Introduction
Background
Fracture of the lumbar spine, as shown in the images below, can occur whenever forces applied to the lower spinal column exceed the strength and stability of the spinal column unit. Common injuries resulting in fractures of the lumbar spine include fall from a height; motor vehicle and motor vehicle and pedestrian accidents; and penetrating trauma, including gunshot wounds and stabbings. Unstable injuries to the pelvis often are associated with injury to the sacral plexus and the lower lumbar spine.
Lumbar spine trauma. Lateral radiograph demonstrates an L3 spinal compression fracture. Note the downward compression of the superior endplate of the L3 (yellow arrow). The anterior portion of the L3 vertebral body has been displaced forward (white arrow).
Lumbar spine trauma. A 35-year-old man presented to the emergency department after a motor vehicle accident. He complained of back pain without paresthesias or weakness of his lower extremities. Sagittal reformatted CT image demonstrates fracture of the anterior L1 vertebral body with a posterior fragment displaced into the spinal canal (black arrow). The fracture extended into the spinous process (yellow arrow). A second fracture in the L3 vertebral body is noted in the posterior aspect of the inferior endplate of the L3 (white arrow).
Sagittal T2-weighted MRI of an L2 compression fracture. Relatively little deformity of the L2 vertebral body is shown, with less than 5° of kyphotic forward angulation. Compression fractures with little angulation often are associated with significant posterior ligamentous trauma (arrow).
Lumbar spine trauma. Two contiguous sagittal T2-weighted MRIs of the lumbar spine demonstrate a compression fracture of the L1 vertebral body. The anterior aspect of the L1 is compressed more than 60%. The posterior margin of the fracture encroaches into the spinal canal at the L1 level.
The goals of the diagnostic radiologist are to identify lumbar spine fractures correctly, to identify and correlate neurologic injury to vertebral fractures, to advise the surgeon (who best defines the extent of injury to supporting structures), to gauge the risk to the spinal cord, and to judge the stability of postoperative fixation. This article highlights the typical patterns of injury and focuses on the imaging methods that are most useful in the clinical practice of trauma radiology.
For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Vertebral Compression Fracture.
Recent studies
Hanson et al reviewed high-speed, whole-spine MRIs to determine variations in lumbar spine anatomy in an outpatient group of 762 patients referred for lumbar spine MR imaging. In their study, whole-spine MRI successfully determined the number of lumbar-type vertebral bodies in 750 (98%) of the patients. One in 5 of these outpatients did not have 5 lumbar-type vertebrae: 14.5% had 6; 5.3% had 4; and 1 patient had 3. The authors noted that variations from typical lumbosacral anatomy may cause confusion and potentially lead to clinical errors. In addition, they suggested that when necessary, supplementary coronal MRs, Ferguson view radiographs, or intraoperative fluoroscopic determinations for lumbosacral transitional vertebrae may be used to gather more information for clinical treatment or surgical planning.1
Gross evaluated chest CT and abdominopelvic CT to detect thoracolumbar spine fractures in blunt trauma patients, particularly whether reformatting is necessary to provide more detailed imaging. The patients received a chest and thoracic spine CT; an abdominopelvic and lumbar spine CT; or both. The authors found that the reformatting of chest CT and abdominopelvic CT scans provided improved sensitivity in the detection of thoracic and lumbar spine fractures in trauma patients. There were 9 of 176 false-negative abdominopelvic CT scans versus 3 of 176 false-negative lumbar spine CT scans; and there were 14 of 175 false-negative chest CT scans versus 2 of 175 false-negative thoracic spine CT scans. According to the authors, the differences in sensitivity were significant for both comparisons.2
Frequency
United States
In young adults, lumbar spine fractures are commonly associated with multisystemic blunt trauma. The rate of spinal fractures in a serious motor vehicle accident is 5-6%; the L1, L2, and T12 levels are most frequently injured. Injuries are most common in patients 30-39 years of age and least common in persons younger than 18 years. Compression fractures are the most typical injury in the lumbar spine. The area of the lumbar spine most often injured is the thoracolumbar junction.
International
Spinal fractures in the lumbar spine occur in people in all nations as a result of accidents and industrial injuries. The incidence of such injuries is proportionate to the number of motorized vehicles. In the developing nations of Asia, spinal fractures frequently are associated with spinal tuberculosis as well. Trauma related to military action occurs in war zones. Spinal injuries resulting from natural disasters including storms and earth quakes have been documented in recent years.
