Thoracic and lumbar fractures and dislocations: Difference between revisions

Latest revision as of 17:13, 27 October 2020

Background

Injury to thoracic spine necessitates severe force
- thoracic spine has enhanced stiffness secondary to articulations with the rib cage
- When spinal cord injury occurs usually complete
- thoracic spinal canal is narrower than in other regions, increased risk of cord injury
Important to evaluate for thoracic spine injuries and aortic injuries in the setting of blunt chest trauma with mediastinlal widening
Follows the three column model - Stable if two or more of the spinal columns are intact:
- Anterior (anterior longitudinal ligament, annulus fibrosus, ant. half of the vertebral body)
- Middle (posterior longitudinal ligament, posterior annulus fibrous, and post. half of vertebral body
- Posterior (supraspinous and interspinous ligaments, ligamentum flavum, facet joint capsule)
Unstable if:
- 50% loss of vertebral height
- Kyphotic angulation around the fracture:
  - >30' for compression fracture
  - > 25' for burst fracture
- Neurologic deficit

Vertebral fractures and dislocations types

Vertebral anatomy.

Numbering order of vertebrae.

Clinical Features

Typically pain over site of injury

Differential Diagnosis

Thoracic Trauma

Airway/Pulmonary
Cardiac/Vascular
- Cardiac injury
- Traumatic aortic transection
Musculoskeletal
Other

Lower Back Pain

Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
Renal disease
Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
Pelvic disease
- PID
Other
- Retroperitoneal hemorrhage/mass
- Meningitis

Evaluation

Thoracic compression fracture of T12.

Workup

Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location

Indications to Image Thoracic and Lumbar Spine after Trauma
- Mechanism
  - Gunshot, High energy trauma, Motor vehicle crash with rollover or ejection, Fall >10 ft or 3 m, Pedestrian hit by car
- Physical Exam
  - Midline back pain, Midline focal tenderness, Evidence of spinal cord or nerve root deficit
- Associated injuries
  - Cervical fracture, ribe fracture, aortic injuries, hollow viscus injuries
Plain radiographs or CT scan to evaluate for body abnormality
Can reformat Chest and Abdomen CT to look at thoracic, lumbar spine
MRI is diagnostic test of choice to evaluate patients with nerve injury
CT myelography alternative when MRI unavailable
anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
Compression fracture + increased posterior interspinous spaces caused by distraction

10% of patients with a spine fracture have second fracture in a different segment

CT IF:

Compression
Wedge
>50% height (rule out middle column & burst)

Diagnosis

Management

Spinal precautions
Consult ortho or neurosurgery (institution dependent)
Stable fractures
- TLSO brace in discussion with consulting service
Unstable fractures
- Emergency operative repair unless medically unstable

