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Spinal column injuries in adults: Definitions, mechanisms, and radiographs Authors Amy Kaji, MD, PhD Robert S Hockberger, MD, FACEP Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: nov 29, 2012. INTRODUCTION — This topic review describes injuries to the cervical, thoracic, and lumbosacral spinal column, including fractures, dislocations, and subluxations of the vertebrae, and injuries to the spinal ligaments. The importance of recognizing and managing injuries to the spinal column is underscored by their association with spinal cord injury. The management of spinal column injuries and other issues related to spinal cord injury are discussed elsewhere. (See "Evaluation and acute management of cervical spinal column injuries in adults" and "Acute traumatic spinal cord injury" and "Anatomy and localization of spinal cord disorders" and "Evaluation of cervical spine injuries in children and adolescents" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the young athlete".) EPIDEMIOLOGY — Among patients included in a large trauma registry, approximately 3 percent of those with blunt trauma sustain a spinal column injury, such as spinal fracture or dislocation, and 1 percent sustains a spinal cord injury . Spinal column injury rates reported in other studies range from 2 to 6 percent . The incidence is likely to be significantly higher in patients with head trauma and those who are unconscious at presentation. Fracture of the thoracolumbar spine, including spinous and transverse process fractures, may occur in as many as 8 to 15 percent of blunt trauma patients cared for at major trauma centers . A systematic review of 13 international studies found great variation (up to a threefold difference) in the rate of spinal column injury among nations, particularly between developed and developing nations [4,5]. Most studies demonstrate a bimodal age distribution where the first peak is found in young adults between 15 and 29 years of age and a second peak in adults older than 65 years of age. Mortality is significantly higher in elder patients . Spinal column injuries are more common in males. Note that statistics from trauma registries can be incomplete and inaccurate, depending on the inclusion criteria, and may underestimate the number of patients with spinal column injury. As examples, victims who die at the accident scene and patients whose neurologic deficits rapidly improve are often not included. Motor vehicle related accidents account for almost half of all spinal injuries , and speeding, alcohol intoxication, and failure to use restraints are the major risk factors. Occupants involved in a rollover accident are at increased risk of a cervical spine injury . Other common causes include falls, followed by acts of violence (primarily gunshot wounds), and sporting activities. The falls of older adults account for a growing proportion of spinal injuries, reflecting the aging population of many developing countries. Missed or delayed diagnosis of spinal column trauma results in a 7.5-fold increase in the incidence of neurologic injuries . ANATOMY — The human spine consists of 33 bony vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (usually fused) . These 26 individual units are separated by intervertebral disks and connected by a network of ligaments. The vertebral column provides the body's basic structural support and also protects the spinal cord, which extends from the midbrain caudally to the level of the second lumbar vertebra and then continues Section Editor Maria E Moreira, MD Deputy Editor Jonathan Grayzel, MD, FAAEM
as the cauda equina. Pictures and radiographs depicting the details of spinal anatomy are found below: Spine anatomy overview (figure 1 and image 1) Vertebral anatomy (figure 2) Cervical vertebrae (figure 3) C1 and C2 vertebrae details (figure 4) Thoracic vertebrae (figure 5) Cervical joints and ligaments (figure 6) Skull and superior cervical spine interface (figure 7) Due to its exposed location above the torso and its inherent flexibility, the cervical spine is the most commonly injured part of the spinal column. Within the cervical spine, the most common sites of injury are around the second cervical vertebra (C2, or axis) or in the region of C5, C6 and C7 . In contrast, the thoracic spine is rigidly fixed, as the thoracic ribs articulate with the respective transverse processes and sternum. Thus, a great amount of force is necessary to damage the thoracic spine of an otherwise healthy adult. In older adults with osteoporosis or patients with bone disease or metastatic lesions minor trauma may be sufficient to cause a compression fracture. The second most commonly injured region is the thoracolumbar (TL) junction. The orientation of the facet joints at the TL junction may concentrate forces created from traumatic impact at this level . At the TL junction, the spinal column changes from a kyphotic to a lordotic curve. Ninety percent of all TL spine injuries occur in the region between T11 and L4. However, these injuries rarely result in complete cord lesions as the spinal canal is relatively wide at this level . MECHANISMS — Spinal column injury may result in spinal cord trauma through a number of mechanisms : Transection – Penetrating or massive blunt trauma resulting in spinal column injury may transect all or part of the spinal cord; less severe trauma may have similar neurologic effects by displacing bony fragments into the spinal canal or through disk herniation. (See "Acute traumatic spinal cord injury".) Compression – When elderly patients with cervical osteoarthritis and spondylosis forcibly extend their neck, the spinal cord may be compressed between an arthritically enlarged anterior vertebral ridge and a posteriorly located hypertrophied ligamentum flavum. Injuries that produce blood within the spinal canal can also compress the spinal cord. (See "Disorders affecting the spinal cord", section on 'Spinal epidural hematoma'.) Contusion – Contusions of the spinal cord can occur from bony dislocations, subluxations, or fracture fragments. Vascular injury – Primary vascular damage to the spinal cord should be suspected when there is a discrepancy between a clinically apparent neurologic deficit and the known level of spinal column injury. As an example, when a lower cervical dislocation compresses the vertebral arteries within the spinal foramina of the vertebrae, thrombosis and decreased blood flow through the anterior spinal artery may result. The anterior spinal artery originates from both vertebral arteries at the level of C1. This injury may erroneously appear to localize to the level of C1 or C2 rather than the site of the dislocation. (See "Disorders affecting the spinal cord", section on 'Spinal cord infarction'.)
