Trauma Thoracic Spine Anatomy, Bio Mechanics Imaging

8/8/2019 Trauma Thoracic Spine Anatomy, Bio Mechanics Imaging

1/8

95

AJR 1993;160:95-102 0361-803X/93/1 601-0095 American Roen tgen Ray Society

Review Artic le

---

Traum a to the Upper Thoracic Sp ine:Anatom y, B iom echanics , and Unique Im aging Featu res

Georges V . EI-Khoury1 and Camelia G . W hitten

Th is review summ arizes th e anatom ic and b iom echan ica lfea tu res o f th e tho racic spine , wh ich are d ifferen t from those o f

th e more m ob ile segm en ts o f th e sp ine, and emphasizes th e irro le in trauma. The dis tingu ish ing characteris tics o f th e tho -

rac ic sp ine are th e p resence o f th e rib s and the ir articu la tion s.The rib cage res tric ts mo tion and adds stiffn ess to th e sp ine .

Du ring traum a, it p rovides th e tho racic sp ine w ith add itionals treng th and energy-ab so rb ing capacity . Above the T10 level,m ost in ju ries p roduce a bas ic pattern consis ting o f an an terio rfrac tu re-d islo catio n in vo lv in g tw o con tiguous verteb rae , o ftenw ith associated neu rolog ic im pairm en t. The defin ition o f sp ina l

in stab ility rem ain s con trovers ial. CT is th e im ag ing techn ique

o f cho ice fo r evalua tion o f sp ine frac tu res; however, MR im ag -

ing is superio r in th e evaluation o f spina l co rd in ju ry and post-traum atic d isk hern ia tion . MR im ag ing also p rovides

p rognos tic in fo rmation no t ob tain ab le w ith o ther im ag ing

methods.

The thoracic spine is the largest segment of the spine, andit is a common site for trauma, especially in its lower portion(T10-T12). The anatom ic and biom echanical fea tures of the

thoracic spine make its response and tolerance to mechani-cal stresses different from those of the more mobile portionsof the spine. This review considers the anatomy, biomechan-ics, and unique im aging features of the norm al and trauma-

tized upper portion of the thonacic spine.

Anatom y and B iomechan ics o f th e Tho rac ic Sp ine

G ross A natom y

The thoracic spine consis ts of 12 vertebrae; it has a yen-tral curve that develops in utero and is m aintained, although

somewhat modified, throughout life. The vertebral bodiesanteriorly are prim arily load-bearing. The arches posteriorlyact in resisting tension. The antenopostenior diam eter of thevertebral bodies gradually increases from Ti to T12,

whereas the transverse w idth decreases from Ti to T3 andthen increases progressively down to T12 [1]. Norm ally, th

vertical height of the thoracic vertebral bodies is about 2-3

mm less anteriorly than posteriorly, which partially contnibutes to thoracic kyphosis. The sides of the bodies are some-

what concave. In the thonacic spine, the lam inae are broad

and heavily overlapped. The pedicles project posteriorlyfrom the superior aspect of the vertebral body. Extending

dorsomedially from the pedicles are the lam inae, which fusein the m idline to form the dorsal wall of the spinal canal [2] . The lumen of the spinal canal varies in size throughout itlength, but its narrowest segment is in the thonacic spine.

Neural elem ents within the thonacic portion of the spinalcanal are, therefore, more frequently affected by conditionsthat result in even m inim al narrowing of the spinal canal [4]. The articular processes arise from both the superior andinferior surfaces of the lam inae. The articulating facets ar

Rece ived Ju ly 1, 1992; accep ted a fte r revis ion July 28, 1992.authors: D epa rtm en t o f R ad iology, The Un ive rsity o f Iowa Hosp ita ls and C linics, 200 Hawkins Dr., Iowa City, IA 52242. Address reprint requ

El-Khoury.


