What is midline palpation and how do I properly document it in a patient with low back and flank pain after a fall, suspected of having a vertebral compression fracture?

Midline Palpation in Suspected Vertebral Compression Fracture

Midline palpation refers to the physical examination technique of applying direct pressure along the spinous processes of the vertebral column to elicit tenderness, which is a key clinical indicator for thoracolumbar spine injury including vertebral compression fractures. 1

Definition and Technique

• Midline is defined as the area directly in-line with the spinous processes of the vertebrae 2
• Midline tenderness refers to pain elicited when palpating or percussing directly over the spinous processes along the posterior spine 1
• This is distinct from paramidline pain, which occurs lateral to one fingerbreadth adjacent to the midline and is more commonly associated with facet joint or sacroiliac joint pathology 2

Clinical Significance in Vertebral Compression Fracture

• Midline spinal tenderness is one of the established criteria for thoracolumbar spine imaging in trauma patients 1
• Multiple validated clinical decision rules include "thoracolumbar tenderness to palpation" as a positive physical examination finding warranting imaging 1
• However, the absence of midline tenderness does NOT exclude vertebral fracture—significant thoracic and lumbar vertebral fractures can occur without posterior midline tenderness in alert, sober patients 3
• This represents a critical pitfall: relying solely on the absence of midline tenderness can lead to missed fractures 3

Proper Documentation

When documenting midline palpation in a patient with suspected vertebral compression fracture after a fall, include the following elements:

Essential Components to Document

• Location examined: Specify the exact spinal levels palpated (e.g., "thoracolumbar spine from T10-L5") 1
• Presence or absence of tenderness: Document whether midline tenderness is present or absent at each level 1, 3
• Specific findings: Note any focal areas of maximal tenderness corresponding to the suspected fracture level 1
• Associated findings: Document any visible contusion, abrasion, or deformity overlying the spine (contusion/abrasion has high diagnostic value with LR+ 31.09 in tertiary care settings) 4, 5
• Neurologic examination: Include any motor weakness, sensory deficits, or reflex abnormalities 1

Documentation Example

"Physical examination: Midline palpation performed along thoracolumbar spine from T10-L5. Focal tenderness to palpation noted at L1 spinous process level. No visible contusion or abrasion. No step-off deformity palpated. Neurologic examination: lower extremity strength 5/5 bilaterally, sensation intact, reflexes symmetric."

Clinical Decision-Making Algorithm

When to Image Based on Physical Examination

Obtain imaging (radiography initially for suspected compression fracture) if ANY of the following are present: 1

• Midline tenderness to palpation 1
• History of osteoporosis or corticosteroid use (even without tenderness) 1, 4
• Age >65 years with mechanism of injury 1
• Visible contusion/abrasion over spine 4
• Any neurologic deficit 1
• Glasgow Coma Scale <15 1

Red Flags Requiring Immediate Advanced Imaging (MRI)

• Progressive neurologic deficits 1, 6
• Cauda equina symptoms (saddle anesthesia, bilateral leg weakness, urinary retention) 1, 6
• Suspicion of malignancy (history of cancer, age >50, unexplained weight loss) 1
• Suspicion of infection 1

Critical Pitfalls to Avoid

• Do not exclude vertebral fracture based solely on absent midline tenderness—this is the most dangerous pitfall, as significant fractures can present without posterior midline tenderness 3
• In patients with risk factors (older age >70 years, trauma, corticosteroid use), obtain imaging even if midline tenderness is absent 4, 5
• The thoracolumbar junction (T12-L1) is especially at risk for compression fractures and warrants careful examination 7
• Plain radiography is appropriate initial imaging for suspected osteoporotic compression fracture in patients with history of osteoporosis or steroid use 1
• MRI without contrast is preferred if neurologic deficit is present or if distinguishing acute from chronic fracture is needed 1