Certain conditions predispose patients to cervical spinal column injury. Down syndrome patients are predisposed to atlanto-occipital dislocation; patients with rheumatoid arthritis are prone to rupture of the transverse ligament of C2. (See "Clinical features and diagnosis of Down syndrome" and "Cervical subluxation in rheumatoid arthritis".) CERVICAL SPINAL COLUMN INJURY Cervical spinal column injury classification — Acute cervical spinal column injury may be classified according to the stability of the injury, its location, or the mechanism (flexion, flexion-rotation, extension, and vertical compression) (table 1) [13,14]. To assess the stability of cervical spinal column injuries below C2, the spine is viewed as consisting of two columns. The anterior column is formed by vertebral bodies and intervertebral disks, which are held in alignment by the anterior and posterior longitudinal ligaments. The posterior column, which contains the spinal canal, is formed by the pedicles, transverse processes, articulating facets, laminae, and spinous processes. The nuchal ligament complex (supraspinous, interspinous, and infraspinous ligaments), capsular ligaments, and ligamentum flavum hold the posterior column in alignment. If both columns are disrupted, the cervical spine can move as two independent units, and there is a high risk of causing or exacerbating a spinal cord injury . In contrast, if only one column is disrupted and the other column maintains structural integrity, the risk of spinal cord injury is far less. Atlanto-occipital dislocation — Pure flexion injuries involving the atlas (C1) and the axis (C2) can cause an unstable atlanto-occipital or atlanto-axial joint dislocation, with or without an associated odontoid fracture (image 2). Several measurements are used to determine the presence of atlanto-occipital joint dislocation on plain lateral x-ray of the cervical spine; however, their accuracy and interobserver reliability are not well studied in trauma patients . The basion-posterior axial line interval (BAI) and the basion-dental interval (BDI) demonstrate consistent relationships in normal adults (figure 8) . They are determined by using a line drawn along the posterior border of the anterior body of C2. Two lines are then drawn from this line: one perpendicularly to the basion (ie, tip of the clivus at the occipital base) and another from the basion to the tip of the dens. A sum of these two lines originating from the basion exceeding 12 mm suggests atlanto-occipital joint dislocation. The Powers ratio is commonly used to assess for atlanto-occipital dislocation (figure 9). It is defined by the ratio of BC:OA, where BC is the distance between the basion and the midpoint of the posterior laminar line of C1, and OA is the distance between the midpoint of the posterior margin of the foramen magnum (opisthion) and the midpoint of the posterior surface of the anterior arch of C1 . A ratio greater than one suggests anterior subluxation. Another radiologic finding suggestive of an atlanto-occipital dislocation is disruption of the “basilar line of Wackenheim,” a line drawn from the posterior surface of the clivus to the odontoid tip [18,19]. Normally, the inferior extension of this line should just touch the posterior aspect of the tip of the odontoid. If the line runs anterior or posterior to the odontoid tip, this suggests an atlanto-occipital dislocation. Atlanto-axial dislocation — Rotary atlanto-axial dislocation is an unstable injury, caused by a flexion-rotation mechanism, best visualized on open-mouth odontoid radiographs or CT scan (figure 10). The interpretation of odontoid radiographs warrants careful attention, since there may be false positive asymmetry between the odontoid process and the lateral masses of C1 if the skull is rotated (image 3). When the x-ray reveals symmetric basilar skull structures, a unilaterally magnified lateral mass confirms a C1-C2 dislocation. C1 (Atlas) fractures Burst (Jefferson) — The Jefferson fracture of C1 is highly unstable and occurs when a vertical compression force is transmitted through the occipital condyles to the lateral masses of the atlas (image 4 and image 5 and figure 11). This force drives the lateral masses outward, resulting in fractures of the anterior and posterior arches of the C1, with or without disruption of the transverse ligament. Disruption of the transverse ligament determines
Type III fractures are mechanically unstable. spinal cord damage is often minimal because the AP diameter of the neural canal is greatest at C2. this fracture is potentially dangerous because of its location. In the AP projection (open-mouth or odontoid view). A predental space greater than 3 mm in adults or 5 mm in children is abnormal . In pure flexion injuries below C2. most commonly. this injury is usually stable and rarely associated with spinal cord injuries. or the lateral masses of the atlas extend laterally beyond those of the axis on the odontoid radiograph. since they allow the odontoid and the occiput to move as a unit. and bilateral pedicle fractures permit spinal canal decompression . The larger piece displaces posteriorly as a unit with the superior cervical spine relative to the . Although this lesion is unstable. Odontoid fractures are best seen on the AP odontoid radiograph (ie. Flexion teardrop — A flexion teardrop fracture results when severe flexion and compression cause one vertebral body to collide with the body below. sagittal plane). and most of the force is expended on the vertebral body anteriorly. open-mouth view) and cause prevertebral soft tissue swelling on lateral radiographs. They usually occur in the lower cervical spine. at the base of the odontoid process where it attaches to C2 (type II) (image 9 and figure 13). Anterior displacement of the atlas greater than 1 cm can injure adjacent spinal cord. The Jefferson fracture may be difficult to recognize on plain x-ray if there is minimal displacement . Because the posterior column remains intact. Type I fractures are stable. may result in a fracture of the odontoid process. clinicians should obtain a CT scan of the cervical spine. Although spinal cord injury is uncommon. Radiographically. Anterior wedge — Forceful flexion of the cervical spine can compress the anterior portion of a vertebral body. and axis functioning as a unit) is thrown into extreme hyperextension as a result of abrupt deceleration (ie. also called the dens. leading to anterior displacement of a wedge-shaped fragment (resembling a teardrop) of the antero-inferior portion of the superior vertebra (image 13 and figure 15). On plain lateral radiographs. The transverse ligament is presumed to be disrupted if the interval between the atlas and the dens is increased on a lateral radiograph. the height of the anterior border of the vertebra is diminished. the fractured vertebra appears to be divided into a smaller anterior fragment and a larger posterior piece. creating an anterior wedge fracture. the strong nuchal ligament complex usually remains intact. A vertical fracture line through the posterior neural arch is seen on lateral x-ray (image 7). C2 (Axis) pedicle fractures — Traumatic spondylolysis of C2 (so-called "hangman's fracture") is an unstable injury that occurs when the cervicocranium (the skull. Posterior arch — A posterior neural arch fracture of C1 results from compression of the posterior elements between the occiput and the spinous process of C2 during forced neck extension. type II odontoid fractures are unstable and complicated by nonunion in over 50 percent of patients treated with halo vest immobilization . Bilateral pedicle fractures of the axis may occur with or without dislocation in this circumstance. Although mechanically stable because the anterior arch and the transverse ligament remain intact. Slight angulation of the force may result in extension of the fracture through the upper portion of the body of C2 (type III) (image 10 and figure 13). Caution is necessary when interpreting the open mouth view as a radiographic line created by the space between the two front incisors may be confused for a dens fracture. Prevertebral hemorrhage combined with disruption of the transverse ligament may cause an increase in the predental space between C1 and the odontoid (dens) seen on the lateral radiograph. In such instances. as might occur with a forward fall onto the forehead. forced extension of an already extended neck) (image 8 and figure 12). causing a simple wedge fracture . atlas. and prevertebral soft tissue swelling is present. Fractures can occur above the transverse ligaments (type I) or. Spinal instability can result if anterior wedge fractures are severe (loss of over half the height of the anterior vertebral body) or multiple adjacent wedge fractures occur (image 11 and image 12 and figure 14).instability. Odontoid fractures — Forceful flexion or extension of the head in an anterior-posterior orientation (ie. the masses of C1 lie lateral to the outer margins of the articular pillars of C2 (image 6).
