Thoracic and lumbar fractures and dislocations: Difference between revisions

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==Pearls==
==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
*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:
***>30deg for compression fx
***>30' for compression fracture
***> 25deg for burst fx
***> 25' for burst fracture
**Neurologic deficit
**Neurologic deficit


==Classification==
{{Vertebral fractures and dislocations types}}
===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


===Burst fracture===
==Clinical Features==
* Unstable
*Typically pain over site of injury
* Can occur with or without injury to posterior elements (posterior involvement increases risk for neuro deficits)
* Be certain not to mistakenly call a burst fracture a wedge fracture
** Obtain CT if unsure


===Flexion-Distraction Injuries (lap belt)===
==Differential Diagnosis==
*Unstable
{{Thoracic trauma DDX}}
*Intra-abdominal injuries more commonly associated than neuro deficits
{{Lower back pain DDX}}
*Obtain sagittally reconstructed CT if suspect lap-belt mechanism or flexion-distraction


===Chance Fx===
==Evaluation==
*Unstable
[[File:T12compressionfracMark.png|thumb|[[Thoracic compression fracture]] of T12.]]
* Lap belt worn above the pelvic bones without a shoulder harness
===Workup===
** Forceful flexion at lap belt leads to compressive failure of ant and middle columns
*Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
*** One or both articular processes fx > upper vertebrae anteriorly dislocates
 
* Imaging
*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
 
 
CT IF:
*Compression
*Wedge
*>50% height (rule out middle column & burst)
 
===Diagnosis===
 
==Management==
*Spinal precautions
*Consult ortho or neurosurgery (institution dependent)
*Stable fractures
**TLSO brace in discussion with consulting service
*Unstable fractures
**Emergency operative repair unless medically unstable
 
==Disposition==


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


==See Also==
==See Also==
[[Spinal Cord Trauma]]
*[[Spinal Cord Trauma]]
*[[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]


==Source==
==References==
*UpToDate
<references/>
*Tintinalli's


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Neurology]]
[[Category:Orthopedics]]

Latest revision as of 17:13, 27 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

Vertebral anatomy.
Numbering order of vertebrae.

Clinical Features

  • Typically pain over site of injury

Differential Diagnosis

Thoracic Trauma

Lower Back Pain

Evaluation

Thoracic compression fracture of T12.

Workup

  • Type and screen/cross, labs including pancreatic enzymes if thoraco-lumbar location
  • 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


CT IF:

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

Diagnosis

Management

  • Spinal precautions
  • Consult ortho or neurosurgery (institution dependent)
  • Stable fractures
    • TLSO brace in discussion with consulting service
  • Unstable fractures
    • Emergency operative repair unless medically unstable

Disposition

See Also

External Links

References

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