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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 - PowerPoint PPT Presentation
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Thoraco-LumbarThoraco-Lumbar RadiographyRadiography
Moritz HaagerMoritz Haager
March 4, 2004March 4, 2004
AnatomyAnatomy
Thoracic SpineThoracic Spine
Lumbar SpineLumbar Spine
Determinants of StabilityDeterminants of Stability
T & L spines are more stable than C-spineT & L spines are more stable than C-spine Strong ligamentsStrong ligaments Stabilization by ribsStabilization by ribs Bigger intervertebral discsBigger intervertebral discs Larger facet jointsLarger facet joints Less mobilityLess mobility
Fractures & dislocations tend to occur where Fractures & dislocations tend to occur where curvature changescurvature changes T11-12 (thoracolumbar junction)T11-12 (thoracolumbar junction) L5-S1 (lumbosacral junction)L5-S1 (lumbosacral junction)
Mechanisms of InjuryMechanisms of Injury
Hyperflexion +/- rotationHyperflexion +/- rotation CommonestCommonest Usually see anterior wedge #’s or Chance #Usually see anterior wedge #’s or Chance #
ShearingShearing Ant or post translationAnt or post translation
HyperextensionHyperextension
Axial loadingAxial loading Compression or burst #’sCompression or burst #’s
3 Column Model3 Column ModelAnterior columnAnterior column
Ant longitudinal ligAnt longitudinal lig Ant annulus fibrosisAnt annulus fibrosis Ant vertebral bodyAnt vertebral body
Middle columnMiddle column Post longitudinal ligPost longitudinal lig Post annulus fibrosisPost annulus fibrosis Post vertebral bodyPost vertebral body
Posterior columnPosterior column Spinous processesSpinous processes Transverse processesTransverse processes LaminaLamina Facet jointsFacet joints PediclesPedicles Post ligamentous complexPost ligamentous complex
2 or more columns disrupted = 2 or more columns disrupted = unstableunstableMost disruption of middle columns are Most disruption of middle columns are unstableunstable
Stable or Unstable?Stable or Unstable?
Radiographic findings suggestive of instabilityRadiographic findings suggestive of instability Vertebral body collapse w/ widening of pediclesVertebral body collapse w/ widening of pedicles > 33% canal compromise on CT> 33% canal compromise on CT > 2.5 mm translation b/w vertebral bodies in any > 2.5 mm translation b/w vertebral bodies in any
planeplane Bilateral facet dislocationBilateral facet dislocation Abnormal widening b/w spinous processes or lamina Abnormal widening b/w spinous processes or lamina
and > 50% anterior collapse of vertebral bodyand > 50% anterior collapse of vertebral body
Stable or Unstable?Stable or Unstable?
Checklist for InstabilityChecklist for Instability Anterior elements disruptedAnterior elements disrupted 2 pts2 pts Posterior elements disruptedPosterior elements disrupted 2 pts2 pts Saggital plane translation > 2.5 mmSaggital plane translation > 2.5 mm 2 pts2 pts Saggital plane rotation > 5Saggital plane rotation > 5oo 2 pts2 pts Spinal cord or cauda equina damageSpinal cord or cauda equina damage 2 pts2 pts Disruption of costovertebral articulationsDisruption of costovertebral articulations 1 pt1 pt Dangerous loading anticipatedDangerous loading anticipated 2 pts2 pts
5 or more pts unstable until healed or surgically 5 or more pts unstable until healed or surgically stabilizedstabilized
Stable or Unstable?Stable or Unstable?
Risk of neurologic Risk of neurologic injury increases withinjury increases with > 35% canal narrowing > 35% canal narrowing
at T11-12at T11-12 > 45% canal narrowing > 45% canal narrowing
at L1at L1 > 55% canal narrowing > 55% canal narrowing
at L2 & belowat L2 & below
Approach to T & L SpinesApproach to T & L Spines
A – adequacy & alignmentA – adequacy & alignment All vertebrae need to be visibleAll vertebrae need to be visible Ant & post longitudinal linesAnt & post longitudinal lines Facet joints should lie on smooth curveFacet joints should lie on smooth curve Normal kyphosis & lordosisNormal kyphosis & lordosis All spinous processes should lie in straight lineAll spinous processes should lie in straight line
B – bonesB – bones Trace cortical margins of each vertebraeTrace cortical margins of each vertebrae Difference b/w ant & post body ht Difference b/w ant & post body ht << 2 mm 2 mm Progressive increase in vertebral body ht moving Progressive increase in vertebral body ht moving
down spinedown spine Wink sign & interpedicular distanceWink sign & interpedicular distance Don’t forget to look at transverse processesDon’t forget to look at transverse processes
Approach to T & L SpinesApproach to T & L Spines
C – cartilageC – cartilage Progressive increase in disc space moving Progressive increase in disc space moving
down spine (except L5-S1)down spine (except L5-S1) Facet joint alignmentFacet joint alignment
S –soft tissueS –soft tissue Look at paraspinal stripe and prevertebral Look at paraspinal stripe and prevertebral
spacespace
Case 1Case 1
38 yo female brought to ED after being 38 yo female brought to ED after being backed over by car driven by boyfriendbacked over by car driven by boyfriend
Intoxicated; c/o back pain & demonstrating Intoxicated; c/o back pain & demonstrating the remarkable versatility of the F-wordthe remarkable versatility of the F-word
Transverse process fracturesof L2-4
Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20%)
Case 2Case 2
46 yo male presents to ED after falling 12 46 yo male presents to ED after falling 12 feet off ladder while putting up Christmas feet off ladder while putting up Christmas lights c/o back painlights c/o back pain
AnterolisthesisOf L4 on L5
CT demonstrates chronic anterolisthesis with no intrusion into spinal canal
Case 3Case 3
50 yo male again 10-12 foot fall off ladder 50 yo male again 10-12 foot fall off ladder while putting up Christmas lights while putting up Christmas lights (dangerous hobby)(dangerous hobby)
Mild ant wedging ofT3 & T4
Mild ant wedging ofT3 & T4
Case 4Case 4
21 yo belted passenger in rollover single 21 yo belted passenger in rollover single vehicle MVA at highway speedvehicle MVA at highway speed
Widened paraspinalline suggestinghematoma
Laterally displacedT5 pedicle
Anterior wedging of T4 & T5w/ loss of 30-40% of body ht
Case 5Case 5
29 yo driver offroading in pick-up truck – 29 yo driver offroading in pick-up truck – rolls it at speedrolls it at speed
Not belted, ejected from vehicle and Not belted, ejected from vehicle and trapped underneath for 3 hrstrapped underneath for 3 hrs
Paramediastinalsoft tissue density & widening
Suggestive ofcompression fractures
Case 6Case 6
22 yo male single vehicle rollover. Not 22 yo male single vehicle rollover. Not restrained – ejected through windshield at restrained – ejected through windshield at highway speedshighway speeds
Comminution & anterior wedgingof L2 w/ 50% loss of body Ht
Posterior displacement
Involvement of pedicles & laminar arch
CT demonstrates severe burst #w/ horizontal plane extending posteriorly through pediclesand transverse processes in keepingw/ a CHANCE fracture
Case 7Case 7
58 yo roofer presents to ED unconscious 58 yo roofer presents to ED unconscious after plunging 12 feet onto concrete after plunging 12 feet onto concrete through skylightthrough skylight
Schmorl’s node
Compression fracture of L3w/ no obvious post elementinvolvement