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THORACIC LUMBAR SACRAL (TLS) SPINE CLEARANCE

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

Thoracic spine fractures occur at about the same rate as cervical spine fractures - 2-5% of the blunt trauma population. While the majority of these patients presents with pain and tenderness, a significant minority (which can approach 20%) do not have associated pain and tenderness at presentation. This may be due to a decrease in sensorium or distracting major injuries, which preclude a reliable physical examination. While the vast majority of patients with vertebral fractures who develop neurologic deficits will have them at the time of presentation in the trauma room, a few will develop them in a delayed manner. The purpose of these guidelines is to increase our detection of subtle TLS fractures and possibly prevent the development of late-onset neurologic sequelae.

All patients with blunt injury should be suspected of having a cervical or thoracic spine injury. The cervical spine should be cleared according to our established protocol and the thoracic spine should be cleared as outlined. All patients should be kept on spine precautions, which includes in-line immobilization of the cervical and upper thoracic spine during any procedures and logrolling. Only after the patient has had an evaluation as outlined and is without a TLS fracture should spine precautions be discontinued.

1. Cooper C, Dunham CM, Rodriquez A: Falls and major injuries are risk factors for thoracolumbar fractures: Cognitive impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma 38:692-696, 1995.
2. Meldon SW, Moettus LN: Thoracolumbar spine fractures: Clinical presentation and the effect of altered sensorium and major injury. J Trauma 39:1110-1114, 1995.
3. Reid DC, Henderson R, Saboe L, et al.: Etiology and clinical course of missed spine fractures. J Trauma 27:980-6, 1987.
4. Samuels LE, Kerstein MD: "Routine" radiologic evaluation of the thoracolumbar spine in blunt trauma patients: A reappraisal. J Trauma 34:85-89, 1993.

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