Thus. an isolated fracture of one of the spinous processes of the lower cervical vertebrae. causing disruption of the . Although technically burst fractures are “stable” since all ligaments remain intact. (See "Anatomy and localization of spinal cord disorders". which are generally not associated with instability.) To reflect this risk of spinal cord injury. producing a triangular-shaped fragment (image 14 and figure 16). burst fractures can be classified as unstable if any of the following are present: Associated neurologic deficits Loss of greater than 50 percent of vertebral body height Greater than 20 degrees of spinal angulation Compromise of more than 50 percent of the spinal canal . a vertebra with a flexion teardrop fracture may lose height from compression . In contrast. such as burst fractures or fracture dislocations. section on 'Ventral (anterior) cord syndrome'. but can also occur at C5 to C7 with diving accidents and can be associated with a central cord syndrome . while the anterior-posterior (AP) radiograph demonstrates a characteristic vertical fracture of the vertebral body (image 16). the body shatters outward. (See "Anatomy and localization of spinal cord disorders".) Spinous process fractures — The clay shoveler's fracture. and may cause one or more vertebral body end-plates to fracture. Such forces are applied from above (via the skull) or below (via the pelvis or feet). whereas transverse fractures often represent avulsion fractures from hyperflexion.) Extension teardrop — An extension teardrop fracture occurs when abrupt neck extension causes the anterior longitudinal ligament to avulse the antero-inferior corner from the remainder of the vertebral body. causing an anterior cord syndrome. Laminar fractures — Most laminar fractures of the cervical spine are associated with other fractures. Facet dislocations Bilateral — Bilateral facet dislocations occur when flexion forces extend anteriorly. resulting in a burst fracture. is a stable injury (image 15). The severe anterior flexion involved in this injury creates distraction forces at the posterior cervical spine and disruption of the posterior longitudinal ligament. (See "Anatomy and localization of spinal cord disorders". Although rare. The lateral radiograph shows a comminuted vertebral body and loss of vertebral height. this fracture is more commonly seen following direct trauma to the spinous process and after motor vehicle crashes involving sudden deceleration that result in forced neck flexion. The pattern of the fracture often reflects the mechanism of injury. Vertical lamina fractures are thought to result from axial loading. It derives its name from its occurrence in clay miners during the 1930s. section on 'Ventral (anterior) cord syndrome'. flexion teardrop fractures are highly unstable. They are associated with acute anterior cervical cord syndrome. Burst fractures — Vertical compression injuries occur in the cervical and lumbar regions when axial loads are exerted on the spine. This unstable injury is found most often at C2. Although similar in radiographic appearance to the flexion teardrop fracture. the vertebra involved in an extension teardrop injury generally does not lose height. can be treated nonoperatively with cervical collar immobilization .vertebrae below. isolated lamina fractures. which usually determine the stability of the injury (image 17) . If there is no posterior displacement of the superior column. section on 'Central cord syndromes'. posteriorly displaced fracture fragments may impinge on the spinal cord. Today. widening of the interlaminar and interspinous spaces supports the diagnosis of a flexion teardrop fracture . When the nucleus pulposus of the intervertebral disk is forced into the vertebral body. The anterior fragment typically remains aligned with the inferior cervical vertebrae.
This injury pattern is more common in children and has been attributed to several causes. Such injuries may be unstable. resulting in anterior displacement of the spine. this is a stable injury despite posterior ligament complex disruption.annulus fibrosus of the intervertebral disc and the anterior longitudinal ligament. including ligamentous injuries. Evaluation of suspected ligamentous injury or SCIWORA in adults is discussed separately. the posterior annulus fibrosus. the displacement will appear to be greater than one half of the anteroposterior (AP) diameter of the lower vertebral body with the superior facets anterior to the inferior facets. (See "Evaluation of cervical spine injuries in children and adolescents". and translational injuries. and the posterior half of the vertebral body. Compression fractures with greater than 30 degrees and burst fractures with greater than 25 degrees angulation are generally considered unstable. The three columns are anterior. a three column scheme may be used to describe injuries of the thoracic and lumbar (TL) spinal column . The presence of a neurologic deficit also indicates spinal instability. associated fractures of the facet or surrounding structures can create instability . A widely used classification for . However. (See "Evaluation and acute management of cervical spinal column injuries in adults". and cervical spondylosis. axial distraction. In a biomechanical study of cadaveric human spines. although they are rarely associated with permanent neurologic damage. On a lateral plain radiograph. resulting in extreme instability. The anterior column includes the anterior longitudinal ligament. and posterior (figure 17). Spinal instability may be inferred when plain radiographs demonstrate a loss of 50 percent of vertebral height or excessive kyphotic angulation around the fracture . middle. and the anterior half of the vertebral body. upper extremity weakness) in the absence of a fracture seen on plain radiographs or CT. plain radiograph series or CT scan. stability is based upon the integrity of two of the three spinal columns. According to the three column scheme. researchers found the middle column to be the major determinant of spine stability when axial or flexion stress was applied . flexion-distraction injuries. The posterior column includes the supraspinous and interspinous ligaments. technically adequate. but it is often defined as the presence of neurologic deficits in the absence of bony injury on a complete. one measured along the superior endplate of the vertebral body one level above the fracture and the other along the inferior endplate of the vertebral body one level below . Radiographically. Rotation occurs around one of the facet joints. Complete spinal cord injury most often results. with the superior facet moving over the inferior facet. Spinal cord injury rarely occurs following isolated unilateral facet dislocation. All of these fractures result from one or more of three mechanisms of injury: axial compression. since the spinal column has failed to protect the spinal cord . Ligamentous injuries and SCIWORA — The definition of spinal cord injury without radiographic abnormality (SCIWORA) varies among studies. section on 'Evaluation for ligamentous injury and SCIWORA'. Since the dislocated articular mass is locked in place. which is best seen on the lateral view (image 18 and image 19).) THORACIC AND LUMBAR (TL) SPINAL COLUMN INJURY TL spinal column injury classification — In contrast to the two column scheme for cervical spinal column injury. and translation [28. as well as the facet joint capsule. and coming to rest within the intervertebral foramen (image 20).33]. the two lateral masses of the dislocated vertebrae may partially overlap giving the appearance of a bow tie (radiologists may refer to a bowtie or double diamond sign) (image 21).) Clinicians should suspect a cervical ligamentous injury in the injured patient who has persistent severe pain or paresthesias or focal neurologic findings (eg. The inferior articulating facets of the upper vertebra pass over the superior facets of the lower vertebra. Few studies have been performed to validate the three column scheme. disc prolapse. the annulus fibrosus. stable and unstable burst fractures. Unilateral — Unilateral facet dislocations involve flexion and rotation. The angle is determined by the intersection of two lines. TL injuries can be divided into four basic patterns: wedge compression fractures. The middle column comprises the posterior longitudinal ligament. dislocation occurs at the contralateral facet joint.