2/8

96 EL-KHOURY AND WHITTEN A JR :16 0, Ja nua ry 19 93

situated on the posterior surface of the superior articular pro-cess and ventral surface of the inferior process . Throughoutmost of the thoracic region (Ti -T i 0), the facets are in the

coronal plane, thus providing significant resistance to ante-non translation. A t Ti 1 and Ti 2, facets begin to change their

orientation to simulate the lumbar pattern (oblique sagitta l

orientation), where they lim it notation and have less effect on

anterior translation [4].The most dis tinguishing features of the thonacic spine are

related to the presence of the nibs and their articulations [1,2] . Ribs articulate with vertebrae at two sites. R ib headsarticulate w ith the vertebrae at the disk, and the rib tubencle

articulates w ith the transverse process at the costotrans-

v er se a rt ic ula tio n.Dem ifacets above and below the disk articulate w ith the

head of the nb to form the costovertebral joint, which is a

synovial joint divided by an intnaarticular ligament into two

separate compartm ents. The heads of the firs t, 11th, and1 2th ribs articulate with single vertebral facets of the come-

sponding vertebrae rather than w ith two dem ifacets of adja-cent vertebrae [1, 2] . The head of the rib is an important

landmark for identifying the intervertebral disk during axialim aging. The nib cage restricts motion and adds stiffness to

the spine. This is especially true in extension and to a lesser

extent in flexion and lateral notation. B iomechanically, the ribcage is considered part of the structure of the spine, thusproviding additional strength and energy-absorbing capacity

during trauma. The rib cage and sternum increase the

moment of inertia and therefore stiffen the spine when it issubjected to rotatory forces [5]. Andniacchi et al. [6] predictedthat the compression tolerance of the spinal column in the

presence of the rib cage is increased by a factor of 4. In din-ical situations, when costovertebral disruption is present, the

ability of the spine to carry normal physiologic loads shouldb e q ue st io ne d.

The transverse processes project laterally from the articu-Ian pillars between the superior and inferior articulan facets.

They dim inish in length from the top to the bottom of the tho-m acic spine. The tip of each transverse process from Ti toTi 0 bears an oval costal facet. Costotransverse joints are

form ed by the articulation of therib tubendles and tips of thetransverse processes. T ii and Ti2 transverse processes donot articulate w ith ribs [1, 2] .

Compared with the cervical and lumbar spine, the heightof disks in the thonacic spine is decreased, but the annulusfibrosus is thicker. The disks in the thonacic region seem tobe effective in lim iting rotation [4]. The anterior and posterior

longitudinal ligam ents, ligamenta flava, and interspinous and

supraspinous ligaments in the thoracic spine are not signifi-

cantly different from these ligaments at other spinal seg-ments .

R adiographic Anatom y

Conventional radiography continues to be the mainstay ofany diagnostic investigation of the thoracic spine. P lain radi-ognaphy should precede any complex im aging procedure,

and the interpretation of these complex studies should be

undertaken only with the plain nadiogmaphs at hand. Antero-posterior and lateral nadiographs are always required.

Anteropostenion radiographs can be obtained easily; ho

even, diagnostic lateral radiographs may be more difficultobtain in patients w ith multisystem trauma becauseexam ination is perform ed with the patient in the supine p

tion. In cooperative patients, high-quality lateral views ofthoracic spine can be obtained by using a long exposure

(3-6 sec, 50 mA, and 70 kVp) and breathing technique.

swimmers view of the upper thoracic spine is often benecial when the upper thonacic vertebrae are not adequatelyvisualized.

Antenopostenior radiographs are ideal for the evaluationthe vertebral bodies . The superior and inferior endplates

the vertebral bodies are seen as linear horizontal lines. Tlateral m argins are concave. Pedidles appear as oval strutunes projecting over the superior corners of the vertebrabodies . Absence of a pedicle, or asymmetry in the sizedensity of the pedic les, w arrants further investiga tion to r

out neoplasm . Pedicle thinning, w ith a slight increase inintenpediculate d is tance at the level of the th inning, is n

mally seen at the thoracolumban junction in 7% of the pop

lation. The thinned pedicles may even have concave medi

borders [7, 8]. The articular facets and Iam inae are difficultevaluate on the anteropostenior view . The transverse pr

cesses are visible as lateral extensions of the upper halfthe vertebrae, whereas the costotnansverse joints candetected as two oblique lines close to the ends of the tranverse processes. R ib heads, which are detected at the lev

of the intervertebral disks, articulate w ith the superiorinferior corners of adjacent vertebral bodies . The panaspin

soft tissues of the thoracic spine should be closely appliedthe vertebral bodies and only m inim ally visible . No fo

swelling should be identified in the paraspinal soft tissuesthe norm al thonacic spine.

