Thoracic and Lumbar Spine Trauma MI Zucker, MD. A dr Z Lecture On injuries of the thoracic and...
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Transcript of Thoracic and Lumbar Spine Trauma MI Zucker, MD. A dr Z Lecture On injuries of the thoracic and...
Thoracic and Lumbar SpineTrauma
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 para-vertebral 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 poly-methylmethacrylate 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 andunstable
• 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-L2UnstableNeurologic 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