Upper thoracic spinal fractures in trauma patients Ð a diagnostic pitfall

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1 Injury, Int. J. Care Injured 31 (2000) 219±223 Upper thoracic spinal fractures in trauma patients Ð a diagnostic pitfall Edwin J.R. van Beek a, d, *, Henk D. Been b, Kees-Jan Ponsen c, Mario Maas a a Department of Radiology, Academic Medical Center, Amsterdam, Netherlands b Department of Orthopedic Surgery, Academic Medical Center, Amsterdam, Netherlands c Department of Surgery, Academic Medical Center, Amsterdam, Netherlands d Section of Academic Radiology, Royal Hallamshire Hospital, Floor C, Glossop Road, She eld S10 2JF, UK Accepted 6 August 1999 Abstract The diagnosis of upper thoracic spinal fractures in multiple-trauma patients remains a challenge. The clinical ndings are often di cult to detect, especially in the presence of other (extremity) fractures, head injuries or in patients on respiratory support. The ndings of chest radiographs and plain spinal lms are described in a series of 23 patients with an upper thoracic spinal fracture. Radiographs were retrospectively reviewed by an orthopaedic surgeon and a skeletal radiologist. Fractures were classi ed according to Magerl and type A1 and A2 compression fractures were excluded. The neurological outcome was assessed using the Frankel scale. Initially, the fracture was missed in 5 patients (22%), mainly due to concomitant life-threatening injuries. Fractures consisted of type A, B and C in one, 10 and 12 patients, respectively. The main ndings were: loss of vertical height of vertebra with or without malalignment (21), widened paraspinal line (21), widened mediastinum (4) and no gross abnormalities (2). Neurological lesions were Frankel A, B, C and E in respectively 14, 1, 1 and 7 patients. Upper thoracic spinal fractures are easily missed in patients with multiple injuries. In patients with neurological symptoms CT and/or MRI is required as soon as the general condition of the patient permits this Elsevier Science Ltd. All rights reserved. Keywords: Thoracic spine; Fractures; Diagnosis; Trauma; Neurology; Respiratory support 1. Introduction The diagnosis of (upper) thoracic spinal fractures in patients with multiple, often severe, injuries can be dif- cult. These patients often su er from coexisting neurological symptoms or head injuries, have multiple (limb) fractures and are often sedated or on respiratory support when rst seen in a casualty department. Hence, a neurological evaluation is often unreliable, if possible at all. Furthermore, the requirement of a quick diagnostic work-up and the di cult circumstances surrounding these patients lead to radiographs * Corresponding author. Fax: address: e.vanbeek@she eld.ac.uk (Edwin J.R. van Beek). which are often di cult to interpret, especially by junior sta. The upper thoracic spine is di cult to visualize, even in ideal circumstances. Thus, the combination of clinical and imaging di culties render upper thoracic spinal fractures liable to being overlooked. Additional diagnostic tests, such as computed tomography or magnetic resonance imaging may not be possible due to pressing interventions for life-threatening complications [1]. Hence, these fractures are frequently not detected until later, which may lead to worsening of the neurological de cit [2]. Although a recent article in this journal drew attention to fractures of the thoracolumbar spine [3], only sparse literature exists with respect to upper thoracic spinal injuries. The main ndings which have been described are: dislocation of the spine, loss of height of a vertebra, widening of the para-spinal line, widening /00/$ - see front matter Elsevier Science Ltd. All rights reserved. PII: S (99)

