Lumbar Spine Fractures and Dislocations Workup

  • Author: Federico C Vinas, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Apr 19, 2011
 

Laboratory Studies

  • The evaluation of a patient with an acute lumbar spine fracture should include routine laboratory tests, such as CBC count, electrolytes, coagulation profile, and blood type and crossmatch. Spinal fractures often are associated with open fractures of the limbs, with significant blood loss and acute anemia. Additional spinal fractures at noncontiguous levels can occur, often in high-energy injuries. These need to be excluded. A careful medical history should be documented, and a careful physical examination, including a thorough neurologic examination, should be performed.
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Imaging Studies

A 42-year-old man fell from a tree. He arrived at A 42-year-old man fell from a tree. He arrived at the hospital with a complete paraplegia. Plain radiographs reveal a fracture of L2 with L2-L3 subluxation. CT scan of a 42-year-old man who fell from a tree.CT scan of a 42-year-old man who fell from a tree. He arrived at the hospital with a complete paraplegia (same patient as in Image above). Note the large amount of bone retropulsed inside the spinal canal. CT scan showing a burst of the L2 vertebral body. CT scan showing a burst of the L2 vertebral body.

The combination of plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI) allows bony and ligamentous injuries to be defined. The analysis of the radiological studies should be based on biomechanical concepts. The information obtained from these studies allows for classification of the injuries and identification of unstable injuries, and it aids in selection of the proper instrumentation to adequately stabilize the bony elements.[24]

  • Plain radiographs
    • The most important initial radiographic examination is a complete spinal radiograph series including anteroposterior (AP), lateral, and oblique views. Upright, weight-bearing, or flexion and extension radiographs may be useful in determining instability from ligamentous injuries in some cases. Analysis of plain radiographs should proceed in an organized sequence, beginning with the alignment on both AP and lateral radiographs, with identification of the margins of the vertebral bodies, spinolaminar line, articular facet joints, interspinous distance, and the position of the transverse processes. Oblique radiographs are useful in examining for pars interarticularis fractures and facet subluxation.
    • In patients with severe multiple traumatic injuries the preliminary radiology studies performed in the trauma room are essential for the management of patients with traumatic injury to the spine. They will have an impact on the need for further testing and type of immediate management.
    • Abnormalities of alignment include disruption of the anterior or posterior vertebral body lines, disruption of the spinolaminar line, dislocated facets, and rotation of spinous processes. Kyphotic angulation often is associated with misalignment and bony fractures. Disruption of the posterior margin of the vertebral body line and widening of the interpediculate distance are important signs of vertebral disruption. Narrowing of a disk space usually accompanies a flexion injury and is seen at the level above the fractured vertebra. Widening of the facet joint or complete baring of the facets indicates a severe posterior ligamentous injury. These findings usually are associated with widening of the interspinous distance.
  • CT scan
    • Following the analysis of routine spinal radiographs, a CT scan is performed on areas of suspected bony injury. CT scanning best defines complex fractures and involvement of the posterior elements.
    • The scan should include one full vertebra above and one full vertebra below the level of the fracture, with 3- to 5-mm thickness. Both bone and soft tissue windows should be imaged and coronal and sagittal reconstructions obtained.
    • Fractures oriented in a horizontal plane, such as Chance fractures and fracture-compression, may not be well visualized with axial CT scans. Coronal reconstructions facilitate the evaluation of complex spinal fractures. Tridimensional reconstructions can be used to better define the extent of canal compromise and posterior element fractures.[14]
  • MRI
    • MRI allows better visualization of the spinal cord and ligamentous structures.[25] On T2-weighted images, high signal intensity indicates spinal cord injury and edema. Ligament disruptions can sometimes be demonstrated with MRI. The anterior and posterior longitudinal ligaments are best seen on T1- and T2-weighted images, respectively. Identifying disrupted ligaments frequently is easier than identifying intact ligaments.
    • One disadvantage of MRI is the need for special nonmagnetic mechanical ventilators and other life-support monitors. Some patients who are hemodynamically unstable may not be candidates for MRI scanning. In addition, patients with multiple traumatic injuries frequently pelvic fractures stabilized with external fixators, which may produce significant metallic artifact. MRI is contraindicated in patients with implanted pacemakers, dorsal column spinal cord stimulators, vagal nerve stimulators, or other metallic mechanical implants.
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Other Tests

