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Thoracic and Lumbar Spine Trauma MI Zucker, MD A dr Z Lecture • On injuries of the thoracic and lumbar spine Radiography • Thoracic: AP, lateral, swimmer’s views • Lumbar: AP, lateral, coned L5-S1, (oblique) views In major trauma, don’t move patient! Lateral is done cross-table and no oblique views Thoracic Spine • AP • Lateral Thoracic Spine • Swimmer’s view to see T1-3 Lumbar Spine • AP • Lateral Lumbar Spine • Coned L5-S1 • Oblique views Thoracic AP View: Anatomy Thoracic Lateral View: Anatomy Lumbar AP View: Anatomy Lumbar Lateral View: Anatomy Lumbar Oblique View: Anatomy The Paraspinal Line • Also called paravertebral stripe, it is the junction between the posterior mediastinum and the lung. The Paraspinal Line • The left line hugs the vertebral column and is less than 50% of the distance to the descending aorta. • The right line is usually not visible. The Paraspinal Line • Abnormal line: either diffuse displacement or focal bulge. • In trauma, it means paraspinal hematoma and so occult spine injury. • It is also an indirect sign of aortic injury. Abnormal Paraspinal Line Role of CT in Spine Trauma • More sensitive and specific than plain films • Can do dedicated thoracic or lumbar CT CT • However, an excellent screening examination can be done by reformatting from abdominal and chest CT’s without additional imaging. • Ideal for major trauma patients Role of MRI in Spine Trauma • Gold standard for spinal canal, thecal sac, cord, disc, nerve roots • Very good for detecting fractures, but not as sensitive or precise as CT • Good for detecting ligament injuries Thoracic and Lumbar Spine The Specific Injuries Fractures: Osteoporosis related • Insufficiency Stress Fracture: Normal stress on abnormally weak bone by repetitive microtrauma -or• Acute compression fracture from a single event, minor trauma on weak bone Osteoporosis related Compression Fractures • Most are considered stable • Symptomatic treatment Osteoporosis related Compression Fractures • For intractable pain, stabilization by vertebraloplasty: Percutanous injection of polymethylmethacrylate cement Complications: nerve root damage, PE Pathologic Fractures • Focal lesions, benign or malignant, that weaken bone and cause it to fracture with trivial forces • Look for an osteoblastic or osteolytic underlying lesion, with special attention to pedicles and inferior end plate Pathologic Fractures • MRI is much more sensitive for identifying lesions and evaluating extension of tumor into the spinal canal Minor Fractures • Transverse process: anyone • Pars: young adults, older adolescents Transverse Process • A minor fracture but occurs with major trauma: hard to break • Do CT ABDOMEN to look for associated intraperitoneal or retroperitoneal injury Pars Fracture • SPONDYLOLYSIS • Occasionally a congenital anomaly, but usually a fatigue type stress fracture: abnormal stress on normal bone. Hurdler, cheerleader, gymnast, weightlifter. Spondylolysis • Oblique view: the famous “Scotty Dog” • The “dog” has a collar on its neck Spondylolisthesis • With bilateral spondylolysis, body slips forward: Spondylolisthesis • Graded 1-4 Major Fractures • • • • Flexion Axial loading Shearing Extension Flexion • Wedge compression fractures: stable and unstable • Chance fractures • Dislocations and fracture-dislocations Compression Fractures • Stable: Isolated to body, less than 50% loss of height, 1 or 2 levels only • Unstable: Posterior arch involved, or more than 50% loss of height, or more than 2 levels • Look for loss of height, loss of straight or anterior concave surface of body • Mechanism: FLEXION. Very common • Neurologic injury: Uncommon Compression Fracture Chance Fracture Compression fracture of body and transverse posterior arch fracture Most common at T10-L2 Unstable Neurologic injury in 15%, abdominal injury in 50% (tear of mesentery, bowel injury): always CT spine AND abdomen Mechanism: FLEXION over a lap seat belt Chance Fracture: Lateral Chance Fracture: AP Chance fracture: Bowel Injury Fracture-dislocation • • • • Marked flexion force Frequently at T10-L2 Very unstable Severe cord/cauda equina injury is common Fracture-dislocation Burst Fracture • Compression fracture of body with superior and inferior end plate fractures, posterior arch fracture with laterally displaced pedicles • Very unstable • Over 2/3 have cord injury from retropulsed fragments. • Axial load/flexion combined mechanism Burst Fracture: Lateral Burst Fracture: AP Burst Fracture: CT • Mandatory to evaluate retropulsed fragments’ effect on spinal canal Shear Injuries • Marked shearing force causing severe fractures and dislocations, very unstable, severe cord injury. Shear Injury Extension Injuries • Predisposing conditions: Degenerative spondylosis, DISH, seronegative spondyloarthropathies (e.g. ankylosing spondylitis). These are conditions that reduce spine elasticity. • Often unstable • Central or complete cord syndromes common, even with relatively minor trauma. Extension Injury: DISH GOODBYE • Copyright 2004 MI Zucker