Thoracic and Lumbar Spine

Trauma
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 and
unstable
• 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-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
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