compression fractures account for 50 to 70 percent of all TL fractures [33. In 2005. since the middle column remains intact (image 23). Compression fractures — Wedge. (See "Evaluation and acute management of cervical spinal column injuries in adults". the Spine Trauma Study Group introduced a classification system for thoracolumbar injuries called the Thoracolumbar Injury Classification and Severity Score (TLICS). Injuries that do not disrupt the posterior ligament complex are stable. Scoring of the TLICS is as follows: Injury morphology Compression = 1 point Burst = 1 point Translational/rotational = 3 points Distraction = 4 points Neurological Status Intact = 0 points Nerve root = 2 points Cord. They usually result from compressive failure of the anterior column under an axial load applied in flexion. Fracture kyphosis is described above. a rotational component to the injury. Fractures with any of these characteristics or a TLICS score ≥4 warrant imaging with CT.TL spinal column injury combines a distinction between major and minor fracture patterns using the three column scheme and the five injury patterns. Neurologic findings or concomitant injuries warrant a thorough evaluation. A score ≥5 suggests instability and the need for operative treatment. and integrity of the posterior ligamentous complex. resulting in spinal instability (image 22). These fractures generally result from falls. ligamentum flavum. A score of 4 is considered indeterminate and either operative or conservative management may be indicated . motor .) Simple wedge fractures demonstrate less than 10 to 30 percent compression and generally cause no neurologic impairment. neurologic status. whereas a score ≤3 suggests stability.) Compression fractures that exhibit between 10 and 40 percent compression are managed on a case-by-case basis in consultation with a spine surgeon. conus medullaris: Incomplete = 3 points Complete = 2 points Cauda equina = 3 points Posterior Ligament Complex Intact = 0 points Injury suspected/indeterminate = 2 points Injured = 3 points The total numerical score is used to guide treatment. or anterior. An additional rotational force is necessary to cause an unstable fracture pattern. and facet joint capsules . interspinous ligament. Management of spinal column injury is discussed separately.36]. (See 'TL spinal column injury classification' above. or compression fractures at multiple levels. If there is severe compression (>50 percent of vertebral height). significant fracture kyphosis (>30 degrees). which includes the supraspinous ligament. This score assigns numerical values to each injury based upon morphology. then the posterior ligamentous complex may fail and progress to involve the middle column.
positioned incorrectly above the pelvic bones. We recommend that a CT be obtained if there is vertebral compression greater than 50 percent or a burst fracture is suspected for any reason. (See "Initial evaluation and management of blunt abdominal trauma in adults". Burst fractures — Burst fractures comprise approximately 14 percent of all TL injuries . no chest restraint) during vehicular trauma . and nearly vertical. Such findings include fracture lines that extend into the posterior cortex and any compression of the posterior cortex. Burst fractures are most commonly associated with falls and motor vehicle collisions. While neurologic deficits are rare.vehicle crashes. one or both articular processes fracture. no vertebral subluxation). posterior element involvement increases the risk for neurologic deficits . unilateral facet dislocations are rare. It is important to confirm that the posterior elements remain intact (ie. Spinal cord injury from retropulsion of bony fragments into the spinal canal can occur. and almost horizontal. since the integrity of the posterior cortex is what distinguishes the stable wedge compression fracture from the unstable burst fracture. 6 experienced radiologists correctly identified only 30 of 39 burst fractures among 53 thoracolumbar radiographs reviewed . Burst injuries can occur with or without injury to posterior elements. and thus. A seat belt sign may be present. Pure ligamentous disruptions also occur and account for 10 to 25 percent of flexion-distraction injuries . which demonstrate anterior compression of the vertebral body without disruption of the posterior cortex. Flexion-distraction (lap belt) injuries — Flexion-distraction injuries account for 10 percent of all TL spinal column injuries and occur most frequently in patients wearing only a lap belt (ie. CT should be performed when plain radiographs suggest any possible involvement of the posterior cortex in what appears to be a wedge compression fracture. articular processes in the lumbar region are large. Unstable burst fractures are often misdiagnosed as stable anterior wedge fractures. and the upper vertebra swings forward. All burst fractures should be considered unstable. are more common. Thus. Burst fractures can be difficult to visualize and are often misdiagnosed by plain radiography because posteriorly displaced bone fragments often lie at the level of the pedicles . associated intraabdominal injuries. They are caused by compressive forces that fracture the vertebral endplate and pressure from the nucleus pulposus upon the vertebral body (image 24 and image 25). 20 percent of CTconfirmed burst fractures were initially misdiagnosed as wedge fractures . curved. . In contrast to the cervical region. where articular processes are small. In an analysis of 67 thoracolumbar radiographs reviewed by two radiologists and two orthopedists. Associated injuries are common and fractures frequently occur at other spinal levels. Lateral x-rays of burst fractures may demonstrate a loss of anterior and posterior vertebral height. flat. AP radiographs may demonstrate a widening of the interpedicular distance (>1 mm difference between the vertebrae above and below). The AP radiograph may demonstrate a subtle increase in the interspinous distance if there is a kyphotic deformity. Classically the patient is wearing only a lap belt.) Chance fractures are representative of TL flexion-distraction injury (image 26 and image 27). leading to compressive failure of the anterior and middle columns and a tear in the posterior longitudinal ligament. Other suggestive features include loss of posterior vertebral height and widening of the interpedicular distance. Chance fractures are often misdiagnosed as compression fractures. and may show a distorted posterior longitudinal ligament line. Instead. Sudden deceleration during a collision causes forceful flexion at the lap belt. In one retrospective trial. since neurologic deficits are seen in 42 to 58 percent of patients . Simple wedge compression fractures are best seen on lateral radiographs. such as small and large intestinal perforations. and occasionally generalized tonic-clonic seizures . resulting in an unstable fracture-dislocation pattern. Standard radiographs may not be adequate to evaluate the integrity of the posterior vertebral cortex.
