Highlights from #AAST2014 - Clearing the ThoracoLumbar Spine

A large Multi-Institutional trial proposes a clinical decision rule for clearing the TL spine.  

Patients with any of:

- Positive physical exam

- High Risk Mechanism (non-ground-level fall, crush, rollover/ejection MVC, open vehicle, pedestrian struck)

- Age 60 or greater

Should have CT of TL spine.

PROSPECTIVE, MULTICENTER DERIVATION OF A CLINICAL DECISION RULE FOR THORACIC AND LUMBAR SPINE EVALUATION AFTER BLUNT TRAUMA

Kenji Inaba* MD, Lauren Nosanov BA, Jay Menaker* MD, Patrick Bosarge MD, David Turay MD, Riad Cachecho* MD, Marc DeMoya* MD, Marko Bukur* MD, Jordan Carl BS, Leslie Kobayashi* MD, Stephen Kaminski MD, Alec Beekley MD, Mario Gomez DO, Dimitra Skiada MD, And The TL-Spine Multicenter Study Group LAC+USC Medical Center

Introduction: Unlike the C-Spine, where NEXUS/Canadian C-Spine Rules can be used, evidence based TL-spine clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the injured TL-spine.

Methods: Adult (≥15yo) blunt trauma patients were prospectively enrolled at 13 US trauma centers (01/12-01/14). Exclusion criteria: C-Spine injury with neurologic deficit, pre-existing paraplegia/tetraplegia, unevaluable examination. The remaining evaluable patients underwent TL-Spine imaging and were followed to discharge. The primary endpoint was a clinically significant TL-Spine injury requiring TL-Spine Orthoses/surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested.

Results: Of 12,479 patients screened, 3,068 (24.6%) met inclusion criteria [age 43.5+/-19.8 years (15-103), ISS 8.8+/-7.5, male gender 66.3%]. The majority underwent CT (93.3%), 6.3% only plain films and 0.2% MRI exclusively. TL-Spine injury was identified in 502 patients (16.4%), of which 268 (8.7%) were clinically significant. The most common clinically significant injury was compression fracture (67.4%) followed by a burst fracture (17.2%) and a fracture dislocation (5.0%). The predictive ability of clinical examination (midline tenderness, step-off or neurologic deficit), age and mechanism were examined. A positive clinical examination resulted in a sensitivity of 78.4% and specificity of 72.9%. Addition of age ≥ 60 and a high risk mechanism (MVC with ejection or rollover, pedestrian struck by auto, fall from height, torso crush, jump from moving vehicle, non-enclosed vehicle crash) increased the sensitivity to 98.5% with a specificity of 29.0%.

Conclusion: Clinical examination alone is insufficient for determining need for imaging in evaluable patients at risk of TL-Spine injury. Addition of age and high risk mechanism results in a clinical decision making rule with a sensitivity of 98.5% for clinically significant injuries. Utilization of this clinical decision rule will significantly lower the negative imaging rate.