Coagulation studies for anticoagulation or planned procedure
INR for warfarin
Anti Xa level if local protocol for DOAC assessment
Targeted labs by scenario
Infection or malignancy concern
C reactive protein for epidural abscess screen
Elevated supports inflammatory process
Normal does not exclude early infection
Blood cultures if febrile or septic
Antibiotics timing after cultures when feasible
Source control planning
Rhabdomyolysis or crush concern
Creatine kinase for prolonged immobilization
Rising trend supports muscle injury
Renal injury monitoring linkage
Diagnostic Tests
Scoring Systems
Thoracolumbar classification and decision tools
TLICS thoracolumbar injury classification and severity score
Injury morphology points
Compression 1
Burst 2
Translation rotation 3
Distraction 4
Posterior ligament complex status points
Intact 0
Suspected 2
Disrupted 3
Neurologic status points
Intact 0
Nerve root injury 2
Complete cord injury 2
Incomplete cord injury 3
Cauda equina 3
Treatment implication thresholds
Score 3 or less nonoperative typical
Score 4 individualized
Score 5 or more operative typical
AO Spine thoracolumbar classification
Type A compression
Type B tension band injury
Type C translation injury
Meyerding grading for spondylolisthesis
Grade I 0 to 25 percent slip
Grade II 26 to 50 percent slip
Grade III 51 to 75 percent slip
Grade IV 76 to 100 percent slip
Radiographs
Plain film pathways
Thoracic and lumbar series when low risk and stable
AP and lateral
Focused level imaging by tenderness
Alignment assessment
Vertebral height loss percent
Kyphosis angle estimation
Indirect instability clues
Widened interspinous distance
Subluxation
Spondylolysis evaluation
Lateral view slip assessment
Oblique pars view if protocol supports
MRI
MRI indications
Neurologic deficit with uncertain CT findings
Cord compression
Nerve root compression
Posterior ligament complex evaluation
TLICS scoring support
Occult distraction injury
Epidural hematoma evaluation
Rapid neurologic progression
Anticoagulation exposure
Spondylolysis stress injury
Bone marrow edema in pars
Early detection before cortical break
CT
CT thoracolumbar spine
High sensitivity fracture detection
Burst fracture posterior wall definition
Chance fracture bony components definition
Indications
High energy mechanism
Midline tenderness with concerning exam
Abnormal radiographs
Distracting injury
Canal compromise features
Retropulsed fragment size
Percent canal narrowing
Adjacent injury mapping
Transverse process fracture correlation with abdominal injury
Rib fracture correlation with thoracic spine injury
Disposition
Admission and transfer criteria
Disposition decision set
Emergent spine consultation
Any neurologic deficit
Progressive symptoms
Admission criteria
Unstable fracture pattern
Uncontrolled pain
Inability to mobilize
Polytrauma
Transfer criteria
Need for operative stabilization without local capability
Suspected epidural hematoma with deficit
Observation criteria
Stable compression fracture with analgesia needs
Frail patient fall risk
Discharge criteria and follow up
Safe discharge framework
Stable pattern on imaging
Compression fracture without posterior element injury
Isolated transverse process fracture with negative abdominal evaluation
Normal neurologic exam
No saddle anesthesia
No urinary retention
Mobility and function
Ambulation with assistive device if needed
Home support adequate
Follow up timing
Spine or orthopedics within 1 to 2 weeks for bracing plan
Primary care for osteoporosis workup when fragility fracture
Treatment
Immediate life-saving interventions
Immediate stabilization set
Airway compromise pathway if needed
Rapid sequence intubation when indicated
Cervical precautions maintained
Hemorrhagic shock resuscitation if present
Balanced blood products
Pelvic and long bone source control when applicable
Neurologic emergency escalation
Emergent MRI when deficit and compressive concern
Emergent spine surgery consult for cauda equina concern
Immobilization and Splinting
Spine immobilization and bracing
Motion restriction principles
Neutral alignment
Avoid flexion and rotation
Brace selection
TLSO for stable compression fractures per specialist plan
Jewett brace option for anterior wedge patterns per specialist plan
Mobilization strategy
Early mobilization when stable and pain controlled
Bed rest avoidance when possible
Reassessment after positioning
Repeat neuro exam after logroll
Pain trend after brace placement
Reduction
Reduction considerations
Thoracolumbar fractures rarely reduced in ED
Specialist directed reduction only
Avoid traction maneuvers
Indirect stabilization
Positioning for comfort without deformity creation
Brace fitting by trained staff
Post intervention checks
Neuro exam after any move
Pain escalation triggers repeat imaging
Open fracture medications and timing
Open spine injury pathway when applicable
Penetrating trauma or open wound over spine
Broad spectrum antibiotics per trauma protocol
Tetanus prophylaxis per immunization status
CSF leak concern
Neurosurgery consultation
Meningitis risk monitoring
DVT prophylaxis when relevant
Venous thromboembolism prevention
High risk groups
Spinal cord injury
Prolonged immobilization
Pharmacologic prophylaxis per trauma protocol
Low molecular weight heparin typical choice
Timing coordinated with spine surgery
Mechanical prophylaxis
Intermittent pneumatic compression
Early mobilization when safe
Pain control and adjuncts
Analgesia framework
Nonopioid first line when possible
Acetaminophen oral 1000 mg every 6 hours maximum 4000 mg per day
NSAID use individualized
Opioid for severe acute pain
Hydromorphone IV titration pathway
Initial dose 0.2 mg IV
Repeat dose every 5 to 10 minutes to analgesia
Hold for sedation or hypoventilation
Typical total dose range 0.5 to 2 mg in ED
Continuous monitoring when repeated dosing
Naloxone availability
Neuropathic pain adjunct when radicular
Gabapentin oral 300 mg nightly