Lateral nadiographs are helpful in assessing vertebra

body height, disk height, endplate irregularity, erosions,

alignment. On the lateral projection, vertebral bodiesseen as rectangular structures . The pedicles extend posteri

only from the superior half of the body. Located abovebelow the pedicles are the articular processes. The spin

canal and neural foram ina are clearly delineated on later

nadiographs. The inferior portions of the neural fonam inaoccluded by the heads of the ribs [1]. The spinous processes

are virtually impossible to visualize on the lateral view ow

to the superimposition of the ribs.

Traum a to the Upper Tho rac ic Sp ine

Fractures in the upper thoracic spine (Ti-Tb) are n

uncommon. O f 2416 patients w ith acute fractures of the y

tebmal column adm itted to the Northwestern University ASpine Injury Center between 1 972 and i 986, 1 6% of the 3fractures involved the upper thonacic spine [9].

F ractures of the Upper Thoracic Spine

H istorically, fractures of the upper thoracic spine (Ti -Thave been grouped with fractures of the thoracolumbar ju

tion and lumbar spine. These regions differ in both their nnologic and osseous aspects [3]. Bohlm an [3] drew attentio

to the unique features of trauma involving the upper thorac


3/8

AJR:160 , January 1993 TRAUMA TO UPPER THORACIC SPINE 97

spine and noted the follow ing: (1) Because of its stiffness,considerable violence is necessary to produce fractures or

fracture-dislocations in the upper thonacic spine.#{149}2)Because of the narrow spinal canal in this region, in juries ofthe spinal cord are frequently associated with in juries of theupper thonacic spine. (3) Most of the osseous injuries occurin flexion and axial loading because very little rotatory

motion occurs in the upper thonacic spine.Antenopostenon and la teral v iew s of the thoracic spine are

helpful in assessing alignment. An abrupt change in align-

m ent indicates spinal injury (Figs. 1A and 2B). The presenceof abnorm al kyphosis, pleural fluid, panaspinal swelling, rib

fractures, dislocations at the costovertebral joints , or w iden-ing of the interpediculate distance also suggests thonacicspine injury (Figs . 2A and 2B).

Rogers et al. [1 0 ] recognized that fractures of the upper

thonacic spine do not fit easily into the common fracture clas-

sifications and thus should be treated separately. In a reviewof 35 patients w ith acute injury to the upper thonacic spine

and associated paraplegia, they found the basic pattern ofin jury, affec ting 32of 35 patients , consisted of an anterior

fracture-dis location involving two contiguous vertebrae(Figs . 2A and 2B). Shanafuddin et al. [ii] described s im ilarradiographic findings in three patients w ith fractune-disloca-

tions of the thonacic spine .Anteriorly wedged vertebrae are usually considered

abnorm al in the c lin ical se tting of trauma. However, normal

wedging of the lower thoracic vertebral bodies, especially inmales, is common [1 2 , 1 3]. Fle tcher [1 2 ] and Laundsen et al.[1 3 ] proposed using a wedging ratio that compares heights

of the anterior vs the posterior vertebral bodies. Wedging

ratios of 0.80 in males and 0.87 in fem ales (95% confidence

lim its) at the T8 to Ti 2 levels are considered w ithin norm al

lim its [12, 13].

The posterior aspects of the vertebral bodies are visible

on lateral nadiognaphs. D isruption, or bulging, of this line in

the spinal canal is a reliable indicator of a burst fracture i

the spine (F ig. 3). In a study of 114 patients w ith burst frac-

tunes, Daffnen et al. [1 4] found disruption of the posterior yetebral body line in all. This line should be carefully scru-

tinized in patients with trauma to the thoracic spine.

The spinous processes consistently project over the m id-

line, and each tubercle (tip) of the spinous process extends

slightly below the inferior endplate of its respective vertebralbody. The double spinous process sign seen on the antero-posterior radiograph is a reliable indicator of a fracture of th

spinous process [15 , 16] (Fig. 4).

