Thoracic and lumbar fractures and dislocations: Difference between revisions

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==Background==
==Background==
*Injury to thoracic spine necessitates severe force
*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
**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)
**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
**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:
*Unstable if:
**50% loss of vertebral height
**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
**Neurologic deficit


==Classification==
==Classification==
===Compression (wedge)===
===Compression (wedge)===
* Only unstable if posterior ligament complex ruptures (requires a rotational force)
*Only unstable if posterior ligament complex ruptures (requires a rotational force)
* Suspect instability and obtain CT if:
*Mechanism: axial loading and flexion
** Severe compression (>50% loss of vertebral height)
*Unlikely to cause cord damage
** Kyphosis >30deg
*Suspect instability and obtain CT if:
** Rotational component to injury
**Severe compression (>50% loss of vertebral height)
** Compression fx at multiple sites
**Kyphosis >30deg
** Posterior cortex abnormality
**Rotational component to injury
**Compression fracture at multiple sites
**Posterior cortex abnormality


===[[Thoracic burst fracture]]===
===[[Thoracic burst fracture]]===
===[[Lumbar burst fracture]]===
===[[Lumbar burst fracture]]===
 
*considered unstable
===Flexion-Distraction Injuries (lap belt)===
*Mechanism: axial load with failure of the anterior and middle columns
*Unstable  
*Can cause cord damage
===Chance Fracture (Flexion-distraction injuries)===
*Common mechanism: seat belt serves as axis of rotation with failure of middle and posterior columns
*Most common at T12-L2 due to spinal curvature and mechanism
*Pure bony injury from posterior to anterior through:
**Spinous process
**Pedicles
**Vertebral body
*Unstable
*Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
*Mechanism: minor anterior vertebral compression with failure of the middle and posterior columns
*May be misdiagnosed as anterior compression fracture, which is usually stable
*Intra-abdominal injuries more commonly associated than neuro deficits
*Intra-abdominal injuries more commonly associated than neuro deficits
*Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction  
*Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction


===Chance Fracture===
===fracture dislocations===
*most common at T12-L2 due to spinal curvature and mechanism
*Unstable
*Unstable
*Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
*Most damaging of all injuries
** Forceful flexion at lap belt leads to compression fx of ant and middle columns  
*Mechanism: multiple can be compression, flexion, distraction, rotation or shearing forces causing failure of anterior, middle and posterior columns
**Associated with intra-abdominal injury (rectus sheath hematoma, intestinal perforation)
 
***One or both articular processes fx > upper vertebrae anterior dislocates/subluxation
 
===Minor Thoracic and Lumbar Spine Fractures===
*Transverse process fracture
*Spinous process fracture
*Pars interarticularis fracture


*Imaging
==Imaging==
**anterior vertebral body compression fx with extension through middle of vertebral body into posterior wall
*Indications to Image Thoracic and Lumbar Spine after Trauma
**Compression fx + increased posterior interspinous spaces caused by distraction
**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


*Management
==Management==
**type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
**type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
**consult ortho or neurosurgery (institution dependent)
**consult ortho or neurosurgery (institution dependent)
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===Translational===
===Translational===
* Massive direct trauma to the back > failure of all 3 columns
*Massive direct trauma to the back > failure of all 3 columns
* Almost invariably demonstrate neuro deficits
*Almost invariably demonstrate neuro deficits


==Differential Diagnosis==
==Differential Diagnosis==
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==Management==
==Management==
LUMBAR
LUMBAR
*Stable Fractures - TLSO brace as directed by Neurosurg


CT IF:
CT IF:
*Compression
*Compression
*Wedge
*Wedge
*>50% height (r/o middle column & burst)
*>50% height (rule out middle column & burst)
 
==Disposition==
 


==See Also==
==See Also==
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*[[Vertebral fractures]]
*[[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:Trauma]]

Revision as of 05:53, 15 June 2019

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

Classification

Compression (wedge)

  • Only unstable if posterior ligament complex ruptures (requires a rotational force)
  • Mechanism: axial loading and flexion
  • Unlikely to cause cord damage
  • Suspect instability and obtain CT if:
    • Severe compression (>50% loss of vertebral height)
    • Kyphosis >30deg
    • Rotational component to injury
    • Compression fracture at multiple sites
    • Posterior cortex abnormality

Thoracic burst fracture

Lumbar burst fracture

  • considered unstable
  • Mechanism: axial load with failure of the anterior and middle columns
  • Can cause cord damage

Chance Fracture (Flexion-distraction injuries)

  • Common mechanism: seat belt serves as axis of rotation with failure of middle and posterior columns
  • Most common at T12-L2 due to spinal curvature and mechanism
  • Pure bony injury from posterior to anterior through:
    • Spinous process
    • Pedicles
    • Vertebral body
  • Unstable
  • Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
  • Mechanism: minor anterior vertebral compression with failure of the middle and posterior columns
  • May be misdiagnosed as anterior compression fracture, which is usually stable
  • Intra-abdominal injuries more commonly associated than neuro deficits
  • Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction

fracture dislocations

  • Unstable
  • Most damaging of all injuries
  • Mechanism: multiple can be compression, flexion, distraction, rotation or shearing forces causing failure of anterior, middle and posterior columns


Minor Thoracic and Lumbar Spine Fractures

  • Transverse process fracture
  • Spinous process fracture
  • Pars interarticularis fracture

Imaging

  • 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

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

  • Massive direct trauma to the back > failure of all 3 columns
  • Almost invariably demonstrate neuro deficits

Differential Diagnosis

Lower Back Pain

Management

LUMBAR

  • Stable Fractures - TLSO brace as directed by Neurosurg


CT IF:

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

Disposition

See Also

External Links

References