Titration per outpatient plan
Muscle spasm adjunct when appropriate
Cyclobenzaprine oral 5 mg at bedtime
Sedation risk counseling
Fracture pattern specific management
Compression fractures
Typical stability
Anterior column involvement
Posterior elements intact on CT
Nonoperative typical pathway
Analgesia and mobilization
TLSO consideration per specialist
Osteoporosis secondary prevention
Calcium and vitamin D review
Bone density referral
Burst fractures
Instability and neurologic risk assessment
Retropulsion and canal compromise on CT
Posterior ligament complex status on MRI when uncertain
Operative consideration triggers
Neurologic deficit
Progressive kyphosis
High TLICS score
Nonoperative criteria typical
Neuro intact
Minimal canal compromise and stable alignment per specialist
Chance fracture flexion distraction
High suspicion features
Seatbelt sign
Horizontal split pattern on imaging
Associated injury evaluation
Abdominal CT when indicated
Bowel injury vigilance
Management typical
Spine surgery consultation
Operative fixation common with ligamentous injury
Transverse process fractures
Stability typical
No spinal canal involvement typical
Pain driven limitation
Associated injury screening
Hematuria evaluation when flank trauma
Abdominal injury evaluation when high energy
Treatment typical
Analgesia
Early mobilization
Spondylolysis and spondylolisthesis
Acute pars stress injury pathway
Activity modification
Physical therapy focus on core stabilization
Slip progression risk
High grade slip specialist follow up
Neurologic symptoms escalation
Imaging follow up
MRI for early pars stress changes
CT for pars cortical definition when needed
Special Populations
Pregnancy
Pregnancy considerations
Imaging strategy
MRI preferred for neurologic deficit when available
CT when maternal benefit outweighs fetal risk
Analgesia selection
Acetaminophen preferred
NSAID avoidance in later pregnancy per obstetric guidance
Fetal assessment
Obstetrics involvement for viable gestation
Rh status evaluation if trauma with bleeding concern
Geriatric
Older adult considerations
Fragility compression fracture pathway
Osteoporosis evaluation referral
Fall risk assessment
Delirium and sedation risk
Opioid minimization
Avoid benzodiazepines when possible
Disposition threshold
Lower threshold for admission
Rehab planning early
Pediatrics
Pediatric considerations
Spondylolysis common in adolescent athletes
Extension related pain pattern
MRI for early stress injury
Chance fracture mechanism risk
Lap belt injury pattern
Abdominal injury screening
Growth and remodeling
Specialist guided bracing decisions
Return to sport clearance process
Background
Epidemiology
Population patterns
Compression fractures
Osteoporosis association common
Low energy mechanism common
Burst and Chance fractures
High energy trauma association common
MVC and fall from height association common
Transverse process fractures
High energy marker
Associated abdominal injury risk
Spondylolysis and spondylolisthesis
Adolescent athlete prevalence higher
L5 level predominance
Pathophysiology
Injury mechanics
Compression fracture
Axial load with flexion
Anterior wedge collapse
Burst fracture
Axial load
Posterior wall failure with retropulsion
Chance fracture
Flexion distraction around lap belt fulcrum
Posterior ligament complex injury common
Transverse process fracture
Avulsion by psoas or paraspinals
Rotational or lateral bending force
Spondylolysis
Repetitive extension stress to pars
Stress reaction to fracture continuum
Spondylolisthesis
Pars defect with anterior translation
Slip progression with growth and load
Therapeutic Considerations
Stability concepts
Three column model utility
Anterior column
Middle column
Posterior column
Posterior ligament complex importance
Instability marker
MRI role
TLICS guided decision making
Lower scores favor nonoperative
Higher scores favor operative
Neurologic outcome priorities
Secondary injury prevention
Avoid hypotension
Avoid hypoxia
Time sensitivity for compressive lesions
Early decompression improves outcomes in selected cases
Rapid progression warrants emergent imaging
Evidence and guideline language
CT as primary imaging in high risk blunt trauma
Class I recommendation in many trauma protocols for high energy with tenderness
Plain radiographs limited sensitivity
Patient Discharge Instructions
Copy discharge instructions
Discharge instructions set
Activity and mobility
Avoid bending lifting twisting
Walking as tolerated if cleared
Brace care if prescribed
Wear schedule per spine team
Skin checks for pressure injury
Pain control plan
Acetaminophen schedule
Opioid only for breakthrough pain
Ice and heat guidance
Ice first 48 hours if helpful
Heat for muscle spasm after 48 hours if helpful
Return to ED now
New or worsening leg weakness
New numbness in groin or buttocks
New urinary retention or incontinence
Fever with severe back pain
Uncontrolled pain despite medications
Follow up
Spine or orthopedics appointment timing provided
Family doctor for bone health workup when fragility fracture
References
Clinical guidelines and evidence sources
Trauma and spine references
ATLS principles for spine trauma evaluation
Spine motion restriction in suspected injury
Secondary survey focus on neurologic deficits
TLICS classification original and validation literature
Morphology PLC neurology decision framework
Nonoperative versus operative thresholds
AO Spine thoracolumbar classification references
Type A B C framework
Management implication mapping
Emergency medicine and imaging references
Trauma imaging protocols for thoracolumbar injury
CT preferred in high energy mechanism with tenderness
MRI for neurologic deficit or PLC assessment
Evidence level notation
ACEP Level C consensus for spine consultation in neurologic deficit
Class I expert consensus for emergent decompression in cauda equina concern
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.