2 220 of the mediastinum, left apical cap and displacement of the naso-gastric tube [4]. Especially these last three ndings may be confused with a traumatic aortic rupture [4±6]. To complicate matters further, the type of injury associated with upper thoracic spinal fractures is also associated with aortic rupture. In this study, we assessed the imaging ndings and the outcome of a consecutive series of patients with upper thoracic spinal fractures, which were more serious than simple (Magerl A1 or A2) compression type injuries. 2. Materials and methods Between January 1983 and December 1998, a series of 26 patients with high thoracic spinal lesions, excluding compression fractures (Magerl types A1 and A2), were identi ed. Follow-up data were available for 23 (88%) of these patients. Of these patients, 10 were initially seen and investigated in another hospital and subsequently transferred, while the remaining patients were all directly managed in our own trauma unit. The case records were evaluated to assess the a etiology of the fracture, initial presence of neurological signs and coexisting injuries. Furthermore, therapeutic management and outcome of the patients was evaluated. Neurological examinations were routinely performed and recorded at regular intervals pre- and postoperatively and graded using the Frankel scale [2]. The initial radiographs, as obtained in the casualty department, were reviewed by a panel consisting of an orthopaedic surgeon with a main interest in spinal surgery and a musculo-skeletal radiologist. Fractures were categorized according to the Magerl classi cation system [7]. Initially, all patients were evaluated using only antero-posterior and lateral thoracic spinal radiographs and chest radiographs. Computed tomography was read at a later stage when available, in order to further classify the injury. Magnetic resonance imaging was not routinely performed in all patients, but MR images were available in a number of these. The MR images were read at a later date and were not part of the initial assessment of this study. The following features were assessed on the chest radiograph: fracture and/or malalignment of thoracic vertebrae, widening of para-spinal line, widening of mediastinum, presence of apical cap, displacement of naso-gastric tube. The thoracic spinal lms were scored for the presence of a fracture, type of injury and widening of a para-spinal line. 3. Results The patients studied consisted of 21 male and 2 Table 1 Radiographic ndings in 23 patients with subsequently proven upper thoracic spinal fractures Radiographic ndings Number of patients (%) Magerl classi cation: A3 1 (4%) B 10 (43%) C 12 (53%) No abnormalities 2 (9%) Loss of vertebral height/malalignment 21 (91%) Widening of para-spinal line 21 (91%) Widening of the mediastinum 4 (18%) Presence of an apical cap 1 (5%) Displacement of naso-gastric tube 1 (5%) female patients, varying in age between 16 and 52 yrs (mean 30.3 yr). The causes of their fractures were a tra c related accident (16 patients), a fall from a great height (4 patients) or miscellaneous (3 patients). At initial examination, 14 patients had a complete neurological lesion (Frankel A), two had incomplete neurological lesions (Frankel B and Frankel C), while 7 patients had no neurological symptoms (Frankel E). The fractures according to Magerl consisted of type A3, B and C injuries in one, 10 and 12 patients, respectively. The main indicators of these fractures are summarized in Table 1. No radiological abnormalities could be detected in 2 patients. Only four patients presented with isolated thoracic spinal trauma. In the remaining patients, coexisting trauma consisted of severe thoracic trauma in 9 patients, severe head injuries in 11 patients and multiple limb fractures in 9 patients. There was no patient with concomitant abdominal trauma. In 5 patients (22%), the diagnosis was initially missed (Figs. 1 and 2). The delay in diagnosis varied between 1 and 6 d. The characteristics and the outcome of these patients are summarized in Table Discussion The initial diagnosis of upper thoracic spinal fractures remains based on plain lms and clinical awareness. In patients who have undergone signi cant injuring forces, which result in exion and twisting of the thoracic spine, the diagnosis should be actively sought. This should consist of a careful inspection and palpation of the back, where gaps between spinous processes may be felt within soft tissue swelling. In spite of this, great di culty may be encountered in obtaining the correct diagnosis in patients in whom a neurological assessment can not be made, i.e. those with reduced consciousness, patients on respiratory support or those with (often multiple) pelvis and limb

3 221 Fig. 1. (a) A 28 yr old man fell from a great height. AP chest lm shows dislocation of the spine at the level Th4-Th5. Furthermore, there is a widening of the mediastinum, widening of the paraspinal line and an apical pleural cap. (b) The axial CT scan shows the complete dislocation Th4-Th5.

4 222 fractures. Previous studies have shown that spinal fractures were missed in 5% to 15% of patients with multiple injuries [8±10]. Stanislas et al reported that nearly 50% of patients with thoracic spine injury and a Glasgow Coma Scale of 10 or less were initially missed [3]. Although this study was aimed at the thoracolumbar spine, our series shows similar ndings with 22% missed fractures (4 patients could not be assessed neurologically, while one patient was mentally incapacitated to describe the signs and symptoms). The importance of an early diagnosis of thoracic spinal injuries was demonstrated by Reid et al., who showed a ten-fold increase in the incidence of neurological de cit in patients in whom the diagnosis was Fig. 2. (a) A 34 yr old man had a severe motor car accident. The AP chest lm shows subtle apical cap and a double contour at the descending aorta representing widened paraspinal line. (b) The AP lm of the thoracic spine shows the displacement at the level Th4-Th5. (c) The coronal and saggital (d) reformation of the CT scan suggest the existence of a congenital deformity between Th4 and Th 5 (block vertebra and laminar stenosis). (e) MRI, however, shows type C lesion with disruption of posterior ligaments and lesion of the spinal cord.

