Emergency and Trauma Imaging of the Thoracolumbar Spine

Abstract

Spine trauma is a devastating event with high morbidity and mortality and many additional medical, psychological, social, and financial consequences for patients, their families, and society. The thoracolumbar spine represents the most common area fractured in the spine. Morphology, extent, and the location of fracture lines are important determinants of stability, which is the core issue in the assessment of vertebral injuries, dictating conservative or surgical treatment. After hospital admission and clinical stabilization, patients with potential spine trauma are screened radiologically. Imaging analysis is based on radiographs, computed tomography, and magnetic resonance imaging. Understanding these three tools is essential to get a clear picture of the extent of any vertebral fracture. A multidisciplinary team should provide assessment, treatment, and education to patients with a spinal injury to achieve a treatment tailored for each patient. Thoracolumbar trauma focusing on spinal biomechanics, stability, imaging modalities, morphology patterns, classifications, and treatment are discussed and reviewed.

Keywords

thoracolumbar spine trauma - stability - CT - MRI - morphology patterns - treatment

• References

• 1 Gamanagatti S, Rathinam D, Rangarajan K, Kumar A, Farooque K, Sharma V. Imaging evaluation of traumatic thoracolumbar spine injuries: radiological review. World J Radiol 2015; 7 (09) 253-265
• 2 Bensch FV, Koivikko MP, Koskinen SK. Multidetector computed tomography of spinal fractures. Semin Roentgenol 2012; 47 (04) 330-341
• 3 Cripps RA, Lee BB, Wing P, Weerts E, Mackay J, Brown D. A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention. Spinal Cord 2011; 49 (04) 493-501
• 4 Patel RR, Adam R, Maldjian C, Lincoln CM, Yuen A, Arneja A. Cervical carotid artery dissection: current review of diagnosis and treatment. Cardiol Rev 2012; 20 (03) 145-152
• 5 Wang H, Zhang Y, Xiang Q. , et al. Epidemiology of traumatic spinal fractures: experience from medical university-affiliated hospitals in Chongqing, China, 2001–2010. J Neurosurg Spine 2012; 17 (05) 459-468
• 6 Marras WS. Biomechanics of the spinal motion segment. In: Herkowitz H, Garfin S, Elsmont FJ, Bell GR, Balderston RA. , eds. Rothman-Simeone The Spine. 6th ed. Philadelphia, PA: Elsevier/Saunders; 2011: 109-128
• 7 Sanan A, Rengachary SS. The history of spinal biomechanics. Neurosurgery 1996; 39 (04) 657-668 , discussion 668–669
• 8 Raniga SB, Menon V, Al Muzahmi KS, Butt S. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging 2014; 5 (03) 321-338
• 9 Khurana B, Sheehan SE, Sodickson A, Bono CM, Harris MB. Traumatic thoracolumbar spine injuries: what the spine surgeon wants to know. Radiographics 2013; 33 (07) 2031-2046
• 10 Looby S, Flanders A. Spine trauma. Radiol Clin North Am 2011; 49 (01) 129-163
• 11 Schueller G, Schueller-Weidekamm C. The traumatized vertebral spine reloaded: injury mechanisms and their radiologic patterns. Semin Musculoskelet Radiol 2014; 18 (03) 240-245
• 12 Daffner RH, Deeb ZL, Rothfus WE. “Fingerprints” of vertebral trauma—a unifying concept based on mechanisms. Skeletal Radiol 1986; 15 (07) 518-525
• 13 Lander P. The rigid spine. In: Cassar-Pullicino V, Imhof H. , eds. Spinal Trauma: An Imaging Approach. Stuttgart, Germany: Thieme; 2006: 155-165
• 14 Sayama C, Chen T, Trost G, Jea A. A review of pediatric lumbar spine trauma. Neurosurg Focus 2014; 37 (01) E6