CT is a useful adjunct to standard radiography whenassessing trauma of the thonacic spine, particularly in the

evaluation of vertebral fracture and retnopulsed fragments[17-20] (Fig. 3B). Keene et a l. [17] and Bnant-Zawadzki et a[1 8 ] demonstrated that CT combined with standard radiogna-

phy is equal on superior to conventional tomography inassess ing the extent of spine trauma. Brant-Zawadzki et a[1 8 ] reported that conventional tomography added no clinically significant inform ation in the acute stage.

Spinal Cord lnjuiy

Fractures associated with spinal cord injury most oftenoccur at C4-C7 and the thoracolumbar junction; however,m idthoracic spine fractures account for a sizable portion o

F ig . 1 .-A bn orm al alig nm en t an d n on co ntig -u o u s f ra c tu r es .

A , A ntero po sterio r ch es t rad io grap h sh ow sfluid in left pleural space and abno rm al align -men t between T2 and T3(arrowheads) , suggest-I ng a f r ac t u re -d is l o ca t Ion .

B, S ag it ta l T 2- we lg hte d MR Im age show s T3and T4 verteb ral bodyfractures (w hite a rro ws )and a noncon tiguous frac tu re o f odon to ld(black arrow).


4/8

I41

B

I -#{188}_____

98 EL-KHOURY AND WHITTEN AJR: 160 , January 1993

Fig. 2 .-Anterior fracture -d is loca tion of the -ra cic s pin e.

A , Ante roposte rio r rad iograph shows in ter-ruption in ou tline of pedicle s at Tb, left para sp i-na l s we lling (arrowheads) , and le ft cos to-verteb ral dis location a t T i 1(arrow).

B, Late ra l r ad io gr ap h o f t ho ra ci c s pi ne s ho wsa nt er io r f ra ct ur e- di sl oc at io n o f T i 0 o n T i 1 , w it h

secondary kyphosis a t T 1 0 -Ti i.C, Sagitta l T2 -weighted MR im ages show

transection of co rd w ith hem orrhage and edem aw ith in sp ina l cord.

F ig. 3.-D isruption of poste rio r ve rtebralbody l i ne .

A , La te ral rad iog raph of thorac ic spine show spos te rio r displacem ent and bu lging of pos ter iorv e r t e b r a l body lin e of Ti0 (arrows) , indicatingre tropu ls ed fragm en ts w ithin spinal canal.

B , Axial CT scan th rough T iO confirm s pres -ence of retropu ls ed fragment within sp inalcanal .


5/8

AJR:160 , January 1993 TRAUMA TO UPPER THORACIC SPINE 99

m ent [42].

fractures with injury to the spinal cord [10]. Owing to thesm all diam eter of the thoracic spinal canal and the sparse

vascular supply to the thoracic spinal cord, fractures of theupper thoracic spine are usually associated w ith neurologicin jury [9 , 21]. Meyer [9] reported that 63% of the fractures of

the upper thonacic spine seen at the Northwestern University

Acute Spine Injury Center between 1972 and 1986 resulted

in complete neunologic injuries to the spinal cord, while thethonacic spinal cord escaped injury in only 10% . C linicalevaluation has been, until recently, the only method for pre-

dicting outcome in patients w ith spinal cord injury. C linical

assessm ent, however, cannot dis tinguish between transec-tion, hemorrhage, and edema of the spinal cord, as indicatedby the occasional observation of significant recovery after anapparently complete lesion [22]. MR imaging is capable ofshow ing edema and hemorrhage w ithin the spinal cord. In

addition, several authors [22-29] have recognized a distinct

correlation between the pattern of spinal cord injury on MRimaging and neurologic recovery. Hemorrhage within thespinal cord suggests that there w ill be little improvement in

neurologic function. Edema w ithin the spinal cord, particu-

lam ly if it is lim ited to one spinal segment, im plies a morefavorable outcome. The optimum tim e for prognostic im ag-ing is 24-72 hr after the injury. For assessm ent of spinalin jury, MR imaging has recently been advocated as the

exam ination of choice, after conventional radiography, par-ticulam ly when a neurologic deficit is present or is progress-ing [27] (F ig. 2C). MR imaging also has the addedadvantage of show ing the cervicothonacic junction in heavypatients [27].

