Do upright radiograph findings affect treatment plans for patients with thoracic and lumbar spine injuries?

Abstract

Background After spinal trauma, upright radiographs are commonly used to evaluate spinal stability. However, the benefits and risks of upright films have not yet been thoroughly studied. This study aimed to elucidate the effect that upright imaging has on patients with thoracic and/or lumbar spinal injuries by evaluating the impact on treatment decisions. Methods A retrospective review of all adult patients who suffered traumatic spine injuries and received thoracic and/or lumbar spine imaging between April 2019 and March 2021 in a Level 1 University Trauma Center. Patients’ charts were reviewed, and those patients who received upright films as a final dynamic evaluation of their spine before clearance for standing were identified. Fractures due to infection or malignancy were excluded as were 17 patients who only received post-operative upright films. We examined whether upright films modified the treatment strategy. Results Of the 353 upright radiographs conducted on patients without prior surgical intervention, 27 (7.6%) of these studies provided information not known from prior imaging; the remaining 92.4% of upright films were considered “unchanged” or “stable.” Of the 27 patients who had changes in uprights, in only 7 cases (2.0%) did the new findings affect the treatment plans. In 6/7 cases, upright films showed increased vertebral body height loss and/or worsening fractures—suggestive of instability—in previously known T12-L1 fractures. Conclusions We studied 353 patients who received T and/or L uprights after suffering a traumatic spine injury and before receiving any surgical interventions. Of these patients, 98.0% did not gain substantial benefit from the additional imaging as the upright radiographs did not affect the treatment strategy. In 2% of cases a significant change in management was indicated following the upright films; virtually all of these were in T11-L2 fractures. The utility of upright films should be re-evaluated and more studies directed to potentially clarify which subgroups of patients will benefit from these radiographs.