Thoracic and lumbar fractures and dislocations: Difference between revisions
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{{Vertebral fractures and dislocations types}} | {{Vertebral fractures and dislocations types}} | ||
==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) | ||
*Mechanism: axial loading and flexion | *Mechanism: axial loading and flexion | ||
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**Posterior cortex abnormality | **Posterior cortex abnormality | ||
===[[Thoracic burst fracture]]=== | ====[[Thoracic burst fracture]]==== | ||
===[[Lumbar burst fracture]]=== | ====[[Lumbar burst fracture]]==== | ||
*considered unstable | *considered unstable | ||
*Mechanism: axial load with failure of the anterior and middle columns | *Mechanism: axial load with failure of the anterior and middle columns | ||
*Can cause cord damage | *Can cause cord damage | ||
===Chance Fracture (Flexion-distraction injuries)=== | ====Chance Fracture (Flexion-distraction injuries)==== | ||
*Common mechanism: seat belt serves as axis of rotation with failure of middle and posterior columns | *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 | *Most common at T12-L2 due to spinal curvature and mechanism | ||
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*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=== | ====fracture dislocations==== | ||
*Unstable | *Unstable | ||
*Most damaging of all injuries | *Most damaging of all injuries | ||
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===Minor Thoracic and Lumbar Spine Fractures=== | ====Minor Thoracic and Lumbar Spine Fractures==== | ||
*Transverse process fracture | *Transverse process fracture | ||
*Spinous process fracture | *Spinous process fracture | ||
*Pars interarticularis fracture | *Pars interarticularis fracture | ||
==Differential Diagnosis== | |||
{{Lower back pain DDX}} | |||
==Imaging== | ==Imaging== | ||
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*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 | ||
==Management== | ==Management== | ||
Revision as of 12:28, 24 October 2020
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
- Cervical fractures and dislocations
- Thoracic and lumbar fractures and dislocations
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
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
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
Management
LUMBAR
- Stable Fractures - TLSO brace as directed by Neurosurg
CT IF:
- Compression
- Wedge
- >50% height (rule out middle column & burst)