Thoracic and Lumbar Spine
Transcript of Thoracic and Lumbar Spine
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Thoracic and Lumbar Spine
TraumaMI Zucker, MD
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A dr Z Lecture
• On injuries of thethoracic and lumbar
spine
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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
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Thoracic Spine
• AP
• Lateral
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Thoracic Spine
• Swimmer’s view tosee T1-3
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Lumbar Spine
• AP
• Lateral
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Lumbar Spine
• Coned L5-S1
• Oblique views
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Thoracic AP View: Anatomy
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Thoracic Lateral View: Anatomy
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Lumbar AP View: Anatomy
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Lumbar Lateral View: Anatomy
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Lumbar Oblique View: Anatomy
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The Paraspinal Line
• Also called para-vertebral stripe, it is
the junction betweenthe posteriormediastinum and thelung.
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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.
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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.
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Abnormal Paraspinal Line
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Role of CT in Spine Trauma
• More sensitive andspecific than plain
films• Can do dedicated
thoracic or lumbar CT
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CT
• However, an excellentscreening examination
can be done byreformatting fromabdominal and chestCT’s without
additional imaging.• Ideal for major trauma
patients
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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
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Thoracic and Lumbar Spine
The Specific Injuries
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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
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Osteoporosis related
Compression Fractures• Most are considered
stable
• Symptomatictreatment
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Osteoporosis related
Compression Fractures• For intractable pain,
stabilization by
vertebraloplasty:Percutanous injection of
poly-methylmethacrylatecement
Complications: nerveroot damage, PE
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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
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Pathologic Fractures
• MRI is much more
sensitive foridentifying lesions andevaluating extensionof tumor into thespinal canal
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Minor Fractures
• Transverse process: anyone
• Pars: young adults, older adolescents
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Transverse Process
• A minor fracture butoccurs with major
trauma: hard to break • Do CT ABDOMEN to
look for associatedintraperitoneal orretroperitoneal injury
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Pars Fracture
• SPONDYLOLYSIS
• Occasionally acongenital anomaly,but usually a fatiguetype stress fracture:
abnormal stress onnormal bone. Hurdler,cheerleader, gymnast,weightlifter.
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Spondylolysis
• Oblique view: thefamous “Scotty Dog”
• The “dog” has a collaron its neck
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Spondylolisthesis
• With bilateralspondylolysis, bodyslips forward:Spondylolisthesis
• Graded 1-4
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Major Fractures
• Flexion• Axial loading• Shearing• Extension
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Flexion
• Wedge compression fractures: stable andunstable
• Chance fractures• Dislocations and fracture-dislocations
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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
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Compression Fracture
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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
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Chance Fracture: Lateral
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Chance Fracture: AP
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Chance fracture: Bowel Injury
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Fracture-dislocation
• Marked flexion force• Frequently at T10-L2• Very unstable• Severe cord/cauda equina injury is common
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Fracture-dislocation
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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
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Burst Fracture: Lateral
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Burst Fracture: AP
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Burst Fracture: CT
• Mandatory to evaluateretropulsed fragments’
effect on spinal canal
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Shear Injuries
• Marked shearing force causing severefractures and dislocations, very unstable,
severe cord injury.
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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.
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Extension Injury: DISH
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GOODBYE
• Copyright 2004MI Zucker