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Spinal Cord Injuries;

Thoracolumbar Fractures

Donald S. Corenman, M.D., D.C.


Anatomy of the Cord and Cauda
Spinal cord from foramen magnum to L1
Conus at L1 for bowel and bladder (nervi
eriganties S1-S5)
Peripheral nerves for lower extremities start from
T9-T12
L1 roots start innervation of lower extremities
Thoracic blood supply to the cord tenuous at T10-T12
(artery of Adamkowitz)
Lumbar blood supply abundant
Physiological Anatomy of the
Thoracic Spine
Facets lie in the frontal plane- allowing rotation
Ribs resist rotation and add 3x the normal stiffness
in lateral rotation
Kyphosis of the T spine loads the anterior column
Lower 2 vertebra have floating ribs and no
costotransverse articulations
Canal size in thoracic spine relatively small
Physiological Anatomy of the
Lumbar Spine
Large discs allow more ROM
Facets prevent rotation
Spinal canal wider
Lordosis loads the facets
Thoracolumbar Junction
Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress
riser)
Lowest 2 thoracic vertebra have less extrinsic stability secondary
to changes in facet orientation and floating ribs (T11-12 have
frontal facets but no conjoined ribs to stabilize, therefore less
rotational resistance)
In pure axial loading, thoracic spine deforms into kyphosis and
lumbar spine into lordosis leaving the transition vertebra exposed
to pure compression
Force distributed over 10 thoracic and 4 lumbar vertebra is
withstood only by 2 vertebra at the thoracolumbar junction
Mechanisms of Injury
How much energy was imparted into the individual
(fall from height vs fall from level skiing vs ejection
from car)
What was the loading force (impact onto buttocks vs
impact onto flexed neck vs impact from object)
What was the force trajectory (beam impact vs
restrained MVA vs collision with tree)
What was the quality of the tissue of the recipient to
resist force (young adult vs senior/ preexisting
pathology)
Patient History
Loss of consciousness
Loss of motor strength (temp or present)
Sensory changes (temp or present)
Incontinence (at scene vs current)
Localized pain to other areas
Dyspnea (pneumothorax)
Past medical history
Patient Examination
ABCs first, then trauma examination
Motor strength L1-S1(for suspected
thoracolumbar injury)
Sensory C4-S3
Reflexes (hyperreflexia asso. with preexisting
myelopathy)
Rectal exam (sensory, tone and contraction)
(missed conus injury)
Bulbocavernosis (if necessary)
Neurologic Injury

Methylprednisolone protocol (30 mg/kg


loading and 5.4 mg/kg x 24 (or 48) hours
Only for central injuries- not peripheral
nerve injuries (conus is central injury)
Concordant Spinal Injuries
3 patterns
Watch out for
distracting injuries
10% of patients can
have other spinal
injuries
Severity of trauma-
splenic/ liver and
vessel injury
Classification System
Holdsworth 2 column theory
Denis 3 column theory
Classification of Injuries
Simple Compression (1-2 column injury)
Stable burst (2-3 column injury)
Unstable burst (3 column injury)
Flexion distraction (2 nonconjoined columns)
Chance (3 column failure all in tension)
Fracture dislocation (3 column injury)
Pure Dislocation (rare) (3 column injury)
Pathological (any and all)
Insufficiency (any and all)
Multiple contiguous fractures (nly 1-2 columns)
Compression Fractures
Only anterior column injury
Middle? and post. OK
Ant. column less than 30%
No more than 10 deg kyphosis
No neuro injury
Flexion distraction
Easy to miss- may
look benign
Anterior column >
50% crushed
Middle column mainly
intact
Significant spinous
process widening
Unstable
Stable Burst

Both ant and middle


column involvement
Minimal kyphosis
No neuro involvement
No laminar fracture
Unstable Burst
3 column involvement
Possible neuro
involvement
Severe communition
Significant pedicle
widening
Look for laminar
fracture (asso. with
root entrapment)
Chance Fractures
Old Seatbelt injuries
Center of rotation is
anterior to ALL
May be bony chance or
purely ligamentous
Normally neuro intact
Bony stable,
ligamentous unstable even
though all are 3 column
injuries
Fracture Dislocations
Translation in lower
lumbar spine may be
developmental (nly L3-S1
spondylolysthesis)
Always abnormal in
thoracic spine (ribs)
Unstable
Normally- neuro deficit
Can be hidden at mid
thoracic spine
3 column injury
Pathological Fractures
Normally in patient with
history of CA
May be hard to distinguish
from insufficiency fracture
May be multiple levels
Fracture out of proportion
to force of trauma
Suspicion calls for MRI
and ?Bx
Insufficiency Fractures
Normally in elderly
females
Osteopenia/malacia
Bones have washed out
appearance
Minimal force vectors
Multiple levels (normally)
Kyphosis greater than 70
degrees may need surgery
?Vertebroplasty
So how do you read the films?
Look at alignment of vertebra
On AP- measure pedicle distance and look
for both SP splaying and laminar fractures
Measure kyphosis from intact endplates
Measure anterior and middle column height
Look for retropulsion
High index of suspicion for other fractures
Look at alignment
Look at how the
anterior and posterior
aspects of the body
line up
Spinous Process Splaying
Indicative of either
chance (stable) or
flexion distraction
(unstable) injury
Laminar Split
Associated with burst
or flex-distraction
fractures
Look on exam for root
injuries (they become
entrapped in lamina)
Possible association
with dural tear
Measure Kyphosis

Measure from closest


intact endplates
Measure Ant. and Middle
Column Heights

Compare with vertebra


above and below
Measure pedicle distances

Compare to vertebra
adjacent to injured one
Anterior Column Fx Treatment
Simple compressions can be
placed in a Jewett or TLSO off
the shelf brace and discharged
from the ED or office as long as
pain is controlled, fracture is
stable with new standing x-rays in
brace and they dont have an
ileus. Cannot treat fractures above
T6 without cervical extension
Stable Bursts and Lateral
Compression Fractures
Admit- pain mgmt and
neuro checks
Brace management -Off the
shelf TLSO for simple
compressions greater than
30% and lateral
compressions, Custom
TLSO for unusual body
habitis, severe bursts and pts
that need stability testing.
CASH for insufficiency Fxs
Complications from Fracture
Pneumothorax (thoracic Fxs with asso rib Fxs)/
Ileus(30-60%)
Splenic, liver and vessel injury (mechanism of injury)
DVT/PE
Decubitis
UTI
Pneumonia
Renal failure (hydronephrosis from cauda equina
involvement)
Stress Testing
Fracture that may be
unstable in custom TLSO
Bed rest until TLSO
arrives
X Rays supine/ 45deg/ 90
deg/ upright
Stop if neuro involvement,
sig. Pain increase or sig.
Increased kyphosis
45 degrees vs upright
Surgical Indications
Neurological Involvement
Flexion distraction injury
Greater than 50% canal compromise with
>15 degrees kyphosis
>25 degrees kyphosis
Failure of stress testing (severe pain,
angulation above 25 degrees, neuro
symptoms)
Fracture dislocations
Soft tissue chance fractures
Time to healing
Most non-surgical fractures heal within 12 weeks
Jewett/ TLSO on whenever upright
When healed- 4 weeks of PT for deconditioning
Residuals of barometric sensitive discomfort and
occasionally problems with lifting
10 % may need to go on to surgery from
instability pain
Thank You