Holdsworth [30] in 1 970 and Bohlm an [3] in 1 985 statedthat shearing fractures of the upper thoracic spine are

always associated w ith complete paraplegia; however, somereports [ii , 31-33] describe patients with severe fracture

dislocations of the thoracic spine in whom the spinal cord

w as not injured.The floating lam inae or floating arches mechanism

may explain how the spinal cord escapes injury in fracture-dislocations of the thoracic spine. B ilateral pedicular frac-tunes at several levels allow the posterior elem ents to rem ainaligned while the vertebral bodies displace forward [31-33].W ith the floating arches m echanism , the spinal canal actu-

ally enlarges, in a fashion sim ilar to that seen w ith spondylo-listhesis, ow ing to a defect in the pans interarticulanis.

S impson et al. [33] warned that although plain nadiognaphsmay suggest transection of the spinal cord, they should

never be used to infer the state of the spinal cord in an

obtunded or unconscious patient. Careful handling of theunstable spine in these circum stances should continue until

the neunologic status of the patient can be thoroughly evalu-ated.

M ultilevel Spinal Injuries

Up to 17% of fractures of the upper thoracic spine are

associated w ith another noncontiguous spinal fracture [10].O ften, the second level of injury is not recognized early

enough to prevent clinically significant extension of the neu-rologic deficit [34]. Common sites for second noncontiguous

fractures are the upper cervical spine and thoracolumbar

junction [10, 34, 35]. The multiplanan capabilities of M

imaging facilita te early diagnosis of multilevel trauma, occasionally revealing unsuspected injuries (F ig. 1 B). It is themefore mandatory to search for other spine fractures whenever

a fracture is detected in the upper thonacic spine. The pres-

ence of these second-level spinal injuries is further testi-

mony to the severity and complicated nature of the forcesinvolved in injuries of the upper thoracic spine [10].

Fracture of the Upper Thoracic Spine vs Aortic Transection

Traditionally, m ediastinal w idening, apical cap, and pleurafluid have been attributed to aortic transection [36]. How

ever, these findings are also seen in more than half the

patients with an injury to the upper thomacic spine [3, 37-39](Fig. 4). Dorm et al. [39] found a 36% fmequency of hemotho-m ax in patients w ith injuries to the thomacic spine. In a review

of the madiogmaphs of 54 patients with fractures between th

C6 and T8 vertebral levels, Dennis and Rogers [38] found

that 69% had a w ide mediastinum . A spine fracture could bdetected on the chest radiograph in half of their patients.These authors concluded that if a fracture of the upper tho-

m acic spine can be detected to account for the mediastinalw idening, aortic rupture becomes unlikely in the absence o

clinical signs and symptom s to support such a diagnosis

[38].

F ractures of the upper thomacic spine and aortic rupturehave an important clinical feature in common: both condi-

tions can cause parapamesis on paraplegia [37]. Aortic muptune can cause dim inished blood supply to the spinal cord,resulting in ischem ia and necrosis [40]. Therefore, in

patients in whom both aortic rupture and fracture of theupper thoracic spine are possibilities, the proper sequencing

of diagnostic tests and careful handling of the patient areessential. Bolesta and Bohlm an [37] recommend firs t ruling

out an aortic injury and then localizing the fracture or dislocation. Such patients should be immobilized and handled

judiciously when they are transported to and from theangiography suite .

S te rn al F ra ctu re s

The sternum is frequently buckled or fractured in patients

w ith trauma to the upper thomacic spine. Radiographically,

the appearance of this indirect injury to the sternum dLfferfrom that of direct trauma to the sternum and should alertradiologists to severe injury in the thomacic spine [41]. Aindirect sternal injury is identified by the pattern of displace-

m ent of the bone fragments. Forces transm itted to the stem

num through the ribs, as a result of spine fracture ordislocation, posteriorly displace the upper sternal fragmentre la tive to the lower portion of the sternum (F ig . 5). This pa t-

tern of displacement is different from that usually seen w itdirect trauma to the sternum , where forces applied to thefront of the chest posteriorly displace the lower sternal f rag


6/8


7/8

IA B

1_,-..

AJR:160, Ja nu ary 1 993 TRAUMA TO UPPER THORACIC SPINE 10 1

F ig . 7 . -De l ayed instability.A, Late ral rad iog raph of thoracic sp ineob -

t amed a t adm iss ion in a 22-year-old wom an In-volved In a car acc id en t sh ow s vertebra lbodyc om pres sio n frac tu re s in vo lvin g th re e m id th o-rac ic verteb rae. She was neu ro log ically In tacta t adm iss ion . The in jury was judged to bestable and was treated with a b race.

