lumbar 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, and injury to the sacrum or pelvis
Xray of the lumbar spine is generally only indicated if there is significant risk of fracture or underlying malignancy - see the lumbosacral spine Xray and consider a CT scan instead
at Western Health, spinal injuries are managed by neurosurgery (either WH or RMH neurosurg reg), NOT by orthopaedics

these may occur in major trauma or falls - particularly onto a blunt object
they are often a marker for abdominal organ injury such as renal trauma
mechanism may be violent muscular contraction or direct trauma
they are said to occur mainly in rotational or extreme lateral flexion injuries
these fractures are generally regarded as being stable and Mx is primarily supportive with analgesia and may require admission for initial analgesia and tertiary trauma survey ¹⁾

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:
- posterior ligamentous injury is likely to be present as well:
  - a compression of more than 40% of the anterior vertebral wall, or,
  - a kyphotic deformity of more than 25° is often associated with
otherwise these are generally stable and rarely cause neurologic problems
- consider a lumbar brace for 6-12 weeks and gradual introduction of physical activity and rehabilitation exercises

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:
- the percentage of canal compromise
- the degree of angulation
- neurologic status
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
  - eg. the kyphotic deformity > 25°
- 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
- ie. the patient may require a TLSO brace worn for at least 12 weeks

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:
- associated injury to the posterior ligaments of the spine
- involves the disks of the spine
other cases may be managed with a lumbar brace for 12 weeks
see also: http://www.learningradiology.com/notes/bonenotes/chancefxpage.htm

similar to a Chance fracture but the fracture line extends anteriorly through the vertebral body to its anterior aspect

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

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

see spondylolisthesis
due to new fracture of the pars interarticularis
usually is associated with major trauma and usually is caused by extreme hyperextension
slip may be present acutely or can occur months to years later as the disk degenerates under shear loads that it cannot sustain

¹⁾