• 15 Tyrrell P, Cassar-Pullicino V. Trauma to the pediatric spine. In: Cassar-Pullicino V, Imhof H. , eds. Spinal Trauma: An Imaging Approach. Stuttgart, Germany: Thieme; 2006: 113-133
• 16 Sava J, Williams MD, Kennedy S, Wang D. Thoracolumbar fracture in blunt trauma: is clinical exam enough for awake patients?. J Trauma 2006; 61 (01) 168-171
• 17 Moser T, Dosch JC. Traumatisme du rachis. In: Laredo JD, Wybier M, Petrover D, Morvan G. , eds. Imagerie rhumatologique et orthopedique. Montpellier, France: Sauramps; 2013: 1029-1067
• 18 Hauser CJ, Visvikis G, Hinrichs C. , et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma 2003; 55 (02) 228-234 ; discussion 234–235
• 19 Wintermark M, Mouhsine E, Theumann N. , et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology 2003; 227 (03) 681-689
• 20 Bohlman HH. Treatment of fractures and dislocations of the thoracic and lumbar spine. J Bone Joint Surg Am 1985; 67 (01) 165-169
• 21 Pizones J, Castillo E. Assessment of acute thoracolumbar fractures: challenges in multidetector computed tomography and added value of emergency MRI. Semin Musculoskelet Radiol 2013; 17 (04) 389-395
• 22 Sheridan R, Peralta R, Rhea J, Ptak T, Novelline R. Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients. J Trauma 2003; 55 (04) 665-669
• 23 Vaccaro AR, Lee JY, Schweitzer Jr KM. , et al; Spine Trauma Study Group. Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J 2006; 6 (05) 524-528
• 24 Radcliff K, Su BW, Kepler CK. , et al. Correlation of posterior ligamentous complex injury and neurological injury to loss of vertebral body height, kyphosis, and canal compromise. Spine 2012; 37 (13) 1142-1150
• 25 Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am 2006; 44 (01) 1-12 , vii
• 26 Parizel PM, van der Zijden T, Gaudino S. , et al. Trauma of the spine and spinal cord: imaging strategies. Eur Spine J 2010; 19 (Suppl. 01) S8-S17
• 27 Leferink VJ, Veldhuis EF, Zimmerman KW, ten Vergert EM, ten Duis HJ. Classificational problems in ligamentary distraction type vertebral fractures: 30% of all B-type fractures are initially unrecognised. Eur Spine J 2002; 11 (03) 246-250
• 28 Pizones J, Izquierdo E, Álvarez P. , et al. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. Eur Spine J 2011; 20 (Suppl. 03) 390-396
• 29 Tins B, Cassar-Pullicino V. Optimizing the imaging options. In: Cassar-Pullicino V, Imhof H. , eds. Spinal Trauma: An Imaging Approach. Stuttgart, Germany: Thieme; 2006: 36-54
• 30 Bensch FV, Kiuru MJ, Koivikko MP, Koskinen SK. Spine fractures in falling accidents: analysis of multidetector CT findings. Eur Radiol 2004; 14 (04) 618-624
• 31 Diaz Jr JJ, Gillman C, Morris Jr JA, May AK, Carrillo YM, Guy J. Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. J Trauma 2003; 55 (04) 658-663 ; discussion 663–664
• 32 Qaiyum M, Tyrrell PN, McCall IW, Cassar-Pullicino VN. MRI detection of unsuspected vertebral injury in acute spinal trauma: incidence and significance. Skeletal Radiol 2001; 30 (06) 299-304
• 33 Shear P, Hugenholtz H, Richard MT. , et al. Multiple noncontiguous fractures of the cervical spine. J Trauma 1988; 28 (05) 655-659
• 34 Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR Am J Roentgenol 2000; 174 (03) 713-717
• 35 Pizones J, Zúñiga L, Sánchez-Mariscal F, Alvarez P, Gómez-Rice A, Izquierdo E. MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures. Eur Spine J 2012; 21 (11) 2222-2231
