CT Thoracic Spine Without IV Contrast
For an elderly female with severe back pain between the shoulder blades and vomiting, order a CT thoracic spine without IV contrast as the initial advanced imaging study. This presentation raises concern for serious pathology including vertebral compression fracture (given age and osteoporosis risk), aortic dissection, or gastrointestinal catastrophe requiring urgent diagnosis 1.
Clinical Context and Red Flags
This patient presents with multiple red flags that mandate immediate imaging:
- Advanced age is a significant risk factor for vertebral compression fractures, even with minimal or no trauma 1
- Severe pain between shoulder blades (thoracic region) with vomiting suggests potential life-threatening pathology 2
- Vomiting combined with severe back pain raises concern for visceral pathology including gastric volvulus, esophageal rupture, or aortic pathology 2, 3
Why CT Thoracic Spine Without Contrast
CT without IV contrast is the appropriate initial study because:
- Rapid acquisition is critical in potentially unstable patients with severe symptoms 1
- Superior bone evaluation for compression fractures, which are common in elderly patients and can occur with minimal trauma 1
- Excellent visualization of fracture patterns, alignment abnormalities, and bone destruction without requiring contrast administration 1
- No delay for IV access or contrast administration in a potentially unstable patient 1
The ACR Appropriateness Criteria specifically designate CT thoracic spine without IV contrast as "usually appropriate" for elderly patients with thoracic back pain and risk factors including advanced age and osteoporosis 1.
When to Add IV Contrast
Consider CT thoracic spine without AND with IV contrast if:
- Soft tissue pathology is suspected (epidural abscess, paraspinal soft tissue tumor extension) 1
- Initial noncontrast CT shows findings requiring further characterization 1
However, in the acute setting with severe pain and vomiting, starting with noncontrast CT allows faster diagnosis of the most immediately life-threatening conditions 1.
Alternative Imaging Considerations
MRI thoracic spine without IV contrast would be equally appropriate if:
- The patient is stable enough for the longer acquisition time 1
- Soft tissue evaluation (spinal cord, nerve roots, intervertebral discs) is the primary concern 1
- Suspected infection or neoplasm requires detailed soft tissue characterization 1
However, CT is preferred initially because:
- Faster acquisition in potentially unstable patient 1
- Better tolerance in patients with severe pain and vomiting who cannot lie still 1
- Superior bone detail for compression fractures 1
Critical Diagnostic Pitfalls
Do not order plain radiographs alone in this clinical scenario. While thoracic spine radiographs may be appropriate for chronic or subacute pain without red flags, they are insufficient for evaluating severe acute pain with vomiting in an elderly patient 1.
Do not delay imaging for conservative management. The combination of severe pain, vomiting, and advanced age constitutes red flags requiring prompt diagnostic imaging 1.
Consider expanding imaging if initial thoracic spine CT is negative but clinical suspicion remains high. The vomiting and severe pain pattern may require:
- CT chest/abdomen/pelvis to evaluate for aortic dissection, esophageal rupture, or gastric volvulus 2, 3
- Complete spine imaging if neurologic symptoms develop 1
Follow-Up Imaging Strategy
If CT thoracic spine without contrast shows:
- Compression fracture: MRI without and with contrast may be added to assess fracture age (acute vs chronic) and exclude pathologic fracture from metastasis 1
- Bone destruction or deformity: MRI thoracic spine without and with contrast is usually appropriate for further characterization 1
- Normal findings: Expand imaging to evaluate other causes of severe pain with vomiting (cardiovascular, gastrointestinal) 2, 3