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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Related Studies

Ontology: Fracture of lumbar spine (C0262544)

Definition (NCI) A fracture of one of the lumbar vertebra.
Concepts Injury or Poisoning (T037)
ICD10 S32.0
SnomedCT 207987002, 125608002
Italian Frattura di vertebra lombare
Japanese 腰椎骨折, ﾖｳﾂｲｺｯｾﾂ
Czech Zlomenina bederního obratle
Korean 허리뼈의 골절
English Fracture of lumbar spine NOS, fractures lumbar vertebra, fracture lumbar spine, fracture of lumbar spine, Fracture;lumbar, fractures lumbar spine, fracture lumbar, lumbar fracture, lumbar vertebra fracture, fracture lumbar vertebra, fractures lumbar, Lumbar vertebral fracture, fracture of lumbar spine (diagnosis), Fracture of lumbar spine, Fracture of lumbar vertebra, Fracture of lumbar spine (disorder), fracture; lumbar spine, fracture; spine or vertebra, lumbar, lumbar; spine, fracture, spine or vertebra; fracture, lumbar, Lumbar Vertebral Fracture
Hungarian Lumbalis csigolyatörés
Spanish fractura de las vértebras lumbares, fractura de la columna vertebral lumbar (trastorno), fractura de la columna vertebral lumbar, Fractura de la vértebra lumbar
Dutch fractuur; lumbale wervelkolom, fractuur; wervel{kolom}, lumbaal, lumbaal; wervelkolom, fractuur, wervel{kolom}; fractuur, lumbaal, Fractuur van lumbale wervel, lendenwervelbreuk
Portuguese Fractura da vertebra lombar
French Fracture de vertèbre lombaire
German Fraktur eines Lendenwirbels
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Fracture of thoracic spine (C0347780)

Concepts Injury or Poisoning (T037)
ICD10 S22.0 , S22
SnomedCT 208214005, 125607007
German Fraktur eines Brustwirbels
English Fracture of thoracic spine, fracture of thoracic vertebra, thoracic spine fracture, fracture thoracic spine, fracture of thoracic spine, fracture of thoracic spine (diagnosis), Fracture of thoracic vertebra, Fracture of thoracic spine (disorder), fracture; vertebra, thoracic
Korean 등뼈의 골절
Dutch fractuur; wervel, thoracaal, Fractuur van thoracale wervel
Spanish fractura de la columna vertebral dorsal (trastorno), fractura de la columna vertebral dorsal, fractura de la columna vertebral torácica
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Injury of thoracic spine (C0432667)

Concepts Injury or Poisoning (T037)
SnomedCT 262523007
English injuries spine thoracic, injury of thoracic spine, thoracic spine injury, injury spine thoracic, Injury of thoracic spine, Injury of thoracic spine (disorder)
Spanish lesión de columna vertebral dorsal (trastorno), lesión de columna vertebral dorsal
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Injury of lumbar spine (C0432668)

Concepts Injury or Poisoning (T037)
SnomedCT 262524001
Italian Traumatismo del midollo spinale lombare
Japanese 腰椎部脊髄損傷, ﾖｳﾂｲﾌﾞｾｷｽﾞｲｿﾝｼｮｳ
English injury of lumbar spinal cord, injury of lumbar spinal cord (diagnosis), Spinal cord injury lumbar, injuries lumbar spine, injury lumbar spine, injury of lumbar spine, cord injuries lumbar spinal, lumbar spine injury, Injury of lumbar spine, Injury of lumbar spine (disorder), injury; spinal cord, lumbar
Czech Poranění bederní míchy
Hungarian Lumbalis gerincvelősérülés
Dutch letsel; ruggenmerg, lumbaal, ruggenmergletsel lumbaal
Spanish lesión de columna vertebral lumbar (trastorno), lesión de columna vertebral lumbar, Lesión traumática de la médula espinal lumbar
Portuguese Lesão traumática da medula lombar
French Lésion de la moelle lombaire
German Rueckenmarksverletzung lumbal
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Lumbar Spine Disorders

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