Thoracolumbar Spine Fractures

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1 Thoracolumbar Spine Fractures C. Craig Blackmore, MD, MPH Professor of Radiology Adjunct Professor of Health Services Harborview Injury Prevention and Research Center University of Washington Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases

2 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases Who Should Undergo Imaging? Limited evidence Validated clinical prediction rule 2404 subjects Sensitivity 100% Specificity 4% Limited effect on utilization Holmes, J Emerg Med 2003

3 Holmes Criteria Thoracolumbar spine pain Thoracolumbar midline spine tenderness Decreased level of consciousness Abnormal peripheral nerve examination Distracting injury Intoxication How to image? Limited evidence Radiography standard CT reconstructions from C/A/P MDCT Low cost No radiation Fast Reimbursement

4 CT Reconstructions Multiple level 3 studies Retrospective, potential biases Few small prospective studies CT sensitivity 78-97% Radiograph sensitivity 32-74% Evidence suggests CT is better Sagittal reformations Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases

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6 Anterior Longitudinal Ligament Posterior Longitudinal Ligament Ligamentum Flavum Capsular Ligaments Interspinous Ligament Supraspinous Ligament Anterior Middle Posterior

7 Failure of two columns is unstable

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9 Anterior 2/3 of vertebral body Anterior longitudinal ligament Posterior 1/3 of vertebral body Posterior longitudinal ligament Posterior bony elements Posterior ligaments

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15 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases Approach Evaluate columns Determine distraction Define stability

16 Fracture Types Flexion McAfee classification Rotation Extension Flexion/ Axial Load

17 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation

18 Anterior Compression Anterior column fails in flexion Loss of height anterior (<40%) Focal kyphosis (<10 ) Mechanically stable Non-operative management

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20 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation

21 Two-Column Burst Technically unstable Non-operative treatment Retropulsion (<50%) Anterior height loss (<50%) Neurologically intact

22 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation

23 Three Column Burst Compression of all three columns Neurological compromise common Level of injury and conus Operative treatment

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28 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation Flexion-Distraction Injuries Highly unstable Three column injuries Operative repair may differ from burst Assessment of distraction is critical

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36 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation

37 Chance Lap belt injury children Fulcrum is belt Pure distraction Associated injuries duodenum

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39 Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation Translation Translation 50% anterolisthesis Lateral subluxation Fracture/Dislocation Disruption of ligamentous stability

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42 Rotational Injuries Rare Subset of flexion Facet jump

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44 Extension Injuries Mechanism is rare Fused spine: less energy Ankylosing spondylitis DISH Surgery Translation common

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48 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases

49 Limbus Vertebrae

50 Spondylolysis

51 Post-traumatic avascular necros (Kuemmell s)

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53 Metastasis

54 Associated injuries Multiple spine fractures Calcaneus Bowel Duodenum Aorta

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56 Case Study 38-year-old woman was a restrained (lap-belted) driver in a rollover MVC C/o mild abdominal and back pain T11 flexion distraction fracture

57 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases

58 Thank You! Questions?