Suspected Vertebral Fracture

Clinical Context and Risk Factors

The American College of Radiology suggests that a high-risk mechanism of injury, such as a fall from height greater than standing, is a significant risk factor for clinically significant thoracolumbar spine injury, particularly in patients aged 56 years or older with severe back pain following trauma 1, 2
The American College of Radiology recommends considering age ≥56 years as a high-risk criterion, although the threshold is ≥60 years, as falls are a major cause of spinal injury in this age group 1, 2
Severe back pain following trauma is a significant risk factor for vertebral fracture, according to the American College of Radiology 1, 2
Falls from height cause a substantial proportion of spinal injuries, second only to motor vehicle accidents, with the thoracolumbar junction being particularly vulnerable to fracture from axial loading mechanisms 4, 1, 2

The American College of Radiology recommends evaluating for neurologic deficits, including motor weakness, sensory changes, or bowel/bladder dysfunction, which would indicate potential spinal cord injury 1, 2
Altered mental status or intoxication necessitates imaging clearance regardless of examination findings, according to the American College of Radiology 1, 2
The presence of distracting painful injuries that could mask spinal symptoms should be considered, as per the American College of Radiology 1, 2
CT is the gold standard and preferred initial imaging modality for suspected vertebral fracture in trauma patients, with a sensitivity of 94-100% for detecting thoracic spine fractures 1, 2, 5
The entire spine should be imaged because 20% of trauma patients with one spinal fracture have noncontiguous fractures at other levels, according to the American College of Radiology 1, 2, 5
Plain radiographs are inadequate as the sole imaging modality due to lower sensitivity than CT for fracture detection, and may miss significant thoracic spine injuries 1, 2, 5, 6, 7
MRI should be obtained if there is clinical suspicion for spinal cord injury or neurologic deficit, concern for ligamentous instability, or nerve root compression, as it provides superior visualization of soft tissues, spinal cord, ligaments, and intervertebral discs 1, 2, 5, 8

The American College of Radiology advises against relying solely on physical examination in patients meeting high-risk criteria, as a prospective study found 98.9% sensitivity for thoracolumbar injury using criteria of positive examination, high-risk mechanism, or age ≥60 years 1, 2
The American College of Radiology recommends against missing multilevel fractures, and always imaging the entire spine when one fracture is identified 1, 2, 5
Delayed imaging in patients with neurologic deficits is associated with poorer outcomes, according to the American College of Radiology and the American Heart Association 9, 4
Maintaining spinal motion restriction by manually stabilizing the head and minimizing movement until fracture is excluded is crucial, as per the American Heart Association and the American College of Radiology 4, 3