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Title: Spine Trauma Authors: Looby S and Flanders A Journal: Radiol Clin N Am 49 (2011) 129-163 Key Points Initial management of the spine trauma patient includes resuscitation and stabilization of the c-spine and baseline neurologic evaluation. Imaging, especially CT and MRI, play a vital role to determine the level and extent of injury and to guide treatment moving forward. Medical management has the primary goal of preventing further medical complication while surgical treatment focuses on stabilizing unstable injury pattern. Clinical Conclusions Baseline neurologic evaluation and aggressive use of imaging modalities to identify potentially unstable spine injury are key to the successful outcome of these often devastating injuries. Section Highlights Overview of Spine Trauma 55% of spinal injuries involve the cervical spine (highest risk of cord injury here), 15% the thoracic spine, 15% the lumbar spine, and 1 15% the lumbosacral spine. Cervical spine fractures most typically occur at the upper and lower ends while the majority of thoracolumbar fractures occur between T12 and L2. Clearing the Spine and Indications for Imaging The National Emergency X-Radiography Use Study (NEXUS) and the Canadian Cervical Spine Group have both created guidelines for the necessity of plain radiographs in trauma patients. Multidetector CT (MDCT) and MRI have replaced radiography as the primary screening modality in most major trauma centers. Stability versus Instability The 3-column theory of Denis which suggests that when one column of the spine is disrupted, the injury is stable but when two are 2 disrupted it is unstable. The radiologic features of instability include displacement/translation of > 2mm indicating ligamentous disruption, widening of the interspinous space, the facet joints, and/or the interpediculate distance, disruption of the posterior vertebral body lien, widening of 3 the intervertebral canal, vertebral body height loss of > 50%, and kyphosis > 20 degrees. Upper cervical spine injuries The most common upper cervical spine injuries include occipital condyle fractures (Figure 1), atlanto-occipital dislocation (Figure 2), acute antantoaxial dislocation (AAD), the classic Jefferson fracture (Figure 3-4), the Hangman’s fracture (Figures 5-6), and fractures of the dens. (Figure 7-9) Lower cervical spine injuries Hyperflexion injuries include the clay shoveler fracture (Figure 10), anterior subluxation (Figure 11-12), a simple wedge compression fracture, bilateral facet dislocation (Figure 13-14), and the flexion teardrop fracture. (Figure 15) Flexion rotation injuries can result in the dislocation of one facet which displaces in front of the superior articular process of the subjacent vertebra and tears the posterior ligaments. Figure 16 Extension injuries such as the extension teardrop fracture are more common in elderly patients and those with ankylosing 4 spondylitis or stenosis. Figs 17-19 Extension rotation injuries such as an articular pillar fracture are generally stable fractures. Figure 20 Burst fractures of the cervical spine can lead to retropulsion of bony fragments into the spinal canal with neurologic compromise. Figure 21 Thoracolumbar Spine Injuries Injuries here include anterior wedge compression fracture (Figs 22-23), lateral compression fracture (Figure 24), burst fracture (Figs 25-27), Chance fracture (Figs 28-29), fracture dislocation (Figure 30), and transverse process fractures. (Figure 31). Sacral Fractures 95% of these fractures are vertical or oblique and 5% are horizontal; 95% occur in association with other pelvic fractures. Fractures confined to the sacrum only are stable while those involving both the sacrum and another part of the pelvis are unstable. Figure 32 MR Imaging of Spinal Trauma MR imaging has replaced myelography and CT myelography for the evaluation of epidural hematoma, ligamentous injury, traumatic disc herniation, and spinal cord compression. Figure 33-38 MR Imaging Findings in Spinal Cord Injury MR imaging is the best imaging modality for the evaluation of spinal cord injury including spinal cord hemorrhage and spinal cord edema. Figure 39 Initial Assessment of Spinal Cord Trauma Initial management of a spinal cord injury patient includes spine stabilization, trauma resuscitation, and baseline neurologic evaluation. The most frequently used scale for classifying spinal cord injury is the American Spinal Injury Association (ASIA) impairment scale (AIS). The neurologic level of injury (NLI) is another clinical parameter used to determine diagnosis and prognosis. Medical Management of Spinal Cord Injury Including Medical Complications The primary goal of medical management at this point is prevention of complications such as infection, pain, depression, deep vein thrombosis, and renal failure. Surgical Treatment of Spinal Cord Injury The goals of surgical management of spinal cord injury should be to use the least invasive method to stabilize the injured segment and prevent long-term complications. Key References 1. Sekhon L.H. and Fehlings M.G., Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976), 2001. 26(24 Suppl): p. S2-12. 2. Denis F., The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976), 1983. 8(8): p. 817-31. 3. Bohlman H.H., Treatment of fractures and dislocations of the thoracic and lumbar spine. J Bone Joint Surg Am, 1985. 67(1): p. 165-9. 4. Murray G.C. and Persellin R.H., Cervical fracture complicating ankylosing spondylitis: a report of eight cases and review of the literature. Am J Med, 1981. 70(5): p. 1033-41.
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