Thoracic and lumbar spine trauma

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Background

  • Injury to thoracic spine necessitates severe force
    • When spinal cord injury occurs usually complete
  • 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, 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)
  • 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

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 fracture of ant and middle columns
    • Associated with intra-abdominal injury (rectus sheath hematoma, intestinal perforation)
      • One or both articular processes fracture > upper vertebrae anterior dislocates/subluxation
  • Imaging
    • anterior vertebral body compression fracture with extension through middle of vertebral body into posterior wall
    • Compression fracture + 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

Management

LUMBAR

  • Stable Fractures - TLSO brace as directed by Neurosurg


CT IF:

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

See Also

References