Thoracic and lumbar fractures and dislocations

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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.

Clinical Features

  • Typically pain over site of injury

Differential Diagnosis

Thoracic Trauma

Lower Back Pain

Evaluation

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

See Also

External Links

References