Among patients rendered paraplegic from TL trauma. causing complete paraplegia in nearly all patients. it is important to obtain sagittal reconstructions of CT images if a lap belt mechanism is known or a flexion-distraction injury is suspected for other reasons (eg.” The Basics patient education pieces are written in plain language. three patients were subsequently found to have compression and burst fractures by CT scan . in high velocity trauma they frequently do not occur in isolation. Several injury patterns can occur. Beyond the Basics patient education pieces are longer. Other TL fracture patterns — Minor spinal fracture patterns account for 14 percent of all TL injuries and include isolated transverse process fractures (image 30 and image 31). (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest. Here are the patient education articles that are relevant to this topic. presence of abdominal seat belt sign. To ensure appropriate diagnosis and management of spinal column injury. and more detailed. more sophisticated. and increased posterior interspinous spaces caused by distraction. Most minor spinal fractures occur in the lumbar region and are caused by direct blows. the majority have sustained a fracture-dislocation injury (image 28 and image 29). bipedicular fractures. INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials. These articles are best for patients who want a general overview and who prefer short. High thoracic spinous process fractures may be associated with brachial plexus injury. known bowel injury) . Shear fractures and pure dislocations result in severe neurologic injury. facet or laminar fractures. A systematic review found that reformatted CT images from visceral studies demonstrated greater sensitivity and specificity than plain TL radiographs in detecting spinal column injury . spinous process fractures (image 32). and fractures of the pars interarticularis. a CT should be obtained when transverse process fractures are seen on plain radiographs. Approximately 26 to 40 percent of these result in permanent neurologic deficits . We encourage you to print or e-mail these topics to your patients. including rotational fracturedislocations. and they answer the four or five key questions a patient might have about a given condition. while lumbar and sacral spinous process fractures may cause lumbosacral plexus injury. Most patients also sustain multiorgan system trauma. Flexion-distraction injuries may be missed on routine axial CT scans since the disruption is oriented in the horizontal plane. shear injuries. CT scan is helpful in evaluating these injuries because it quantifies the extent of spinal cord impingement. Translational spinal column injury — Massive direct trauma to the back can cause failure of all three columns of the TL spine resulting in translational injuries. Patients with a complete vertebral dislocation from massive trauma almost invariably demonstrate neurologic deficits. and pure vertebral dislocations. Displacement is unusual. since the mechanism does not involve a significant rotational or translational component. at the 5th to 6th grade reading level.) Basics topics (see "Patient information: Vertebral compression fracture (The Basics)" and "Patient information: Neck fracture (The Basics)") . Thus. Pure dislocations appear as a complete displacement of the superior vertebrae relative to the one below. In one retrospective analysis of 28 patients who initially appeared to have isolated transverse process fractures by plain x-ray. easy-to-read materials. Sudden contraction of the psoas muscles can result in avulsion of a transverse process. The thoracolumbar junction (T10 to L2) is the most common site .Radiographic findings of flexion-distraction injuries include compression fractures of the vertebral body. A characteristic finding is increased length of the vertebral segment as a result of distraction. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. “The Basics” and “Beyond the Basics. While transverse process fractures are considered stable. Fracture fragments created by shearing forces may lodge in the spinal canal.
SUMMARY AND RECOMMENDATIONS Blunt trauma. and C7. and ligamentous injuries. Elder patients who fall are also at risk. dislocations. in particular. The anatomy of the spinal column and common mechanisms of injury are described in the text. (See 'Cervical spinal column injury' above and 'Thoracic and lumbar (TL) spinal column injury' above. (See 'Anatomy' above and 'Mechanisms' above.) Differences in the structure and location of the cervical and thoracolumbar portions of the spinal column lead to different types of injuries. ACKNOWLEDGMENT — We are saddened by the untimely death of John Marx. MD.) The cervical spine is the most commonly injured part of the spinal column. We wish to acknowledge Dr. Approximately three percent of blunt trauma patients sustain such an injury.) The degree of stability is perhaps the most important feature of any spinal column injury. his work as editor-in-chief for Emergency Medicine and as a section editor and author for Adult Trauma. Marx's dedication and his many contributions to UpToDate. Topic 357 Version 20. or axis) or in the region of C5. the most common sites of injury are around the second cervical vertebra (C2. The stability of common spinal injuries is described in the text and summarized in the accompanying table (table 1). The cervical spinal column is susceptible to a wide range of fractures. particularly motor vehicle collisions. who passed away in July 2012. (See 'Epidemiology' above.0 . C6. Within the cervical spine. although there is some overlap. Compression fractures are the most common injury of the thoracolumbar spinal column. Use of UpToDate is subject to the Subscription and License Agreement. accounts for most spinal column injuries.