Disposition

External Links

EAST Guidelines for screening for thoracolumbar injuries

References

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
 *Injury to thoracic spine necessitates severe force
+**thoracic spine has enhanced stiffness secondary to articulations with the rib cage
 **When spinal cord injury occurs usually complete
-*[[Unstable spine fractures‎|Stable]] if two or more of the spinal columns are intact:
+**thoracic spinal canal is narrower than in other regions, increased risk of cord injury
+*Important to evaluate for thoracic spine injuries and aortic injuries in the setting of blunt chest trauma with mediastinlal widening
+*Follows the three column model - [[Unstable spine fractures‎|Stable]] if two or more of the spinal columns are intact:
 **Anterior (anterior longitudinal ligament, annulus fibrosus, ant. half of the vertebral body)
 **Middle (posterior longitudinal ligament, posterior annulus fibrous, and post. half of vertebral body
-**Posterior (supraspinous and interspinous ligaments, facet joint capsule)
+**Posterior (supraspinous and interspinous ligaments, ligamentum flavum, facet joint capsule)
 *Unstable if:
 **50% loss of vertebral height
-**Kyphotic angulation around the fx:
+**Kyphotic angulation around the fracture:
-***>30' for compression fx
+***>30' for compression fracture
-***> 25' for burst fx
+***> 25' for burst fracture
 **Neurologic deficit
-==Classification==
+{{Vertebral fractures and dislocations types}}
-===Compression (wedge)===
-* Only unstable if posterior ligament complex ruptures (requires a rotational force)
-* Suspect instability and obtain CT if:
-** Severe compression (>50% loss of vertebral height)
-** Kyphosis >30deg
-** Rotational component to injury
-** Compression fx at multiple sites
-** Posterior cortex abnormality
-===[[Thoracic burst fracture]]===
+==Clinical Features==
-===[[Lumbar burst fracture]]===
+*Typically pain over site of injury
-===Flexion-Distraction Injuries (lap belt)===
+==Differential Diagnosis==
-*Unstable
+{{Thoracic trauma DDX}}
-*Intra-abdominal injuries more commonly associated than neuro deficits
+{{Lower back pain DDX}}
-*Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction
-===Chance Fracture===
+==Evaluation==
-*most common at T12-L2 due to spinal curvature and mechanism
+[[File:T12compressionfracMark.png|thumb|[[Thoracic compression fracture]] of T12.]]
-*Unstable
+===Workup===
-*Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
+*Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
-** Forceful flexion at lap belt leads to compression fx of ant and middle columns
-**Associated with intra-abdominal injury (rectus sheath hematoma, intestinal perforation)
-***One or both articular processes fx > upper vertebrae anterior dislocates/subluxation
-*Imaging
+*Indications to Image Thoracic and Lumbar Spine after Trauma
-**anterior vertebral body compression fx with extension through middle of vertebral body into posterior wall
+**Mechanism
-**Compression fx + increased posterior interspinous spaces caused by distraction
+***Gunshot, High energy trauma, Motor vehicle crash with rollover or ejection, Fall >10 ft or 3 m, Pedestrian hit by car
+**Physical Exam
+***Midline back pain, Midline focal tenderness, Evidence of spinal cord or nerve root deficit
+**Associated injuries
+***Cervical fracture, ribe fracture, aortic injuries, hollow viscus injuries
+*Plain radiographs or CT scan to evaluate for body abnormality
+*Can reformat Chest and Abdomen CT to look at thoracic, lumbar spine
+*MRI is diagnostic test of choice to evaluate patients with nerve injury
+*CT myelography alternative when MRI unavailable
+*anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
+*Compression fracture + increased posterior interspinous spaces caused by distraction
+% of patients with a spine fracture have second fracture in a different segment
-*Management
-**type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
-**consult ortho or neurosurgery (institution dependent)
-**spinal precautions
-**emergency operative repair unless medically unstable
-===Translational===
+CT IF:
-* Massive direct trauma to the back > failure of all 3 columns
+*Compression
-* Almost invariably demonstrate neuro deficits
+*Wedge
+*>50% height (rule out middle column & burst)
-==Differential Diagnosis==
+===Diagnosis===
-{{Lower back pain DDX}}
 ==Management==
-LUMBAR
+*Spinal precautions
+*Consult ortho or neurosurgery (institution dependent)
+*Stable fractures
+**TLSO brace in discussion with consulting service
+*Unstable fractures
+**Emergency operative repair unless medically unstable
+==Disposition==
-CT IF:
-*Compression
-*Wedge
-*>50% height (r/o middle column & burst)
 ==See Also==
@@ Line 68: / Line 68: @@
 *[[Vertebral fractures]]
-==Source==
+==External Links==
-*UpToDate
+*[https://www.east.org/education/practice-management-guidelines/thoracolumbar-spinal-injuries-in-blunt-trauma%2C-screening-for EAST Guidelines for screening for thoracolumbar injuries]
-*Tintinalli's
+==References==
+<references/>
 [[Category:Trauma]]
+[[Category:Neurology]]
+[[Category:Orthopedics]]