5 223 Table 2 Characteristics and outcome of 5 patients in whom upper thoracic spinal fractures were initially missed Patient Concomitant injuries Magerl type Level Frankel initial 1 yr 1 head; immediate surgery C Th7 C E 2 cognitively impaired B Th4 B D 3 head; multiple fractures; respiratory support B Th4 A A 4 head; chest; respiratory support C Th6 A A 5 chest; respiratory support C Th7 E E initially missed [11]. In our series, the neurological outcome was not negatively a ected by the fact that the fracture was recognized 1 to 6 d later in 4 patients, while some neurological de cit may have been caused by late diagnosis in one patient who was cognitively impaired (he developed incontinence for urine after discharge from a casualty department elsewhere; this did not recover following surgery). The body of literature on upper thoracic spinal injuries is small when compared with cervical and thoracolumbar spinal fractures. This is partly related to the fact that thoracic fractures are less common. Nevertheless, they nearly always present with accompanying major injuries. In our series, 83% of patients had concomitant head or chest trauma or pelvis and lower limb fractures. This also indicates the di culties that present the trauma team: life-threatening complications need to be tackled and the diagnostic techniques may be compromised as a result of this, as was also demonstrated by Chan et al. [8]. An added problem is the fact that the upper thoracic spine is di cult to show clearly, even in ideal circumstances. In patients who are in a casualty department, the upper thoracic spine is even more di cult to image, due to projection of the shoulders and upper three ribs. Furthermore, the mediastinum is denser in radiographs which are obtained with a patient supine, while coexisting chest trauma may cause such abnormalities as lung contusion, rib fractures with focal haematoma and pulmonary oedema, which all reduce the ability to assess the spine. Nevertheless, useful signs on the radiographs include widening of the paraspinal line, displacement or tilting of vertebrae or spinous processes, loss of height of vertebral bodies, alteration in shape or alignment of articular facets, widening of the mediastinum, left apical cap and displacement of the naso-gastric tube [4±6]. In our patients, two patients did not show any abnormalities, even in retrospect. In one of these patients, even CT (including multiplanar reformating) was unable to detect the injury. In both patients, MR imaging was required to assess the full extent and complexity of the sustained injury. In both patients, a complex rotation injury had been sustained (Magerl C). One should be aware that this type of injury is so unstable, that semi-spontaneous reduction of the fracture may be achieved, simply by positioning the patient on the table. In conclusion, upper thoracic spinal fractures are easily missed due to a variety of reasons. The radiological signs may be minimal during the rst assessment. Most importantly, patients in whom a full neurological examination is not feasible at the time of injury should be regarded as having an upper thoracic spinal fracture even in the absence of clear plain lm features. This fact has implications for the nursing care of such patients in the intensive care unit. One has to be aware that CT may also miss complex rotation fractures and MRI is warranted in these cases. References [1] Anderson S, Biros MH, Reardon RF. Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients. Academic Emergency Medicine 1996;3:832±9. [2] Gertzbein SD. Neurologic deterioration in patients with thoracic and lumbar fractures after admission to the hospital. Spine 1994;19:1723±5. [3] Stanislas MJC, Latham JM, Porter KM, Alpar EK, Stirling AJ. A high risk group for thoracolumbar fractures. Injury 1998;29:15±8. [4] Dennis LN, Rogers LF. Superior mediastinal widening from spine fractures mimicking aortic rupture on chest radiographs. American Journal of Roentgenology 1989;152:27±30. [5] Bolesta MJ, Bohlman HH. Mediastinal widening associated with fractures of the upper thoracic spine. Journal of Bone and Joint Surgery 1991;73A:447±50. [6] Earls JP, Kenney JP, Patel NH. A mediastinal hematoma after a fall. Americam Journal of Roentgenology 1997;169:659. [7] Magerl F, Aebi M, Gertzbein SB, Harms J, Nazarian S. A comprehensive classi cation of thoracic and lumbar injuries. European Spine Journal 1994;3:184±202. [8] Chan RNW, Ainscow D, Sikorski JM. Diagnostic failures in the multiple injured. Journal of Trauma 1980;20:684±7. [9] Enderson BL, Reath DB, Meadows J, et al. The tertiary trauma survey: a prospective study of missed injury. Journal of Trauma 1990;30:666±9. [10] Laasonen EM, Kivioja A. Delayed diagnosis of extremity injuries in patients with multiple injuries. Journal of Trauma 1991;31:257±60. [11] Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. Journal of Trauma 1987;27:980±6.

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