com . 5th ed. The IV foramina (seen also in part B) are openings in the lateral wall through which spinal nerves exit the vertebral canal. Lippincott Williams & Wilkins. Dalley AF. The isolated vertebrae are typical of each of the three mobile regions. weightbearing column of vertebral bodies and IV discs forms the anterior wall of the vertebral canal. Clinically Oriented Anatomy. thoracic cage. The lateral and posterior walls of the canal are formed by the series of vertebral arches. representing the skeleton of the back.lww. like shingles on a roof.GRAPHICS Spine anatomy overview (A) This anterior view shows the isolated vertebral column. (B) This right lateral view shows the isolated vertebral column. http://www. The continuous. The posterior wall is formed by overlapping laminae and spinous processes. Philadelphia 2006. Copyright © 2006 Lippincott Williams & Wilkins. (D) This medial view of the axial skeleton in situ demonstrates its regional curvatures and its relationship to the cranium (skull). and hip bone. (C) This posterior view of the vertebral column includes the vertebral ends of ribs. Reproduced with permission from: Moore KL. Note the increase in size of the vertebrae as the column descends.
which typically ends at the L1–L2 level in adults. Dalley AF.Spine anatomy MRI This sagittal MRI study shows the primary contents of the vertebral canal. Philadelphia 2006. The dura mater.lww. The medullary cone (L. Clinically Oriented Anatomy. Lippincott Williams & Wilkins. Copyright © 2006 Lippincott Williams & Wilkins. Reproduced with permission from: Moore KL. the external overing of the spinal cord (gray).com . 5th ed. http://www. conus medullaris) is the cone-shaped inferior end of the spinal cord. is separated from the spinal cord by a fluid-filled space (black) and from the wall of the vertebral canal by fat (white) and thin-walled veins (not visible here).
Lippincott Williams & Wilkins. 5th ed. (A) Functional components include the vertebral body (bone color). http://www. Philadelphia 2006. Clinically Oriented Anatomy. a vertebral arch (red). (B. (D) The superior and inferior notches of adjacent vertebrae plus the IV disc that unites them form the IV foramen for the passage of a spinal nerve and its accompanying vessels. Copyright © 2006 Lippincott Williams & Wilkins.lww.com . Dalley AF. Note that each articular process has an articular facet where contact occurs with the articular facets of adjacent vertebrae (B-D). C) Bony formations of the vertebrae are demonstrated. The vertebral foramen is bounded by the vertebral arch and body. A small superior vertebral notch and a larger inferior vertebral notch flank the pedicle. represented by L2.Basic vertebral anatomy A "typical" vertebra. and seven processes: three for muscle attachment and leverage (blue) and four that participate in synovial joints with adjacent vertebrae (yellow). Reproduced with permission from: Moore KL.
and 7th are "atypical. bifid spinous processes. and transverse foramina. 2nd. Copyright © 2006 Lippincott Williams & Wilkins. the 1st. http://www." Typical vertebrae demonstrate rectangular bodies with articular uncinate processes on their lateral aspects.Cervical vertebrae transverse view The 3rd-6th cervical vertebrae have a "typical" structure.lww. Dalley AF. Reproduced with permission from: Moore KL.com . 5th ed. triangular vertebral foramina. Philadelphia 2006. Lippincott Williams & Wilkins. Clinically Oriented Anatomy.
Dalley AF.C1 and C2 bone anatomy (A) Observe the occipital condyles that articulate with the superior articular surfaces (facets) of the atlas (vertebra C1). It consists of two lateral masses connected by anterior and posterior arches. (C. Clinically Oriented Anatomy. has neither a spinous process nor a body. Copyright © 2006 Lippincott Williams & Wilkins. http://www. on which the cranium rests. It articulates anteriorly with the anterior arch of the atlas ("Facet for dens" in part B) and posteriorly with the transverse ligament of the atlas (see part B). 5th ed. Reproduced with permission from: Moore KL. D) The tooth-like dens characterizes the axis (vertebra C2) and provides a pivot around which the atlas turns and carries the cranium. (B) The atlas. Philadelphia 2006.lww.com . Lippincott Williams & Wilkins.
costal facets on the transverse processes. Copyright © 2006 Lippincott Williams & Wilkins. http://www. 5th ed.lww. (C) T12 has bony processes and a body size similar to a lumbar vertebra.Thoracic vertebrae (A) T1 has a vertebral foramen and body similar to a cervical vertebra. Clinically Oriented Anatomy. and long sloping spinous processes are characteristic of thoracic vertebrae. Lippincott Williams & Wilkins. Philadelphia 2006. The planes of the articular facets of thoracic vertebrae define an arc (red arrows) that centers on an axis traversing the vertebral bodies vertically. Dalley AF.com . (D) Superior and inferior costal facets (demifacets) on the vertebral body. (B) T5-T9 vertebrae have typical characteristics of thoracic vertebrae. Reproduced with permission from: Moore KL.
Clinically Oriented Anatomy. Intertransverse. Copyright © 2006 Lippincott Williams & Wilkins. Philadelphia 2006.lww. 5th ed. the spinous processes are deeply placed and attached to an overlying nuchal ligament. and interspinous ligaments are demonstrated in association with the vertebrae with intact vertebral arches.Cervical spine joints and ligaments (A) The ligaments in the cervical region are shown. Dalley AF. Reproduced with permission from: Moore KL. The pedicles of the superior two vertebrae have been sawn through and the vertebral arches removed to reveal the posterior longitudinal ligament. Lippincott Williams & Wilkins.com . http://www. (B) The ligaments in the thoracic region are shown. supraspinous. Superior to the prominent spinous process of C7 (vertebra prominens).
Copyright © 2006 Lippincott Williams & Wilkins. Philadelphia 2006.Craniovertebral joints and ligaments (A) Ligaments of the atlanto-occipital and atlantoaxial joints. The tectorial membrane and the right side of the cruciate ligament of the atlas have been removed to show the attachment of the right alar ligament to the dens of vertebra C2 (axis). Dalley AF. Clinically Oriented Anatomy. Reproduced with permission from: Moore KL. . (B) The hemisected craniovertebral region shows the median joints and membranous continuities of the ligamenta flava and longitudinal ligaments in the craniovertebral region. Lippincott Williams & Wilkins. 5th ed.
