TY - JOUR
T1 - Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department
T2 - A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging
AU - VandenBerg, James
AU - Cullison, Kevin
AU - Fowler, Susan A.
AU - Parsons, Matthew S.
AU - McAndrew, Christopher M.
AU - Carpenter, Christopher R.
N1 - Funding Information:
This work was supported by the National Center for Advancing Translational Sciences, United States , National Institutes of Health (grant numbers UL1 TR000448 and TL1 TR000449 ). These funding sources had no involvement in the study design; collection, analysis, and interpretation of data; the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding Information:
Conflict of interest—CMM declares having received funding from Zimmer Biomet, United States for consulting, and holds a faculty position for AOTrauma/AOTrauma North America: which includes speaking and travel fees. The remaining authors declare no conflicts.This work was supported by the National Center for Advancing Translational Sciences, United States, National Institutes of Health (grant numbers UL1 TR000448 and TL1 TR000449). These funding sources had no involvement in the study design; collection, analysis, and interpretation of data; the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Publisher Copyright:
© 2018 Elsevier Inc.
PY - 2019/2
Y1 - 2019/2
N2 - Background: Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic 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. Objective: Our aim was to quantify 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, were 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 detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1–152.2; I 2 = 94%; p < 0.001) and negative likelihood ratio (−LR) = 0.43 (95% CI 0.32–0.59; I 2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1–467.9; I 2 = 87%; p < 0.001) and −LR = 0.04 (95% CI 0.02–0.08; I 2 = 23%; p = 0.26). Conclusions: CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
AB - Background: Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic 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. Objective: Our aim was to quantify 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, were 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 detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1–152.2; I 2 = 94%; p < 0.001) and negative likelihood ratio (−LR) = 0.43 (95% CI 0.32–0.59; I 2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1–467.9; I 2 = 87%; p < 0.001) and −LR = 0.04 (95% CI 0.02–0.08; I 2 = 23%; p = 0.26). Conclusions: CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
KW - blunt trauma
KW - computed tomography
KW - diagnostic imaging
KW - radiography
KW - spine trauma
UR - http://www.scopus.com/inward/record.url?scp=85059200184&partnerID=8YFLogxK
U2 - 10.1016/j.jemermed.2018.10.032
DO - 10.1016/j.jemermed.2018.10.032
M3 - Article
C2 - 30598296
AN - SCOPUS:85059200184
SN - 0736-4679
VL - 56
SP - 153
EP - 165
JO - Journal of Emergency Medicine
JF - Journal of Emergency Medicine
IS - 2
ER -