  • Electromyography and nerve conduction studies
    • Needle electrode muscle evaluation studies and nerve conduction studies are complementary techniques, usually performed together. Because results usually are negative if the studies are performed during the acute period, these studies are important during the subacute phase (1 or 2 wk following the injury).
      • Electromyography can show evidence of denervation in the lower extremity muscles or abnormalities in the sphincter muscles. Examination of the paraspinal muscles makes it possible to distinguish lesions on the spinal cord or cauda equine from lesions in the lumbar or sacral plexus.
      • Nerve conduction studies are an essential part of the evaluation of suspected radiculopathy. For example, the demonstration of a superficial peroneal sensory response in the face of L5 symptoms and a sural sensory response in the face of S1 symptoms are useful in localizing the lesions to proximal levels. Motor nerve conduction study results can be normal in most patients with lumbosacral radiculopathies, and peroneal motor conduction velocity may be mildly slowed.
  • Urodynamic studies
    • Patients with spinal fractures can develop urinary retention.
    • Methods of objectively testing the behavior of the lower urinary tract during filling, storage, and micturition include uroflowmetry, cystometry, sphincteric electromyography, and combined studies. The appropriate use of urodynamic testing provides valuable information for the evaluation and subsequent treatment of neurourological dysfunction.
  • Evoked potentials: Somatosensory evoked potentials and nerve action potentials may be employed to both illustrate preoperative dysfunction and confirm postoperative improvement.
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Contributor Information and Disclosures
Author

Federico C Vinas, MD  Consulting Neurosurgeon, Department of Neurological Surgery, Halifax Medical Center

Federico C Vinas, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons, Florida Medical Association, and North American Spine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Lee H Riley III, MD  Chief, Division of Orthopedic Spine Surgery, Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, Johns Hopkins University

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

William O Shaffer, MD  Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association

Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

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A 42-year-old man fell from a tree. He arrived at the hospital with a complete paraplegia. Plain radiographs reveal a fracture of L2 with L2-L3 subluxation.
CT scan of a 42-year-old man who fell from a tree. He arrived at the hospital with a complete paraplegia (same patient as in Image above). Note the large amount of bone retropulsed inside the spinal canal.
CT scan showing a burst of the L2 vertebral body.
Postoperative lateral radiograph; although the patient was paraplegic, in order to prevent severe kyphotic deformity of the spine and to allow a rapid mobilization, a posterior arthrodesis was performed with pedicle screws, hooks, and rods.
A 37-year-old man who underwent an anterior approach for an unstable L1 burst fracture. A corpectomy was performed, with a vertebral reconstruction with Harms cages and a screw to stabilize the cage. The patient subsequently underwent a posterior arthrodesis with iliac crest bone graft and transpedicular screw placement.
A 52-year-old man was involved in a severe motor vehicle collision. He arrived at the hospital with severe pain but no neurologic deficit. Lateral plain radiographs show a fracture at T12.
Sagittal T2-weighted image of a 52-year-old man who was involved in a severe motor vehicle collision. He arrived at the hospital with severe pain but no neurologic deficit (same patient as in Image 6). Image reveals a significant mass effect within the spinal canal.
Patients with compression fractures not compromising the spinal canal can be treated by means of a kyphoplasty. The use of a percutaneous balloon allows for expansion of the fractured vertebrae. Then, the void created by the balloon is filled with bone cement
Patients with an acute compression fracture treated with kyphoplasty. AP and lateral views demonstrate a good expansion of the compressed vertebral body and nice feeling with cement.
A 47-year-old man was involved in a motor vehicle accident. He arrived at the hospital with paraplegia but preserved sensation in both lower extremities. He was immediately taken to surgery for an open reduction of the fracture, decompression of the cauda equine, and arthrodesis of the spine. He regained motor function following the surgery.
 
 
 
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