pedestrians or bicyclists struck by a motor vehicle, sports, recreational activities, and physical abuse Clinical Considerations Clinical Recognition Thoracolumbar spine injuries usually result from high-energy mechanisms and may have associated injuries to the torso and abdomen Special early attention to these related injuries is paramount for the coordination of the multidisciplinary patient care Triage Considerations All patients presenting with trauma after a high-energy or concerning mechanism as described above should be maintained on spine precautions until cleared by a physician Patients presenting via Emergency Medical Services (EMS) with spine immobilization should be removed from their backboard immediately, using standard procedure, to avoid iatrogenic injury such as pain, skin ulceration, aspiration, and respiratory compromise Complete vital signs should be obtained to assess for spinal shock and the need for resuscitative measures Clinical Assessment The initial assessment should follow trauma protocol and maintain strict spine precautions Patients can be “logrolled” to inspect the spine as long as flexion, extension, or twisting movements not occur The mechanism of injury and estimated severity of the force of injury should be elicited from the family or EMS Patient assessment should include review of vital signs and thorough examination of the back with palpation and inspection for pain, ecchymosis, abrasions, step-offs, sensory changes, or other abnormalities of the neurologic examination The most common finding on physical examination in the patients with thoracolumbar fracture is point tenderness over the fractured vertebrae However, the sensitivity and specificity of the examination may be imperfect in pediatric patients, as the examination may be complicated by age-related reliability, referred pain, location of fracture (anterior vs posterior), and false positives secondary to contusion Certain physical findings can suggest the possibility of a coexisting spinal cord injury, which may or may not be associated with bony fracture These findings include asymmetry of movement and reflexes between the arms and legs, absence of sacral reflexes, lax anal tone, priapism, spinal shock, autonomic hyperreflexia, diaphragmatic breathing, and urinary retention, as well as any evidence of a motor or sensory deficit level There must