Thoracolumbar vertebrae fracture may be ‘silent’

By Lynda Williams, Senior MedWire Reporter

Imaging is essential to avoid missing fractures to the thoracolumbar vertebrae in patients who have sustained blunt injury, UK researchers say.

The team found that clinical examination for signs and symptoms of injury, such as pain, bruising, deformity , or neurologic indicators, predicted fracture in just a third of patients with a confirmed fracture on computed tomography (CT), and only half of patients with unstable fractures.

"The important message of this study is that an absence of clinical signs does not exclude serious injury to the thoracolumbar spine," emphasize M Venkatesan and co-workers, from the University of Leicester.

As published in the British edition of the Journal of Bone and Joint Surgery, the researchers examined for thoracolumbar vertebrae injuries in 303 patients who underwent CT scans of the chest and abdomen following motor vehicle or motorcycle injury, a fall, or a crush injury.

Although thoracic and intra-abdominal injuries to the viscera were detected by CT in just 2.0% and 1.3% of cases, respectively, 16.8% of patients had thoracolumbar vertebrae fractures, half of whom had no other injury. The majority of these patients (57%) had a single fracture, 43% had two or more, and 21.5% had three or more fractures.

While 46% of the 94 fractures were "trivial," clinically significant stable fractures occurred in 29 patients. Furthermore, 22 patients had unstable fractures requiring surgery or thoracolumbosacral orthosis, such as burst fractures, flexion-distraction injuries, and fracture-dislocations.

Of concern, clinical examination was just 33.3% sensitive for thoracolumbar spine fracture, with a sensitivity of 21% and 50% for stable and unstable fractures, respectively.

The team notes that the 11 patients with unsuspected unstable fracture were protected from further injury by adherence to the spinal protection protocol.

Although thoracolumbar fracture was predicted by a high Injury Severity Score, a low Glasgow Coma Scale, and hemodynamic instability, the researchers note that 67% of fracture patients were "alert, awake, and conversant."

The team therefore concludes: "A high index of suspicion and a standardised method of assessing the thoracolumbar spine are mandatory if this problem is to be addressed."

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