thoracic and lumbar spine

8/8/2019 Thoracic and Lumbar Spine

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Thoracic and Lumbar Spine

TraumaMI Zucker, MD



A dr Z Lecture

• On injuries of thethoracic 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! Lateralis done cross-table and no oblique views



Thoracic Spine

• AP

• Lateral



Thoracic Spine

• Swimmer’s view tosee 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 betweenthe posteriormediastinum and thelung.



The Paraspinal Line

• The left line hugs thevertebral column and

is less than 50% of thedistance to thedescending aorta.

• The right line isusually not visible.



The Paraspinal Line

• Abnormal line: eitherdiffuse displacement

or focal bulge.• In trauma, it means

paraspinal hematomaand so occult spineinjury.

• It is also an indirectsign of aortic injury.



Abnormal Paraspinal Line



Role of CT in Spine Trauma

• More sensitive andspecific than plain

films• Can do dedicated

thoracic or lumbar CT



CT

• However, an excellentscreening examination

can be done byreformatting fromabdominal and chestCT’s without

additional imaging.• Ideal for major trauma

patients



Role of MRI in Spine Trauma

• Gold standard for spinalcanal, thecal sac, cord,disc, nerve roots

• Very good for detectingfractures, but not assensitive or precise as CT

• Good for detectingligament injuries



Thoracic and Lumbar Spine

The Specific Injuries



Fractures: Osteoporosis related

• Insufficiency Stress Fracture: Normalstress on abnormally weak bone by

repetitive microtrauma

-or-

• Acute compression fracture from a singleevent, minor trauma on weak bone



Osteoporosis related

Compression Fractures• Most are considered

stable

• Symptomatictreatment



Osteoporosis related

Compression Fractures• For intractable pain,

stabilization by

vertebraloplasty:Percutanous injection of

poly-methylmethacrylatecement

Complications: nerveroot damage, PE



Pathologic Fractures

• Focal lesions, benign ormalignant, that weakenbone and cause it to

fracture with trivial forces

• Look for an osteoblastic

or osteolytic underlyinglesion, with specialattention to pedicles andinferior end plate



Pathologic Fractures

• MRI is much more

sensitive foridentifying lesions andevaluating extensionof tumor into thespinal canal



Minor Fractures

• Transverse process: anyone

• Pars: young adults, older adolescents



Transverse Process

• A minor fracture butoccurs with major

trauma: hard to break • Do CT ABDOMEN to

look for associatedintraperitoneal orretroperitoneal injury



Pars Fracture

• SPONDYLOLYSIS

• Occasionally acongenital anomaly,but usually a fatiguetype stress fracture:

abnormal stress onnormal bone. Hurdler,cheerleader, gymnast,weightlifter.



Spondylolysis

• Oblique view: thefamous “Scotty Dog”

• The “dog” has a collaron its neck



Spondylolisthesis

• With bilateralspondylolysis, bodyslips 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 than50% loss of height, or more than 2 levels

• Look for loss of height, loss of straight or anteriorconcave surface of body

• Mechanism: FLEXION. Very common• Neurologic injury: Uncommon



Compression Fracture



Chance Fracture

Compression fracture of body and transverseposterior arch fracture

Most common at T10-L2UnstableNeurologic injury in 15%, abdominal injury

in 50% (tear of mesentery, bowel injury):always CT spine AND abdomenMechanism: 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 superiorand inferior end plate fractures, posterior

arch fracture with laterally displacedpedicles• 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 evaluateretropulsed fragments’

effect on spinal canal



Shear Injuries

• Marked shearing force causing severefractures and dislocations, very unstable,

severe cord injury.



Extension Injuries

• Predisposing conditions: Degenerativespondylosis, DISH, seronegative

spondyloarthropathies (e.g. ankylosingspondylitis). These are conditions that reducespine elasticity.

• Often unstable

• Central or complete cord syndromes common,even with relatively minor trauma.



Extension Injury: DISH



GOODBYE

• Copyright 2004MI Zucker

thoracic and lumbar spine

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