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
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
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
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
Anterior Longitudinal Ligament Posterior Longitudinal Ligament Ligamentum Flavum Capsular Ligaments Interspinous Ligament Supraspinous Ligament Anterior Middle Posterior
Failure of two columns is unstable
Anterior 2/3 of vertebral body Anterior longitudinal ligament Posterior 1/3 of vertebral body Posterior longitudinal ligament Posterior bony elements Posterior ligaments
Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases Approach Evaluate columns Determine distraction Define stability
Fracture Types Flexion McAfee classification Rotation Extension Flexion/ Axial Load
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
Anterior Compression Anterior column fails in flexion Loss of height anterior (<40%) Focal kyphosis (<10 ) Mechanically stable Non-operative management
Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation
Two-Column Burst Technically unstable Non-operative treatment Retropulsion (<50%) Anterior height loss (<50%) Neurologically intact
Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation
Three Column Burst Compression of all three columns Neurological compromise common Level of injury and conus Operative treatment
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
Flexion Injuries Anterior Compression 2 Column Burst 3 Column Burst Flexion Distraction Chance Translation
Chance Lap belt injury children Fulcrum is belt Pure distraction Associated injuries duodenum
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
Rotational Injuries Rare Subset of flexion Facet jump
Extension Injuries Mechanism is rare Fused spine: less energy Ankylosing spondylitis DISH Surgery Translation common
Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases
Limbus Vertebrae
Spondylolysis
Post-traumatic avascular necros (Kuemmell s)
Metastasis
Associated injuries Multiple spine fractures Calcaneus Bowel Duodenum Aorta
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
Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases
Thank You! Questions?