B , 8 weeks a fte r A, th e p at ie nt r etu rn ed withw eakness and neurologic deficits in low ercx -trem itles . L ateral ra dio grap h s ho ws in cre ase dwedging of bodies of T6 and T i and progres-dye kyphosis as com pared w ithA.

A

F ig . 8 .-K Um mells disease .A , L atera l rad io grap h o f th oraco iu mb ar ju nctio n o bta in ed o n d ay o f in ju ry sh ow s n orm al T i 1 verteb ra .B, L atera l rad io grap h o bta in ed 2 m on th s afte r In ju ry sh ow s collap se o f T i 1 verteb ra .C , Sag itta lly reconstruc ted CT scan, obtained at s am e tim e asB, shows Intraverteb ral and in tradiska l vacuum phenom ena, cha racte ris tic ally assoc i-

ated w ith K Um mells dis ea se .

Delayed Posttraum atic Vertebral Collapse (K#{252}m mellsDisease)

Delayed posttraumatic vertebral collapse, also known as

KOmmells disease, has been reported in the thomacic andthoracolumbar regions [52]. This is a poorly understood phe-nomenon, but it is generally accepted that m inor traumaw ithout overt fracture can lead to delayed collapse of theinvolved vertebra. Evidence favors avasculam necrosis as the

mechanism for the delayed collapse, as the majority ofreported patients were on long-term corticostemoid therapy[53]. Spinal angiogmaphy and pathologic findings also sup-

port avasculan necrosis as the mechanism underlyingdelayed vertebral collapse [52]. Radiographically, K#{252}mm ellsdisease presents as vertebral body collapse after m inortrauma and often is associated w ith intravertebral andintnadiskal vacuum phenomena (F ig. 8).

REFERENCES

1 . Louis R .S urgery of the spine.B erlin : S prin ge r-ve rla g, 1 98 3:2 6-3 42. W illiam s PL, W arw ick R , Dyson M , Bannister LH .G ra ys a na to my, 37th

e d. N ew York : C hu rc hill L iv in gs to ne , 1 98 9:3 19 -3 22 ,496-4973. B ohlm an H H. T reatm ent of fractures and disloca tions of the thoracic a

lum ba r spine. J Bone Jo int Su rg [Am]1985;67-A:165-1694. M aim an DJ, P inta r FA . Ana tomy and clinical b iom echanics o f the tho rac

spine. C li n N e ur os ur g 1 992 ;38:296 -324

5. W hite AA III, Panjabi MM .Clin ica l b iom echanics o f the sp ine .Phi ladel-

phia : Lippinco tt, 1978 :42-47, 191 -192

6. Andriacchi T , Schultz A , B elytschko T , G alante J. A m odel for s tudiesmechanical inte ractions betw een the human spine and rib cage.J B io -

mech i 974 ;7 :497-507

7. Benzian S R, M ainzer F , G ooding C A. Pedicula te th inning: a norm al vant a t the tho racolum bar junction.B r J R ad iol 197144:936-939

8. C hanlton O P, M artinez 5 , G ehw eiler JA Jr. Pedicle th inning at the thocolum ba r junction : a no rm al varian t.A JR 19 8 0; 1 3 4: 82 5 -8 2 6

9. Meyer PR . F ractures of the thoracic spine : T i to T iO . In : Meyer Ped . Surge ry o f spine trauma .N ew York: C hurchill Livingstone, 1989:525-571


8/8

10 2 EL-KHOURY AND WHITTEN A JR :1 60 , J an ua ry1993

10. R ogers LF , Thayer C , W einberg PE , K im KS . A cute injuries of the uppertho ra cic spin e a ssociate d w ith p ara ple gia .A JR 1 980 ;1 34:67-73

11 . Shara fuddin MJA, Hitchon PW , E l-Khoury GY , Dyste GN . Locked facets inthe thoracic sp ine : repo rt of three ca se s and a review .S pina l D iso rd

1990 ;3 :255-258

1 2. F le tch er G H. A nterior v erte bral w ed gin g: fre que nc y an d sig nifica nce .AJR1947 ;57 :232-238

13 . Laun id sen KN, De Carva lho A , Ande rsen AH. Degree o f verteb ral wedging

of the dorso-lum ba r sp ine.A cta R ad io l i984;25:29-32

14 . D affner RH , Deeb zL, Ro thfus WE. The poste rio r ve rtebra l body line :im portance in the detection of burst fractures.A JR 1 987;148:93-96

15 . Bake r BK , Sundaram M , Awwad EE. Case repo rt 688 .S kele tal R adio!

