Evaluation of thoracolumbar spine injury utilizing plain film and physical exam in the pediatric population: A multicenter study

OBJECTIVES: Pediatric thoracolumbar spinal injuries (TLSIs) are rare and uncommonly require intervention. In adults, plain x-ray is not adequate to screen for spinal injury. In children, plain film utilization for screening is variable and supportive evidence is lacking. Liberal CT screening for TLSI in children results in significant unnecessary radiation exposure. We investigated the utility of plain x-rays and physical exam (PE) to screen children for TLSI. METHODS: Children aged 1 to 18 years with MRI or CT-confirmed TLSI presenting to one of five Level 1 pediatric trauma centers between 2017 and 2022, who had a plain film involving the injured spine, were identified. ICD10 codes for injuries, imaging types, intervention (surgery or bracing), age, mechanism, BMI, fracture type (thoracic, lumbar, both), comorbidities, PE findings, and type of radiograph (spine, chest, abdomen) were identified and compared. RESULTS: Two hundred thirty-two children with MRI or CT-confirmed TLSI and plain x-rays were identified (46% thoracic, 34.9% lumbar, 18.1% both). 57.3% (n=133) of patients underwent dedicated spine radiographs, while the others had only chest (n=87, 37.5%) or only abdominal (n=10, 4.3%) radiographs. In total, 13.79% of patients underwent surgery, 43.9% required bracing, and the remaining had no intervention. Of the patients with dedicated spine films, x-rays alone were 82.7% sensitive for injury and 100% sensitive for injury needing surgery. Patients with lumbar spine injuries who had positive spine x-rays and suspicious PE findings were significantly more likely to require intervention (p<0.0001). No child with a normal spinal x-ray in the lumbar region required intervention, regardless of PE findings. CONCLUSIONS: In this retrospective study, dedicated spinal x-rays combined with PE reliably excluded >99% of all injuries and 100% of injuries requiring intervention. These findings suggest children can be effectively screened for TLSI with PE and spinal x-rays, reserving cross-sectional imaging for positive x-ray findings and persistent PE findings on repeat exam. (J Trauma Acute Care Surg. 2026;100:915-921. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.