Louis 2006. Walls. Mosby. Copyright ©2006 Elsevier. . 6th ed. RS.Classification of spinal injuries Mechanisms of spinal injury Flexion Anterior wedge fracture Flexion teardrop fracture Clay shoveler's fracture Subluxation Bilateral facet dislocation Atlanto-occipital dislocation Anterior atlantoaxial dislocation with or without fracture Odontoid fracture with lateral displacement Fracture of transverse process Flexion-rotation Unilateral facet dislocation Rotary atlantoaxial dislocation Extension Posterior neural arch fracture (C1) Hangman's fracture (C2) Extension teardrop fracture Posterior atlantoaxial dislocation with or without fracture Vertical compression Burst fracture of vertebral body Jefferson fracture (C1) Isolated fractures of articular pillar and vertebral body Stable Extremely unstable Stable Unstable Unstable Usually stable in flexion. Hockberber. unstable in extension Unstable Stable Unstable Stable Extremely unstable Stable Potentially unstable Always unstable Unstable Unstable Unstable Stable Stability Reproduced with permission from: Marx. Rosen's emergency medicine: concepts and clinical practice. St. Inc.. RM. JA.
. Courtesy of Mary Hochman. MD.Atlanto-occipital disassociation Severe flexion injuries involving the atlas (C1) can cause an atlanto-occipital dislocation or disassociation.
BAI and BDI cervical spine measurements .
Powers ratio for cervical spine .
Atlanto-axial dislocation .
Guide for odontoid cervical spine x-ray Reproduced with permission from: Mower WR. Lippincott Williams & Wilkins. Wolfson AB (Ed). Hoffman JR. Cervical spine fractures. Mahadevan SV. Philadelphia 2009.com . Copyright © 2009 Lippincott Williams & Wilkins. http://www. In: Harwood-Nuss Clinical Practice of Emergency Medicine. 5th ed.lww.
MD . which normally are in alignment.C1 arch fractures: Jefferson fracture This odontoid or open-mouth view shows a Jefferson fracture. Courtesy of Mary Hochman. Note the step-off of the lateral masses (white arrow).
C1 arch fractures: Jefferson fracture This lateral radiograph shows increased predental space between C1 and the odontoid (red arrow). MD . Courtesy of Mary Hochman. Also note the soft tissue swelling anterior to the site of injury.
.Burst (Jefferson) fracture of C1 The Jefferson fracture of C1 is highly unstable and occurs when a vertical compression force is transmitted through the occipital condyles to the lateral masses of the atlas.
These findings suggest a Jefferson fracture of C1. Courtesy of Richard Waite. There is more subtle malalignment of left C1 lateral mass (red arrow) relative to C2.Open mouth (odontoid) view of C1/C2 dislocation The AP open mouth view of C1/C2 intervertebral joint space and the odontoid reveals an obvious offset of the right lateral mass of C1 (white arrow) over the corresponding lateral mass of C2. MD .
Courtesy of Mary Hochman.C1 posterior neural arch fracture A posterior neural arch fracture of C1 results from compression of the posterior elements between the occiput and the spinous process of C2 during forced neck extension. A vertical fracture line through the posterior neural arch is seen on this lateral x-ray (white arrow). MD .
C2 pedicle fractures: Hangman's fracture Traumatic spondylolysis of C2 (so-called "hangman's fracture") is an unstable injury that occurs when the cervicocranium (the skull. and axis functioning as a unit) is thrown into extreme hyperextension. Courtesy of Mary Hochman. MD . atlas.
Pedicle fracture of C2 (axis) .
MD . Courtesy of Mary Hochman.Odontoid fracture type II Type II odontoid fractures are the most common type and occur at the base of the odontoid process where it attaches to C2. They are considered unstable.
Odontoid fractures .
They are mechanically unstable. MD . since they allow the dens and the occiput to move as a unit. Courtesy of Mary Hochman.Odontoid fracture type III Type III odontoid fractures travel through the upper portion of the body of C2.
Cervical anterior wedge fracture: Lateral view Anterior wedge fractures result from extreme flexion. Spinal instability can occur with severe anterior wedge fractures (loss of over half the vertebral height) or multiple adjacent wedge fractures. Courtesy of Mary Hochman. MD .
MD .Cervical anterior wedge fracture Courtesy of Mary Hochman.
Anterior wedge fracture of the cervical spine .
Courtesy of Mary Hochman. leading to anterior displacement of a wedge-shaped fragment (resembling a teardrop).Cervical vertebral body fractures: Flexion tear drop fracture A flexion teardrop fracture results when severe flexion causes a vertebral body to collide with the one below. MD .
Flexion teardrop fracture of the cervical spine .
Courtesy of Mary Hochman. MD .Cervical extension teardrop fracture The extension teardrop fracture occurs when abrupt neck extension causes the anterior longitudinal ligament to pull the anteroinferior corner away from the remainder of the vertebral body. producing a triangular-shaped fragment (red arrow).
Extension teardrop fracture of the cervical spine .
Spinous process fractures: Clay shoveler's fracture The clay shoveler's fracture is an isolated fracture of one of the spinous processes of the lower cervical vertebrae. MD . It is a stable injury that most often occurs with direct trauma to the spinous process. Courtesy of Mary Hochman.
the body shatters outward. resulting in a burst fracture. MD .C7 burst fracture and C6 flexion teardrop Vertical compression injuries such as burst fractures occur in the cervical spine when axial loads are exerted on the spine. Note the fracture fragment on the CT image above (white arrow) that is displaced into the spinal canal. Courtesy of Mary Hochman. When the nucleus pulposus of the intervertebral disk is forced into the vertebral body.
Lippincott Williams & Wilkins. Diagnosis. Flander AE. Philadelphia 2007.Bilateral laminar fractures of cervical spine Lateral radiograph (A) demonstrates posterior impaction with multiple comminuted laminar and spinous processes fractures from C2 to C6 (white arrows). and Management. The acute vacuum disc (black arrow) with abnormal widening of the anterior C6-7 disc space is a sign of anterior and middle column distraction. The corresponding CT images (B and C) demonstrate displacement of the spinous processes and bilateral comminuted laminar fractures (white arrows). Reproduced with permission from: Schwartz ED. . Copyright © 2007 Lippincott Williams & Wilkins. Spinal Trauma: Imaging.
causing the inferior articulating facets of the upper vertebra to pass over the superior facets of the lower vertebra. Courtesy of Mary Hochman. MD . Complete spinal cord injury most often results.Bilateral facet dislocations (C4/C5) Bilateral facet dislocations occur when flexion forces extend anteriorly.
Bilateral facet dislocations
These CT images show a bilateral facet dislocation (red arrows) at the C6-C7 level.
