians does not recognise the importance of a distracting injury in masking the symptoms and signs of spinal fracture; it states that injury to the spine can be ruled out without the use of x rays in patients who are “awake, alert, sober, neurologically normal, not experiencing neck or back pain, and do not have tenderness to spine palpation.”9Cases 5 and 6 would have been missed if this advice had been followed. Attempts have been made to target the use of radiography by using clinical criteria, and two studies reported no missed fractures but they included only 39 fractures of the thoracolumbar spine between them. 3 10
Neurological deficit after trauma may suggest spinal injury and may mask other symptoms and signs.3 The presence of a fracture of the cervical spine is associated with further fractures lower down the spine in 7-10% of cases. 4 10 11For these reasons, radiography of the entire spine should be requested if neurological symptoms are present in cases of multiple trauma.
Although retrospective reviews of patient records can be unreliable we are confident that bony tenderness and back pain were absent in all six patients. In two patients the initial examination of the spine was done by a consultant, in two by registrars, and in two by senior house officers. All six were assessed by a consultant from a trauma specialty within 24 hours; in two cases this occurred on arrival. The “log roll” procedure is a team effort and it would be obvious to team members if pain or tenderness were present. It is unclear both in our series and the published literature whether the spine was palpated or percussed gently.
We propose that all major trauma patients with an altered level of consciousness, other painful injury, neurological symptoms or signs, or fractures of the cervical spine undergo radiographic examination of the thoracolumbar spine. The simplest and safest approach is to ensure that radiographs are taken of the whole spine in every patient who has had a major traumatic injury. The possibility of asymptomatic fractures of the spine should also be borne in mind in less seriously injured patients who meet one or more of the criteria outlined in the box.
Absence of pain in major trauma Back pain and tenderness may be absent in patients with fractures of the thoracolumbar spine if:
the patient has an altered level of consciousness from any cause
the patient has a painful injury elsewhere (a “distracting” injury)
there are neurological symptoms or signs,
there is a fracture of the cervical spine.
Patients are at high risk of having a fracture of the thoracolumbar spine if they have fallen from heights of over 3 metres or if they have been involved in a motorcycle accident.
Radiographs of the thoracolumbar spine may be difficult to obtain in the resuscitation room; it may be possible to delay taking them until after surgery, provided that spinal immobilisation is continued.
Contributors: Lynne Dadley assisted in identifying the cases and suggested alterations to the manuscript. Gillian Bryce reviewed the manuscript and suggested changes. The problem was first highlighted to the group by Mike Clancy. SM is guarantor for the paper.
The names of the members of the study group appear at the end of the paper
Conflict of interest None.