1. Thoracic and Lumbar Spine Trauma
MI Zucker, MD

2. A dr Z Lecture
On injuries of the thoracic and lumbar spine

3. 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

4. Thoracic Spine AP
Lateral

5. Thoracic Spine
Swimmer’s view to see T1-3

6. Lumbar Spine AP
Lateral

7. Lumbar Spine
Coned L5-S1
Oblique views

8. Thoracic AP View: Anatomy

9. Thoracic Lateral View: Anatomy

10. Lumbar AP View: Anatomy

11. Lumbar Lateral View: Anatomy

12. Lumbar Oblique View: Anatomy

13. The Paraspinal Line
Also called para-vertebral stripe, it is the junction between the posterior mediastinum and the lung.

14. 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.

15. 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.

16. Abnormal Paraspinal Line

17. Role of CT in Spine Trauma
More sensitive and specific than plain films
Can do dedicated thoracic or lumbar CT

18. 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

19. 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

20. Thoracic and Lumbar Spine
The Specific Injuries

21. 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

22. Osteoporosis related Compression Fractures
Most are considered stable
Symptomatic treatment

23. Osteoporosis related Compression Fractures
For intractable pain, stabilization by vertebraloplasty:
Percutanous injection of poly-methylmethacrylate cement
Complications: nerve root damage, PE

24. 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

25. Pathologic Fractures
MRI is much more sensitive for identifying lesions and evaluating extension of tumor into the spinal canal

26. Minor Fractures Transverse process: anyone
Pars: young adults, older adolescents

27. Transverse Process
A minor fracture but occurs with major trauma: hard to break
Do CT ABDOMEN to look for associated intraperitoneal or retroperitoneal injury

28. Pars Fracture SPONDYLOLYSIS
Occasionally a congenital anomaly, but usually a fatigue type stress fracture: abnormal stress on normal bone. Hurdler, cheerleader, gymnast, weightlifter.

29. Spondylolysis Oblique view: the famous “Scotty Dog”
The “dog” has a collar on its neck

30. Spondylolisthesis
With bilateral spondylolysis, body slips forward: Spondylolisthesis
Graded 1-4

31. Major Fractures
Flexion
Axial loading
Shearing
Extension

32. Flexion Wedge compression fractures: stable and unstable
Chance fractures
Dislocations and fracture-dislocations

33. 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

34. Compression Fracture

35. Chance Fracture
Compression fracture of body and transverse posterior arch fracture
Most common at T10-L2
Unstable
Neurologic injury in 15%, abdominal injury in 50% (tear of mesentery, bowel injury): always CT spine AND abdomen
Mechanism: FLEXION over a lap seat belt

36. Chance Fracture: Lateral

37. Chance Fracture: AP

38. Chance fracture: Bowel Injury

39. Fracture-dislocation
Marked flexion force
Frequently at T10-L2
Very unstable
Severe cord/cauda equina injury is common

40. Fracture-dislocation

41. 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

42. Burst Fracture: Lateral

43. Burst Fracture: AP

44. Burst Fracture: CT
Mandatory to evaluate retropulsed fragments’ effect on spinal canal

45. Shear Injuries
Marked shearing force causing severe fractures and dislocations, very unstable, severe cord injury.

46. Shear Injury

47. 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.

48. Extension Injury: DISH

49. GOODBYE
Copyright 2004
MI Zucker