Courtesy of Mary Hochman, MD
Unilateral facet dislocation (C5/C6)
Unilateral facet dislocations involve flexion and rotation. Rotation occurs around one of the facet joints; dislocation occurs at the contralateral facet joint, with the superior facet moving over the inferior facet. In the CT images above note the normal juxtaposition of the facets on the right and the dislocation on the left.
Courtesy of Mary Hochman, MD
Cervical spine unilateral facet dislocation with bow tie sign
The plain x-ray of the cervical spine in the lateral projection reveals unilateral malalignment of the facets of C3 (red arrows) compared with subjacent column which are widely separated resulting in the bow tie appearance of the posterior elements as they line up (D, red overlay). Associated mild subluxation is present. The yellow arrows show normal alignment of the facet joints of C4, C5, and C6. These findings are reminiscent of a unilateral facet dislocation.
Copyright © 2007 Lippincott Williams & Wilkins. Donaldson III WF. Philadelphia. Peitzman AB (Ed). 3rd ed. Injuries to the spinal cord and spinal column. Lippincott Williams & Wilkins. 2007.Three columns of the thoracolumbar spine Reproduced with permission from: Jankowitz BT. In: The Trauma Manual. Welch WC. et al. http://www.lww.com .
Plain x-ray of thoracic compression fracture with kyphosis The patient is a 55-year-old female who fell and presented with back pain. 5. 4. A kyphosis of the thoracic spine of about 30 degrees has resulted. The plain x-ray of the thoracic spine in the AP (A) and lateral (B) projections reveal a compression fracture of T5 (red arrows) with about 70 percent loss of height of the vertebral body. Courtesy of Richard Waite. Associated findings include mild osteopenia and chronic fractures of the left sided ribs 3. and 6. A second compression fracture of T7 (white arrows) has resulted in about 15 percent loss of height of the vertebral body. The fractures are better appreciated on the lateral examination in both instances. MD .
The white arrow shows a near normal appearing L2 in the AP projection with normal interpedicular distance. There is less than 20 percent loss of vertebral height.Mild compression fracture of second lumbar vertebra The x-rays of the lumbar spine in the AP (A) and lateral projections (B). and magnified view of the lateral view (C). Note the stepoff deformity of the anterior and superior aspect of the endplate of L2 (yellow arrow) which is a manifestation of the injury. . reveal a mild compression fracture of the superior endplate of L2 (red arrow).
com . Lippincott Williams & Wilkins. Bucholz RB. http://www. 7th ed.lww. Fractures and dislocations of the thoracolumbar spine. Copyright © 2010 Lippincott Williams & Wilkins. In: Rockwood and Green's Fractures in Adults. Reproduced with permission from: Whang PW. (ed). Vaccaro AR.Lumbar burst fracture Anteroposterior (A) and lateral (B) radiographs demonstrating a L3 burst fracture with retropulsion of bony fragments into the spinal canal noted on an axial CT image (C). Philadelphia 2010.
The Adult and Pediatric Spine. Philadelphia 2004. Reproduced with permission from: Frymoyer JW. Wiesel SW. Copyright © 2004 Lippincott Williams & Wilkins.Vertebral burst fracture of the lumbar spine: Plain radiograph The x-rayx are from a 37-year-old female drug addict who jumped from a building in a suicide attempt. The plain x-rays in lateral projection (A) and AP projection (B) of the lumbar spine show a burst fracture of L1 characterized by loss of height and malposition of the L1 vertebral body with posterior retropulsion into the spinal canal (white arrow). The posterior elements are splayed as reflected in the widening of the pedicles (red arrows). et al. Lippincott Williams & Wilkins. .
Chance fracture is often due to seatbelt injury. Associated fractures of the lamina. . pedicles and interspinous ligament has splayed the posterior elements (white arrow).Chance fracture of the lumbar spine The plain film of the lumbar spine in the lateral projection shows a transverse fracture of the third lumbar (L3) vertebral body. Note the wide radiolucent gap between the two fracture segments (black arrows).
Lumbar spinous process and vertebral body fractures A lateral radiograph of the lumbar spine (A. MD. The 54-year-old male sustained hyperflexion injury with distraction resulting in a transverse fracture through the T12 spinous process (white arrowhead) and a compression fracture of the vertebral body (blue arrow). magnified in B). Courtesy of Robert Ward. .
Bucholz RB. Reproduced with permission from: Whang PW. Copyright © 2010 Lippincott Williams & Wilkins. In: Rockwood and Green's Fractures in Adults. (ed). Lippincott Williams & Wilkins.Thoracolumbar fracture-dislocation radiograph Anteroposterior (A) and lateral (B) radiographs of a T12-L1 fracturedislocation.com . Philadelphia 2010.lww. http://www. 7th ed. Vaccaro AR. Fractures and dislocations of the thoracolumbar spine.
The red arrows define the spinous processes on the frontal film and demonstrate the abrupt angulation centered at the dislocated level. . MD.X-ray shear fracture T12 The plain x-ray of the thoracolumbar spine in AP (A and B) and lateral projections (C and D) reveals a fracture dislocation centered around T11/T12. Courtesy of Richard Waite. The yellow arrows point to the posterior cortices of the vertebral bodies and highlight the extent of abnormal translation.
Philadelphia 2004. Copyright © 2004 Lippincott Williams & Wilkins. Yochum and Rowe's Essentials of Skeletal Radiology.X-ray fracture of lumbar transverse process The plain film tomogram of the left sided transverse processes of the lumbar spine in the AP projection reveals transverse fractures of the L3 and L4 vertebra (arrows). Rowe LJ. 3rd Edition. Lippincott Williams & Wilkins. Reproduced with permission from: Yochum TR. .
.CT transverse process fracture The CT scan of lumbar spine in the transverse projection reveals an acute incomplete fracture of the left transverse process (arrow).
A fracture of a left sided 11th rib is of incidental note. A CT scan using sagittal reformatting (C) and transverse projection (D) are more convincing for fractures through the spinous process of T11 (white arrowhead) and T12 (small white arrow).Thoracic spinous process fracture The radiograph of the thoracolumbar spine in lateral projection (A. . Courtesy of Gregory Waryasz. MD. and magnified in B) reveals an equivocal abnormality of the spinous process of T12.
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