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