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 | **Kyphotic angulation around the fracture: | ||
***>30' for compression | ***>30' for compression fracture | ||
***> 25' for burst | ***> 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 | **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- | *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 | ||
=== | ===fracture dislocations=== | ||
*Unstable | *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== | ||
**anterior vertebral body compression | *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 | **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 ( | *>50% height (rule out middle column & burst) | ||
==Disposition== | |||
==See Also== | ==See Also== | ||
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*[[Vertebral fractures]] | *[[Vertebral fractures]] | ||
== | ==External Links== | ||
* | *[https://www.east.org/education/practice-management-guidelines/thoracolumbar-spinal-injuries-in-blunt-trauma%2C-screening-for EAST Guidelines for screening for thoracolumbar injuries] | ||
==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
- Mechanism
- 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
- 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
- Other
Management
LUMBAR
- Stable Fractures - TLSO brace as directed by Neurosurg
CT IF:
- Compression
- Wedge
- >50% height (rule out middle column & burst)