Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

Abstract

Background: Delayed diagnoses of unstable thoracolumbar-spine (TL-spine) fractures can result in neurological deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.Objectives: Quantifying the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.Methods: A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2×2 tables, were duplicates, not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. Results:In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for the detection of TL-spine fractures with plain

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study

“…In our observation, XR is specific for fractures of the thoracic and lumbar spine, but cross-tabulation for sensitivity and calculations of the LR − (thoracic spine: 0.6; lumbar spine: 0.4) demonstrate that XR is not capable to safely rule-out fractures of these regions. Our findings are supported by a recently published meta-analysis, which demonstrates a pooled LR − of 0.43 for XR to detect fractures of the thoracolumbar spine in adults with blunt, high-and low-energy injury mechanisms [15]. Current guideline recommendations are inconsistent as regards imaging modalities.…”

“…Imaging approaches have to allow rapid and effective clinical decision-making and care [34]. To date, neither guidelines nor available evidence on imaging recommendations for blunt thoracolumbar injuries are satisfactory in quantity and quality, even less so in the older population [15]. Our data now add some new information concerning the older population and low-energy trauma based on a large cohort.…”

“…With regard to diagnostic accuracy, reformatted thoracolumbar spine CT showed higher accuracy than the chest-abdomen-pelvis CT [15], with an unknown impact on clinical management. However, in this meta-analysis, the pooled LR + was 81.1 (95% CI: 14.1-467.9) and the LR − was 0.04 (95% CI: 0.02-0.08) for diagnosing thoracolumbar spine fractures with the chest-abdomen-pelvis CT.…”

“…Standard of care diagnosis of skeletal injuries relies on plain XR, although XR might miss a substantial portion of fractures of the rib cage and pelvic ring [10][11][12][13]. Evaluation of the vertebral column is frequently limited to imaging of the cervical spine [14], whereas supplementary imaging of the thoracolumbar spine often depends on clinical presentation and clinical experience of the treating physician, which might be submitted to diagnostic inaccuracy [15].…”

“…Supplementary imaging of the thoracolumbar spine often depends on clinical presentation and clinical experience of the treating physician. Moreover, history and physical examination findings are generally inaccurate to rule-in or rule-out fractures of the thoracolumbar spine [15], and the current guidelines [16,17] cannot be readily applied to older adults with LEF.…”