199120:463-464

16. Zanca P . Lodm ell EA . F racture of the spinous processes: a new sign forthe recognition of fractu res of ce rvical and uppe r dorsal sp inous p ro-

cesses. Radio!ogy 1 95 1 5 6:4 27 -4 2817 . K eene JS , Goletz TH , L ille as F, A lter A J, S ackett JF. D iagnosis o f verte-

b r a l f ra c tu r es . J Bone Joint S urg [Am ]i982;64-A:586-59518. B rant-Zaw adzki M , M iller EM , Federle M P. CT in the evaluation of spine

t rauma. A JR i981;136:369-375

19. Ghoshhajra K , R ao KCVG . CT in spina l trauma.C lin Im a gin g 1980;4:309-318

20. McA fee PC , Yuan HA,Fred rickson BE , Lubicky JP . The va lue of com -puted tom ography in tho racolumbar fractures.J Bone Joint Su rg [Am]

i983;65-A:461-473

21 . Meyer PR . vascu la r ana tom y of the sp ina l co rd: Ti to Tb. In: Meye r PR ,

ed . Surgery of sp ine trauma .New York: Churchill Livingstone , 1989:85-106

22 . Bondurant FJ, Co tle r HB, Kulkarni M v, M cA rdle CB , Harris JH Jr. A cu te

spinal co rd injury: a study using physica l exam ination and magnetic reso-

n an ce i ma gi ng .Spine 1990;15:16i-16823. Yamashita Y , Takahashi M , Matsuno Y , e t a l. A cute spinal cord in jury:

m agne tic resonance im aging correla ted with myelopa thy.B r J Radio!

199164:201-209

24 . Kulkarn i My, M cA rdle CB , Kopanicky D, e t al. A cu te spinal co rd in jury:

M R imaging at 1 .5 T .Radiology 1987:164:837-84325 . Kulkarn i M y, Bondurant FJ, Rose SL, Narayana PA . 1 .5 Tesla m agne tic

re sonance im ag ing o f acu te spinal traum a.RadioGraphics i988;8:

1059-1082

26. Hackney DB , Asato A , Joseph PM , etal. H em orrhage and edema in

a cu te sp in al c ord co mpress io n: d em onstra tio n by M R im aging .Radiologyi98 6;161 :387-390

27. K erslake RW, Jaspan T , Worth ington B S. M agnetic resonance im aging ofs pin al tr au m a. BrJ Radio! 199164:386-402

28. Schaefer DM , F landers A , Northrup BE , Doan HT , O sterholm JL. Mag-netic resonance imaging o f acute cervica l sp ine trauma : correla tion w ith

s ev er ity o f n eu ro lo gi ca l in ju ry .Spine 1989;14:1090-109529. S chaefer D M, F landers A E, O sterholm JL, N orthrup B E. P rognos tic signif-

icance of m agne tic re sonance im ag ing in the acu te phase of cervica l

s p in e i n ju ry . J Neu r o s u rg 1992 ;76 :2 i8 -223

30. Ho ldsworth F. Fracture s, d isloca tions, and fractu re-dis locations of the

spine. J Bon e Joint S urg [Am ]i970;52-A:1534-1 551

31. G ertzbein S D, O ftierskiC . C om ple te fra cture -d isloc ation o f the tho ra cic

spine without sp ina l co rd in jury: a ca se report.J Bone Join t S urg [Am ]

i9 79 ;6 1 -A :4 49 -4 51

32. S asson A , M ozes G . C om plete fracture-disloca tion of the thoracicw ith ou t n eu ro lo gic d eficit.Spine 1987;12:67-70

33. S impson AHRW , W illiam son DM , Golding SJ , Houghton GR. Thspine translocation withou t cord inju ry.J Bone Jo int S urg [B r)I 9 9 0 ;7 2 -

