Thoracic and lumbar fractures and dislocations: Difference between revisions
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==Management== | ==Management== | ||
LUMBAR | LUMBAR | ||
*Stable Fractures - TLSO brace as directed by Neurosurg | |||
CT IF: | CT IF: |
Revision as of 17:46, 10 November 2015
Background
- Injury to thoracic spine necessitates severe force
- When spinal cord injury occurs usually complete
- 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)
- Unstable if:
- 50% loss of vertebral height
- Kyphotic angulation around the fx:
- >30' for compression fx
- > 25' for burst fx
- Neurologic deficit
Classification
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
Lumbar burst fracture
Flexion-Distraction Injuries (lap belt)
- Unstable
- Intra-abdominal injuries more commonly associated than neuro deficits
- Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction
Chance Fracture
- most common at T12-L2 due to spinal curvature and mechanism
- Unstable
- Seat Belt Injury: lap belt worn above the pelvic bones without a shoulder harness
- 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
- anterior vertebral body compression fx with extension through middle of vertebral body into posterior wall
- Compression fx + increased posterior interspinous spaces caused by distraction
- 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 (r/o middle column & burst)
See Also
Source
- UpToDate
- Tintinalli's