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Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries

BACKGROUND The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. METHODS From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury. RESULTS A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. CONCLUSION In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure. LEVEL OF EVIDENCE Diagnostic study, level IV; therapeutic/care management study, level IV.