• 36 Forster BB, Koopmans RA. Magnetic resonance imaging of acute trauma of the cervical spine: spectrum of findings. Can Assoc Radiol J 1995; 46 (03) 168-173
• 37 Gonzalez-Beicos A, Nuñez Jr DB, Fung AW, Sanchez M, Gahbauer H. Trauma to the ankylotic spine: imaging spectrum of vertebral and soft tissue injuries. Emerg Radiol 2007; 14 (06) 371-378
• 38 Shen H, Tang Y, Huang L. , et al. Applications of diffusion-weighted MRI in thoracic spinal cord injury without radiographic abnormality. Int Orthop 2007; 31 (03) 375-383
• 39 Rajasekaran S, Kanna RM, Shetty AP. Diffusion tensor imaging of the spinal cord and its clinical applications. J Bone Joint Surg Br 2012; 94 (08) 1024-1031
• 40 Venkatesan M, Fong A, Sell PJ. CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. J Bone Joint Surg Br 2012; 94 (08) 1097-1100
• 41 Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury 2003; 34 (06) 426-433
• 42 Miller CP, Brubacher JW, Biswas D, Lawrence BD, Whang PG, Grauer JN. The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center. Spine 2011; 36 (19) 1532-1540
• 43 Levi AD, Hurlbert RJ, Anderson P. , et al. Neurologic deterioration secondary to unrecognized spinal instability following trauma—a multicenter study. Spine 2006; 31 (04) 451-458
• 44 Koivikko MP, Kiuru MJ, Koskinen SK. Multidetector computed tomography of cervical spine fractures in ankylosing spondylitis. Acta Radiol 2004; 45 (07) 751-759
• 45 Balbi V, Moraux A, Glaude E, Chastanet P, Demondion X, Cotten A. Traumatismes du rachis et de la paroi thoracique. In: Cotten A. , ed. Imagerie musculosquelettique. Pathologies générales. 2nd ed. Issy-les-Moulineaux, France: Elsevier Masson; 2013: 895-941
• 46 Groves CJ, Cassar-Pullicino VN, Tins BJ, Tyrrell PN, McCall IW. Chance-type flexion-distraction injuries in the thoracolumbar spine: MR imaging characteristics. Radiology 2005; 236 (02) 601-608
• 47 Bilston LE, Brown J. Pediatric spinal injury type and severity are age and mechanism dependent. Spine 2007; 32 (21) 2339-2347
• 48 Basu S. Spinal injuries in children. Front Neurol 2012; 3: 96
• 49 Aufdermaur M. Spinal injuries in juveniles. Necropsy findings in twelve cases. J Bone Joint Surg Br 1974; 56B [phone]
• 50 Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (08) 817-831
• 51 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3 (04) 184-201
• 52 Vaccaro AR, Lehman Jr RA, Hurlbert RJ. , et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine 2005; 30 (20) 2325-2333
• 53 Joaquim AF, Fernandes YB, Cavalcante RA, Fragoso RM, Honorato DC, Patel AA. Evaluation of the thoracolumbar injury classification system in thoracic and lumbar spinal trauma. Spine 2011; 36 (01) 33-36
• 54 Oner FC, Ramos LM, Simmermacher RK. , et al. Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 2002; 11 (03) 235-245
• 55 Sethi MK, Schoenfeld AJ, Bono CM, Harris MB. The evolution of thoracolumbar injury classification systems. Spine J 2009; 9 (09) 780-788
• 56 Rajasekaran S. Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment. Eur Spine J 2010; 19 (Suppl. 01) S40-S47
• 57 Oner FC, Wood KB, Smith JS, Shaffrey CI. Therapeutic decision making in thoracolumbar spine trauma. Spine 2010; 35 (21, Suppl): S235-S244
• 58 Wilcox RK, Boerger TO, Allen DJ. , et al. A dynamic study of thoracolumbar burst fractures. J Bone Joint Surg Am 2003; 85-A (11) 2184-2189
• 59 Trivedi J. Therapy: options and outcomes. In: Cassar-Pullicino V, Imhof H. , eds. Spinal Trauma: An Imaging Approach. Stuttgart, Germany: Thieme; 2006: 113-133