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Thoraco-Lumbar Radiography. Moritz Haager March 4, 2004. Anatomy. Thoracic Spine. Lumbar Spine. Determinants of Stability. T & L spines are more stable than C-spine Strong ligaments Stabilization by ribs Bigger intervertebral discs Larger facet joints Less mobility

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thoraco lumbar radiography

Thoraco-LumbarRadiography

Moritz Haager

March 4, 2004

determinants of stability
Determinants of Stability
  • T & L spines are more stable than C-spine
    • Strong ligaments
    • Stabilization by ribs
    • Bigger intervertebral discs
    • Larger facet joints
    • Less mobility
  • Fractures & dislocations tend to occur where curvature changes
    • T11-12 (thoracolumbar junction)
    • L5-S1 (lumbosacral junction)
mechanisms of injury
Mechanisms of Injury
  • Hyperflexion +/- rotation
    • Commonest
    • Usually see anterior wedge #’s or Chance #
  • Shearing
    • Ant or post translation
  • Hyperextension
  • Axial loading
    • Compression or burst #’s
3 column model
3 Column Model
  • Anterior column
    • Ant longitudinal lig
    • Ant annulus fibrosis
    • Ant vertebral body
  • Middle column
    • Post longitudinal lig
    • Post annulus fibrosis
    • Post vertebral body
  • Posterior column
    • Spinous processes
    • Transverse processes
    • Lamina
    • Facet joints
    • Pedicles
    • Post ligamentous complex
  • 2 or more columns disrupted = unstable
  • Most disruption of middle columns are unstable
stable or unstable
Stable or Unstable?
  • Radiographic findings suggestive of instability
    • Vertebral body collapse w/ widening of pedicles
    • > 33% canal compromise on CT
    • > 2.5 mm translation b/w vertebral bodies in any plane
    • Bilateral facet dislocation
    • Abnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral body
stable or unstable9
Stable or Unstable?
  • Checklist for Instability
    • Anterior elements disrupted 2 pts
    • Posterior elements disrupted 2 pts
    • Saggital plane translation > 2.5 mm 2 pts
    • Saggital plane rotation > 5o 2 pts
    • Spinal cord or cauda equina damage 2 pts
    • Disruption of costovertebral articulations 1 pt
    • Dangerous loading anticipated 2 pts
    • 5 or more pts unstable until healed or surgically stabilized
stable or unstable10
Stable or Unstable?
  • Risk of neurologic injury increases with
    • > 35% canal narrowing at T11-12
    • > 45% canal narrowing at L1
    • > 55% canal narrowing at L2 & below
approach to t l spines
Approach to T & L Spines
  • A – adequacy & alignment
    • All vertebrae need to be visible
    • Ant & post longitudinal lines
    • Facet joints should lie on smooth curve
    • Normal kyphosis & lordosis
    • All spinous processes should lie in straight line
  • B – bones
    • Trace cortical margins of each vertebrae
    • Difference b/w ant & post body ht < 2 mm
    • Progressive increase in vertebral body ht moving down spine
    • Wink sign & interpedicular distance
    • Don’t forget to look at transverse processes
approach to t l spines12
Approach to T & L Spines
  • C – cartilage
    • Progressive increase in disc space moving down spine (except L5-S1)
    • Facet joint alignment
  • S –soft tissue
    • Look at paraspinal stripe and prevertebral space
case 1
Case 1
  • 38 yo female brought to ED after being backed over by car driven by boyfriend
  • Intoxicated; c/o back pain & demonstrating the remarkable versatility of the F-word
slide14

Transverse process fractures

of L2-4

Significance of transverse process

fractures is not the fractures in and

of themselves but rather the high

incidence of associated serious

intraabdominal injury (~20%)

case 2
Case 2
  • 46 yo male presents to ED after falling 12 feet off ladder while putting up Christmas lights c/o back pain
slide16

Anterolisthesis

Of L4 on L5

case 3
Case 3
  • 50 yo male again 10-12 foot fall off ladder while putting up Christmas lights (dangerous hobby)
case 4
Case 4
  • 21 yo belted passenger in rollover single vehicle MVA at highway speed
slide22

Widened paraspinal

line suggesting

hematoma

Laterally displaced

T5 pedicle

Anterior wedging of T4 & T5

w/ loss of 30-40% of body ht

case 5
Case 5
  • 29 yo driver offroading in pick-up truck – rolls it at speed
  • Not belted, ejected from vehicle and trapped underneath for 3 hrs
slide25

Paramediastinal

soft tissue density

& widening

Suggestive of

compression

fractures

case 6
Case 6
  • 22 yo male single vehicle rollover. Not restrained – ejected through windshield at highway speeds
slide28

Posterior displacement

Involvement of pedicles &

laminar arch

Comminution &

anterior wedging

of L2 w/ 50% loss

of body Ht

slide29

CT demonstrates severe burst #

w/ horizontal plane extending

posteriorly through pedicles

and transverse processes in keeping

w/ a CHANCE fracture

case 7
Case 7
  • 58 yo roofer presents to ED unconscious after plunging 12 feet onto concrete through skylight
slide31

Schmorl’s

node

Compression fracture of L3

w/ no obvious post element

involvement