From the Guidelines
For a patient involved in a motor vehicle accident 2 days ago presenting with neck and back pain, mild abdominal tenderness, and voluntary guarding, imaging studies including cervical spine X-rays or CT, thoracolumbar spine imaging, and abdominal CT with contrast are crucial to evaluate for potential injuries. The patient's symptoms of neck and back pain, along with mild abdominal tenderness and voluntary guarding, raise concerns for potential spine and intra-abdominal injuries. According to the American College of Radiology Appropriateness Criteria 1, any high-risk patient, including those with midline thoracolumbar tenderness or a high-energy mechanism of injury, should undergo imaging of the thoracolumbar spine. Given the patient's presentation, the following investigations are recommended:
- Cervical spine X-rays or CT to evaluate for fractures or ligamentous injuries
- Thoracolumbar spine imaging to assess for vertebral fractures
- Abdominal CT with contrast to evaluate for solid organ injuries, free fluid, or bowel perforation Additional studies, such as chest X-ray to evaluate for rib fractures or pneumothorax, and focused assessment with sonography for trauma (FAST) to rapidly detect free fluid in the abdomen, may also be considered. The choice of imaging modalities should be guided by the patient's clinical presentation and the suspected type of injury, as outlined in the clinical policy for evaluating adult patients presenting to the emergency department with acute blunt abdominal trauma 1. It is essential to monitor the patient closely for changes in vital signs, increasing pain, or new symptoms that might indicate deterioration of an undiagnosed injury.
From the Research
Patient Assessment and Investigation
The patient presents with neck and back pain, mild abdominal tenderness, and voluntary guarding after a motor vehicle accident (MVA) 2 days ago. Given the mechanism of injury and symptoms, it is essential to consider potential intra-abdominal injuries.
Intra-Abdominal Injury Risk
A study published in the Journal of Pediatric Surgery 2 found that 38% of patients with spinal fractures after an MVA required laparotomy, with the most common findings being hollow viscus injury, mesenteric tear, and solid organ injury. Although this study focused on pediatric patients, it highlights the importance of considering intra-abdominal injuries in patients with spinal fractures after an MVA.
Diagnostic Investigations
Diagnostic peritoneal lavage (DPL) or focused abdominal sonography for trauma (FAST) may be considered as screening investigations for hemodynamically stable patients after blunt abdominal trauma 3. However, computed tomography (CT) is increasingly used as the principal investigation for these patients.
Considerations for This Patient
Given the patient's symptoms and mechanism of injury, a CT scan of the abdomen and pelvis may be considered to rule out intra-abdominal injuries. Additionally, a CT scan of the cervical and thoracolumbar spine may be necessary to evaluate the patient's neck and back pain.
Other Considerations
Other studies have reported on the distribution of pain and predictors of widespread pain after an MVA 4, as well as unusual cases of penetrating neck trauma 5 and treatment of central pain sensitization using graded motor imagery principles 6. However, these studies are not directly relevant to the patient's current presentation and need for diagnostic investigations.
- Potential diagnostic investigations:
- CT scan of the abdomen and pelvis
- CT scan of the cervical and thoracolumbar spine
- Diagnostic peritoneal lavage (DPL) or focused abdominal sonography for trauma (FAST) if CT is not available or contraindicated
- Consider consultation with a general surgeon or other specialist if intra-abdominal injury is suspected or confirmed.