spine_injury_tx
thoracic spine trauma
introduction
initial Mx should be as per
trauma
as per trauma protocols, spinal precautions should be utilised until cleared of potentially unstable injuries and patients should be investigated to exclude blunt renal, liver or spleen trauma, as well as fractured ribs and potential for associated pneumothorax or haemothorax, aortic dissection, etc.
unstable fractures or thoracic disc herniation may cause spinal cord injury and paraplegia
in addition, between T4 and T9, the anterior part of the spinal cord is further at risk as the blood supply is dependent upon the anterior spinal artery which may be compromised in trauma or herniation of disc
at Western Health, spinal injuries are managed by neurosurgery (either WH or RMH neurosurg reg), NOT by orthopaedics
anatomic considerations
a rib is attached to each thoracic vertebral body and is named the same number as the body, as is the digital nerve that exits under that rib
T1-4 share some features with the cervical vertebrae
T5-8 are then typical thoracic vertebrae
T9-12 share some features with the lumbar vertebrae although there is a distinct transition at T12 which makes T12 the most at risk for injury in trauma due to the transitional stresses
in a sagittal plane, the thoracic spine is said to consist of 3 columns:
anterior column:
middle column:
posterior aspect of the vertebral bodies
the posterior annulus fibrosis
the posterior longitudinal ligament
posterior column:
flexion injuries
compression fractures
height of the vertebral body is maintained posteriorly but compression of the anterior aspect results in wedge appearance
the most common fracture type, particularly in the elderly or those with
osteoporosis
surgical Mx may be indicated if:
otherwise these are generally stable and rarely cause neurologic problems
axial burst fractures
loss of height of both posterior and anterior aspects of the vertebral body
often caused by a fall from a height and landing on the feet
it is important to assess:
unstable injuries generally require surgery:
significant comminution
severe loss of vertebral body height
canal compromise > 40%
excessive forward bending or angulation at the injury site
significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord
other cases may be treated as for compression wedge fractures
Chance fracture
distraction fracture with the vertebral body pulled apart as in a high speed car accident with pelvis immobilised by a lap seat belt (risk is now much lower with seat belts with a shoulder component), it is now perhaps more common with falls than from car accidents
it is caused by violent forward flexion, causing distraction injury to the posterior elements
mainly occur at T12-L2 (and mid-lumbar region in children)
consists of a compression injury to the anterior portion of the vertebral body and a transverse fracture through the posterior elements of the vertebra and the posterior portion of the vertebral body
~50% of patients with Chance fractures have associated intraabdominal injuries - particularly to pancreas, duodenum, and mesentery
on the lateral films, look for a horizontal fracture through the spinous process, laminae, pedicles and vertebral body
same mechanism of injury may not produce a fracture in children but may still be associated with intestinal and urinary bladder injuries
surgery may be indicated if:
other cases may be managed with a thoracolumbar brace for 12 weeks
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horizontal fissure fracture
Smith fracture
fracture line involves the superior articular processes, the arch, and a small posterior fragment of the sup/post. aspect of the vertebral body
spinous process is intact however, the posterior ligaments are disrupted
fracture dislocation injury
generally caused by rotational injury such as high speed car accidents
all 3 columns of the spine are disrupted
frequently cause serious spinal cord compression and thus require spinal precautions and assessment and Mx of spinal cord injury, and surgical stabilisation
thoracic disc herniation
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most commonly involved T11 and T12
higher levels can be involved if either:
herniation at T4-T9 runs risk of compromise to anterior spinal cord blood supply by pressure on the anterior spinal artery
spine_injury_tx.txt · Last modified: 2019/01/08 10:07 (external edit)