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Clinical Review Lesson of the week

Fractures of the thoracolumbar spine in major trauma patients

BMJ 1998; 317 doi: (Published 21 November 1998) Cite this as: BMJ 1998;317:1442
  1. Steve Meek, consultant (
  1. Emergency Department, Royal United Hospital, Bath BA1 3NG

    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 reports

    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 …

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