B:80-8334 . C aleno tf L, Chessa re JW , Rogers LF, Toe rge J, Rosen JS . Multip le l

spin al in juries : im portan ce of ea rly recog nition .A JR 1978;130:665-669

35. G upta A , E l M asn W 5. M ultilevel spina l in juries: incidence , distria nd n eu ro lo gica l p atte rn s.J B on e Join t S urg [B r] 1 989 ;7 1-B :6 92-69 5

36. G undry S R, B urney R E, M ackenzie JR , et a l. A ssessm ent of m ediaswidening associa ted with trauma tic rup tu re o f the ao rta .J Trauma

i983;23:293-2993 7. B ole sta M J, B oh lm an H H. M ediastina l w ide nin g a sso cia ted w ith fra

o f the upper tho racic spine.J Bone Join t Su rg [Am )1991 ; 73 -A :4 4 7 -4 5 0

38 . D ennis LN, Roge rs LF. S uperio r media stinal w iden ing from spine

tune s m im ickin g a ortic ru ptu re on ch est ra dio gra ph s.A JR 1 98 9; 1 5 2: 27 -3 0

39. D orr LD , Harvey JP Jr. N ickel VL. C linica l review of the early s tabs pi ne i nj ur ie s. Spine 1982;7:545-550

40. Dom misse GF . The blood supply of the spina l cord: a critica l vaszone i n s pi na l surgery. J Bone Joint S urg [Br]1974;56-B:225-235

41 . Gopalakrishnan KC, E l M asri W 5. Fracture s of the stem um associa te

w ith s pin al in ju ry.J Bone Jo int Su rg [B r]i986;68-B:178-181

42 . F ow ler AW. F le xion -co mp res sio n in jury o f the s tern um .J Bone Join t Su rg[Br) 1957;39-B:487-496

43. E ismont F J, A rena MJ, G reen BA . Extrusion of an intervertebra ldisca ssociated w ith traum atic sub luxation o r dislocation of ce rvical facc a se r ep o rt . J Bone Jo int Surg[Am]i991;73-A:1555-1560

44 . R izzo lo SJ, P iazza MR , Colter JM , Ba lde rston RA , S chaefer 0, Fland

A. In te r ve r teb ra l disc injury com plica ting cervica l spine traum a.Spinei 991 ; i6 :5187-S189

4 5. R ob ertso n PA, R yan M D. N eu rolog ic al de terio ration a fter re du ctio nvica l sub luxation: m echanical com pression by disc tissue.J Bone Jo int

S ur g [ Br ) i992;74-B:224-22746. P ratt ES , Green DA, Spengle r DM . Hern ia ted in terve rteb ra l discs a ss

a te d w ith u ns ta ble s pin al in ju rie s.Spine 1990:15:662-66547. T racy PT , W right R M, Hanigan W C. M agnetic resonance im aging

n a l i nj ur y. Spine 1989;14:292-301

48. F landers AE , S chaefer DM , Doan HT , M ishkin MM, GonzalezN orth ru p B E. A cute ce rvic al sp in e tra um a: correlation o f M R im agingings w ith deg ree of neurological de ficit.Radiology i990;177:25-33

49 . Denis F . The three co lum n sp ine and its significance in the classificatio

o f a cu te th ora co lu mb ar s pin al in ju rie s.Spine 1983;8:81 7-83150. D affner R H, D eeb ZL G oldberg AL, Kandabarow , R othfus W E. The

logic asse ssm en t of post-traum atic ve rtebra l s tability.S ke leta l R adio !

i990;19:103-10851 . Yoganandan N , Ma im an DJ, P inta r F , et a l. M icro traum a in the lum

spine : a cause of low back pain.Neurosurgety 1988;23:162-16852 . Brow er A C, Downey EF Jr. KO mm ell d isease: report of a case w ith

radiographs. Radiology 1981;14i :363-36453. M aldague BE , N oel HM , M alghem JJ. The intravertebra l vacuum c

sign o f isch em ic verteb ral collap se.Radiology 1978:129:23-29

Trauma Thoracic Spine Anatomy, Bio Mechanics Imaging

Documents

Transcript of Trauma Thoracic Spine Anatomy, Bio Mechanics Imaging