Introduction

• Thoracolumbar and general spinal injuries carry substantial risk of neurological deterioration, deformity, and chronic disability.
• This standard outlines baseline clinical and imaging pathways across regional trauma networks to promptly identify or clear blunt spinal injuries, preventing secondary harm.
• Penetrating spinal column trauma confirmed on imaging is excluded and requires urgent direct surgical referral.

Standards

• Network Protocols: All trauma networks must adopt consistent, evidence-based spinal protection protocols (incorporating rigid collars, manual inline stabilisation, log rolling, and transfer procedures) across pre-hospital services and acute receiving units.
• Spinal Clearance & Clinical Assessment: Alert, unintoxicated, and asymptomatic trauma patients with no distracting injury who have normal active range of motion and no midline tenderness may be cleared clinically without radiographic imaging.
• Standard Imaging Pathways: High-energy trauma mechanisms, midline spinal tenderness, or altered neurology mandate cross-sectional imaging, adhering closely to NICE guideline NG41 standards.

Investigation

• Whole Spine CT: For adult blunt trauma with suspected thoracolumbar injury or where whole-body trauma CT is undertaken, thin-slice volumetric CT reconstruction of the entire spine is the gold standard.
• Indications for Urgent Spinal MRI:
  • Unexplained, progressive, or fixed neurological deficit (including cord or cauda equina syndromes).
  • Ankylosing conditions (e.g., Ankylosing Spondylitis, DISH) with spinal tenderness or ambiguous CT findings.
  • Obtunded, comatose, or intubated patients where injury cannot be definitively excluded clinically or on CT.
  • Suspected soft-tissue ligamentous injury, posterior tension band disruption, or contraindications to ionising radiation (e.g., pregnancy).
• Reporting Timelines: Preliminary radiological reporting must be available within 1 hour of imaging, followed by a formal definitive report within 24 hours.

Management

• Clearance of Precautions: Spinal precautions and hard immobilisation devices must be removed as soon as mechanical and neurological stability is established or excluded to prevent pressure ulceration.
• Non-Operative Care Documentation: When non-operative treatment is selected for thoracolumbar fractures, the clinical team must formally record the degree of fracture stability, the explicit bracing regimen (orthosis type, duration, hygiene, and fitting precautions), and follow-up plans.
• Surgical Referrals & Cord Injury: Displaced, translation/rotation, or distraction injuries (AOSpine / TLICS high scores) and those with evolving neurology require urgent referral to regional spinal surgical teams, coordinated under the Traumatic Spinal Cord Injury standard.

Documentation and Governance

• Formal clinical documentation in the electronic or written health record must detail the exact fracture stability classification, neurological exam, treatment rationales, and structured outpatient surveillance.
• A designated treatment summary and plan must be communicated to the patient and carers prior to hospital discharge.