Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: A review of the literature

Background. Accurate screening of the thoracolumbar spine (TLS) remains problematic in the care of trauma patients. The current standard of care for TLS screening is not clearly defined. In trauma patients undergoing computed tomography (CT) of the chest and or abdomen, compelling supportive evidence for reformatting and reusing this CT data to clear the thoracolumbar spine has accumulated over the last 3 years. The objective of this review was to identify and review all published studies comparing reformatted CT to traditional plain radiography for TLS clearance. Methods. A Medline search for all English language articles published on this subject since 1980 identified seven studies. Each was classified according to the levels of evidence classification of the Agency for Health Care Policy and Research. The methodology of each study was reviewed for the CT protocol, utilization of radiologist blinding and whether historical dictated reports or de novo image readings were used for comparison. The sensitivity and specificity of each study and the gold standard utilized in its calculation was noted. Where available, detailed information regarding the missed injuries and their clinical relevance was abstracted for each study. Results: All evaluated studies demonstrated superior sensitivity and inter-observer variability for reformatted CT compared with plain radiographic screening. CT was also more accurate in localizing, classifying, and delineating the age, bony intrusion, and soft-tissue damage associated with the fracture. For studies with time-motion components, a protocol utilizing CT clearance was not only more accurate but faster and more economical. Screening with reformatted visceral CT data required no additional scan time or radiation exposure. Conclusion: The evidence to date demonstrates the superior sensitivity of reformatted visceral CT for detecting thoracolumbar spine injury. With no further patient movement, radiation exposure, cost, or time, trauma patients undergoing visceral CT can have their thoracolumbar spine promptly evaluated. Further prospective evaluation of the CT protocols to optimize visualization of both the viscera and the bone is warranted.