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Thoraco-Lumbar Radiography Moritz Haager March 4, 2004.

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Presentation on theme: "Thoraco-Lumbar Radiography Moritz Haager March 4, 2004."— Presentation transcript:

1 Thoraco-Lumbar Radiography Moritz Haager March 4, 2004

2 Anatomy

3 Thoracic Spine

4 Lumbar Spine

5 Determinants of Stability T & L spines are more stable than C-spine Strong ligaments Strong ligaments Stabilization by ribs Stabilization by ribs Bigger intervertebral discs Bigger intervertebral discs Larger facet joints Larger facet joints Less mobility Less mobility Fractures & dislocations tend to occur where curvature changes T11-12 (thoracolumbar junction) T11-12 (thoracolumbar junction) L5-S1 (lumbosacral junction) L5-S1 (lumbosacral junction)

6 Mechanisms of Injury Hyperflexion +/- rotation Commonest Commonest Usually see anterior wedge #s or Chance # Usually see anterior wedge #s or Chance #Shearing Ant or post translation Ant or post translationHyperextension Axial loading Compression or burst #s Compression or burst #s

7 3 Column Model Anterior column Ant longitudinal lig Ant longitudinal lig Ant annulus fibrosis Ant annulus fibrosis Ant vertebral body Ant vertebral body Middle column Post longitudinal lig Post longitudinal lig Post annulus fibrosis Post annulus fibrosis Post vertebral body Post vertebral body Posterior column Spinous processes Spinous processes Transverse processes Transverse processes Lamina Lamina Facet joints Facet joints Pedicles Pedicles Post ligamentous complex Post ligamentous complex 2 or more columns disrupted = unstable Most disruption of middle columns are unstable

8 Stable or Unstable? Radiographic findings suggestive of instability Vertebral body collapse w/ widening of pedicles Vertebral body collapse w/ widening of pedicles > 33% canal compromise on CT > 33% canal compromise on CT > 2.5 mm translation b/w vertebral bodies in any plane > 2.5 mm translation b/w vertebral bodies in any plane Bilateral facet dislocation Bilateral facet dislocation Abnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral body Abnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral body

9 Stable or Unstable? Checklist for Instability Anterior elements disrupted2 pts Anterior elements disrupted2 pts Posterior elements disrupted2 pts Posterior elements disrupted2 pts Saggital plane translation > 2.5 mm2 pts Saggital plane translation > 2.5 mm2 pts Saggital plane rotation > 5 o 2 pts Saggital plane rotation > 5 o 2 pts Spinal cord or cauda equina damage2 pts Spinal cord or cauda equina damage2 pts Disruption of costovertebral articulations1 pt Disruption of costovertebral articulations1 pt Dangerous loading anticipated2 pts Dangerous loading anticipated2 pts 5 or more pts unstable until healed or surgically stabilized 5 or more pts unstable until healed or surgically stabilized

10 Stable or Unstable? Risk of neurologic injury increases with > 35% canal narrowing at T11-12 > 35% canal narrowing at T11-12 > 45% canal narrowing at L1 > 45% canal narrowing at L1 > 55% canal narrowing at L2 & below > 55% canal narrowing at L2 & below

11 Approach to T & L Spines A – adequacy & alignment All vertebrae need to be visible All vertebrae need to be visible Ant & post longitudinal lines Ant & post longitudinal lines Facet joints should lie on smooth curve Facet joints should lie on smooth curve Normal kyphosis & lordosis Normal kyphosis & lordosis All spinous processes should lie in straight line All spinous processes should lie in straight line B – bones Trace cortical margins of each vertebrae Trace cortical margins of each vertebrae Difference b/w ant & post body ht < 2 mm Difference b/w ant & post body ht < 2 mm Progressive increase in vertebral body ht moving down spine Progressive increase in vertebral body ht moving down spine Wink sign & interpedicular distance Wink sign & interpedicular distance Dont forget to look at transverse processes Dont forget to look at transverse processes

12 Approach to T & L Spines C – cartilage Progressive increase in disc space moving down spine (except L5-S1) Progressive increase in disc space moving down spine (except L5-S1) Facet joint alignment Facet joint alignment S –soft tissue Look at paraspinal stripe and prevertebral space Look at paraspinal stripe and prevertebral space

13 Case 1 38 yo female brought to ED after being backed over by car driven by boyfriend Intoxicated; c/o back pain & demonstrating the remarkable versatility of the F-word

14 Transverse process fractures of L2-4 Significance of transverse process fractures is not the fractures in and of themselves but rather the high incidence of associated serious intraabdominal injury (~20%)

15 Case 2 46 yo male presents to ED after falling 12 feet off ladder while putting up Christmas lights c/o back pain

16 Anterolisthesis Of L4 on L5

17 CT demonstrates chronic anterolisthesis with no intrusion into spinal canal

18 Case 3 50 yo male again foot fall off ladder while putting up Christmas lights (dangerous hobby)

19 Mild ant wedging of T3 & T4

20 Mild ant wedging of T3 & T4

21 Case 4 21 yo belted passenger in rollover single vehicle MVA at highway speed

22 Widened paraspinal line suggesting hematoma Laterally displaced T5 pedicle Anterior wedging of T4 & T5 w/ loss of 30-40% of body ht

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24 Case 5 29 yo driver offroading in pick-up truck – rolls it at speed Not belted, ejected from vehicle and trapped underneath for 3 hrs

25 Paramediastinal soft tissue density & widening Suggestive of compression fractures

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27 Case 6 22 yo male single vehicle rollover. Not restrained – ejected through windshield at highway speeds

28 Comminution & anterior wedging of L2 w/ 50% loss of body Ht Posterior displacement Involvement of pedicles & laminar arch

29 CT demonstrates severe burst # w/ horizontal plane extending posteriorly through pedicles and transverse processes in keeping w/ a CHANCE fracture

30 Case 7 58 yo roofer presents to ED unconscious after plunging 12 feet onto concrete through skylight

31 Schmorls node Compression fracture of L3 w/ no obvious post element involvement

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