Thoracolumbar Trauma

Aka: Thoracolumbar Trauma, Thoracolumbar Injury, Thoracolumbar Fracture, Lumbar Spine Trauma, Lumbar Spine Injury, Lumbar Vertebral Fracture, Thoracic Vertebral Fracture, Thoracic Spine Trauma, Thoracic Spine Injury

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II. Epidemiology

  1. Males are 4 fold higher risk than females for Thoracolumbar Injury

III. Precautions

  1. Thoracolumbar Trauma is associated with other organ system injury in 50% of cases
    1. Thoracic level Paraplegia confers a 7% mortality risk
  2. Physical Exam is inadequate alone to exclude significant thoracolumbar spine injury
    1. Inaba (2011) J Trauma 70(1): 174-9 [PubMed]

IV. Pathophysiology

  1. Thoracolumbar junction (T10 to L2) is the most common region for Spinal Injury
    1. Represents transition from the long, stiff thoracic kyphosis to the mobile, lumbar lordosis

V. Causes

  1. Motor Vehicle Accidents
  2. Falls
  3. Sports Injury

VI. Exam

  1. Vertebral tenderness
  2. Midline spine deformity
  3. Neurologic Exam correlated to spinal levels and Dermatomes
    1. Motor Exam
    2. Sensory Exam
    3. Reflex Exam

VII. Associated Conditions: Stable Vertebral Fracture

  1. Wedge Compression Fracture
    1. Forward flexion injury
    2. Isolated anterior column failure
    3. Neurologic deficits are rare
    4. Non-operative management with bracing (e.g. Jewitt extension brace)
  2. Stable Burst Fracture
    1. Anterior and Middle column failure
    2. Evaluate for retropulsion of Fracture fragment into neural canal
  3. Isolated spinous process Fractures (without ligamentous instability)
    1. May treat conservatively outpatient

VIII. Associated Conditions: Unstable Vertebral Fracture

  1. Unstable Burst Fracture
    1. Anterior and Middle column failure (compression) AND
    2. Posterior Column failure due to compression, lateral flexion or rotation
  2. Chance Fracture
    1. See Chance Fracture
    2. High velocity Traumatic Injury (e.g. MVA with Lap belt only)
    3. Causes flexion and distraction of the thoracolumbar spine
    4. Unstable, transverse Fracture through the anterior, middle and posterior Vertebral body
  3. Flexion Distraction Injury
    1. Anterior column failure (compression) AND
    2. Middle and Posterior Column failure (tension)
  4. Translation Injury
    1. Anterior, middle and Posterior Column failure (shear)
    2. Neural canal malalignment (horizontal plane)

IX. Associated Conditions: General

  1. Vertebral dislocation
  2. Vertebral instability
  3. Paraplegia
  4. Quadriplegia
  5. Nerve root injury

X. Imaging

  1. Indications
    1. Not alert
    2. Not able to be evaluated
    3. Positive physical exam findings
    4. High risk mechanism
    5. Age > 65 years old
    6. Inaba (2015) J Trauma Acute Care Surg 78(3): 459-65 [PubMed]
  2. Modalities
    1. Plain film xray is inadequate to exclude serious injury (misses 25% of burst Fractures)
      1. Ballock (1992) J Bone Joint Surg Br 74(1): 147-50 [PubMed]
    2. CT Imaging
      1. Modern multidetector CT has excellent Test Sensitivity for Fractures and unstable spine injuries
        1. Multidetector CT rarely misses an unstable spine injury (Ligamentous Injury) that is identified on MRI
      2. CT imaging of the thoracolumbar spine is preferred in acute Trauma
        1. Have a low threshold for CT in older patients, even in low mechanism (esp. Dementia, Delirium)
      3. CT reconstruction allows for high efficacy imaging without the addition of extra radiation
        1. CT Thoracic Spine can be reconstructed from CT chest
        2. CT Lumbar Spine can be reconstructed from CT Abdomen and Pelvis
    3. MRI
      1. Consider spine MRI (especially in children and adolescents)
      2. Emergent Spine MRI is indicated in suspected cord syndrome, Cauda Equina Syndrome or Spinal Infection

XI. Management

  1. See Trauma Primary Survey
  2. See Trauma Secondary Survey
  3. See Spinal Cord Syndrome
  4. Manage Lumbar SpineFractures and stability
    1. Consult neurosurgery or Spine Surgery
    2. Thoracolumbar Injury Classification Scale (TLIC)

XII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Jhun, Riddell and Inaba in Herbert (2016) EM:Rap 16(12): 13-4
  3. Muralidhar (2014) J Clin Diagn Res 8(2): 121-3 [PubMed]

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