Thoracolumbar Spine Fractures. Outline. Outline. Holmes Criteria. Disclosure:

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1 Thoracolumbar Spine Fractures C. Craig Blackmore, MD, MPH Department of Radiology Virginia Mason Medical Center Affiliate Professor, University of Washington Disclosure: Book Royalties, Springer-Verlag Evidence Based Imaging: Optimizing Imaging for Patient Care Evidence Based Imaging in Pediatrics: Optimizing Imaging for Patient Care 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 Criteria Thoracolumbar spine pain Thoracolumbar midline spine tenderness Decreased level of consciousness Abnormal peripheral nerve examination Distracting injury Intoxication Holmes, J Emerg Med 2003

2 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

3 Anterior 2/3 of vertebral body Anterior longitudinal ligament Posterior 1/3 of vertebral body Posterior longitudinal ligament Posterior bony elements Posterior ligaments

4 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases

5 Approach Evaluate columns Determine distraction Define stability Fracture Types Flexion McAfee classification Rotation Extension Flexion Injuries A1.1 Endplate impaction AO Classification B1.1 Flexion distraction (ligamentous) with transverse disk disruption A1.2 Wedge impaction B1.2 Flexion distraction (ligamentous) with type vertebral body fracture A1.3 Vertebral body collapse A2.1 Sagittal split fracture A2.2 Coronal split fracture B2.1 Flexion distraction (osseous) with transverse bicolumn fracture B2.1 Flexion distraction (osseous) with transverse disc disruption B2.1 Flexion distraction (osseous) with type A vertebral body fracture A2.3 Pincer fracture B3.1 Anterior disc hyperextension shear with hyperextension subluxation A3.1Incomplete burst fracture A3.2 Burst-split fracture A3.3 Complete burst fracture B3.2 Anterior disc hyperextension shear with hyperextension spondylolysis B3.3 Anterior disc hyperextension shear with posterior dislocation C1.1 Rotation with A1 (wedge) C1.2 Rotation with A2 (split) C1.3 Rotation with A3 (burst) C2.1 Rotation with B1 C2.2 Rotation with B2 C2.3 Rotation with B3 (shear) C3.1 Rotation with shear slice fracture C3.2 Rotation with shear oblique fracture Flexion Injuries Anterior Compression Anterior column fails in flexion Loss of height anterior (<40%) Focal kyphosis (<10 ) Mechanically stable Non-operative management

6 Flexion Injuries Two-Column Burst Technically unstable Non-operative treatment Retropulsion (<50%) Anterior height loss (<50%) Neurologically intact

7 Flexion Injuries Three Column Burst Compression of all three columns Neurological compromise common Level of injury and conus Operative treatment

8 Flexion Injuries Flexion-Distraction Injuries Highly unstable Three column injuries Operative repair may differ from burst Assessment of distraction is critical

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10 Flexion Injuries

11 Lap belt injury children Fulcrum is belt Pure distraction Associated injuries duodenum Chance Flexion Injuries Flexion Injuries

12 Translation 50% anterolisthesis Lateral subluxation Rotation (45 degrees) Fracture/Dislocation Disruption of ligamentous stability Rare Subset of flexion Facet jump Rotational Injuries Extension Injuries Mechanism is rare Fused spine: less energy Ankylosing spondylitis DISH Surgery common

13 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases AS Discussion of AS Extensive, low energy Locations, multiple lesions Complications hemoerhage (get cspine case) AS v fusion Biomechanics of weakness Sagittal Lamina Split Dural tear (8%) Neurological involvement in split

14 Thoracic Fracture Dislocation Burst Fracture Posterior sternal dislocation Calcaneal compression fracture Flexion Distraction Flexion Distraction Duodenal injury Duodenal injury Aortic injury Pathological Fracture Post-traumatic Avascular Necrosis (Kümmell s)

15 Outline Who and how? Evidence Based Imaging Anatomy Patterns of injury Biomechanics Special cases