Among a sample of earthquake victims multilevel spinal injuries occurred in nearly 30%. The lumbar spine was most commonly injured. Thoracic injury contributed to the majority of the neurologic injury while lumbar injury seldom resulted in permanent neurologic damage. Almost all cervical injuries were associated with severe spinal cord injury. The majority of patients sustained other serious injuries. The frequent occurrence of multilevel injuries of the spine and additional injuries confirms the need for comprehensive assessment of multiple trauma victims.3
Mortality/Morbidity
Pain is the primary morbidity in most patients with lumbar fractures. Spinal pain may be seen in patients with acute fractures and fractures associated with advanced age. Other common forms of morbidity are lower extremity weakness or paralysis.
Mortality in patients with lumbar spine fractures is primarily the result of associated injuries to the spleen, liver, aorta, and pelvis. Delayed mortality may be associated with urinary tract infections if the injury resulted in a neurotropic dysfunction of bladder control.
Neurologic recovery is best for fractures with kyphosis of greater than 15° and minimal compromise of the spinal canal. Such injuries have been associated with a greater than 90% likelihood of neurologic recovery. Fractures with kyphosis of less than 15° and maximum canal compromise are associated with a less than 50% likelihood of neurologic recovery. Fractures with kyphosis of 15° or less and maximum canal compromise at the level of the ligamentum flavum are associated with variable neurologic recovery.
The prognosis for neurologic recovery can be estimated on the basis of the initial radiographic findings. A kyphosis of greater than 15° with only minimal deformity of the posterior aspect of the lumbar vertebral body is associated with a good prognosis. On the other hand, a Chinese study in 87 patients with thoracolumbar burst fractures found that the degree of neurologic recovery could not be reliably predicted from the extent of initial spinal canal encroachment and kyphotic deformity.4
Race
- Bone density may be greater in blacks than in other races.
- Compression fractures in elderly women are more common in whites than in blacks.
- Postmenopausal estrogen use is associated with an increased likelihood of back pain and impaired back function in elderly white women (see Intervention).
Sex
- Because young males participate in at-risk behaviors and have more accidents, they are more likely than others to have fractures of the lumbar spine.
- The occupational risk of a fall from a great height is greater among men than women.
- Compression fractures are more common among older women than other individuals.
Age
Two age distributions are noted in the occurrence of lumbar spine fractures.
- An increased frequency of abnormal radiologic findings of the lumbar spine is noted in young athletes who participate in various sports. Young elite skiers (ski jumpers) have a significantly higher rate of anterior endplate lesions of the lumbar spine than do control subjects. This difference has been attributed to excessive loading and repetitive high-velocity trauma to the immature spine. Other high-risk activities such as rock climbing, motorcycle racing, and skydiving are associated with an increased occurrence of compression and burst fractures of the lumbar spine.
- At the other end of the age spectrum, compression fractures more commonly occur in middle-aged and older women and men than in others; often, these fractures are precipitated by minimal trauma.
Presentation
Anatomy
The lumbar vertebral bodies, as shown in the images below, have a vertical height that is less than their horizontal diameter. An intervertebral disk lies between each lumbar vertebral body. The disk consists of the outer annulus fibrosis and nucleus pulposus. Generally, 5 similar lumbar vertebral bodies are distinguished from the thoracic bodies by the absence of rib facets. The pedicles project from the upper portion of the vertebral body. The spinous process is primarily horizontal in orientation, while the posterior inferior border projects below the upper level of the spinous process below.
The laminae of the lumbar region are thick and project below the pedicles. The transverse processes are long and thin with a slant that is both upward and backward. The articular facets are heavier than those of the thoracic or cervical spine. The superior facets face medially, while the inferior facets face laterally. The interarticular joints are in a parasagittal plane. When viewed in an oblique projection, the outline of the facets and the pars interarticularis appear like the neck of a Scottie dog.
The movement of the lumbar spine is largely confined to flexion and extension with a minor degree of rotation. The region between the superior articular process and the lamina is the pars interarticularis. A spondylolysis occurs if ossification of the pars interarticularis fails to occur.
The primary ligamentous support for the lumbar spine is the anterior longitudinal ligament, the posterior longitudinal ligament, the attachments of the annulus fibrosis, the facet joints, and the interosseous ligaments between the spinous processes.
Lumbar spine trauma. Drawing of the thoracolumbar spine viewed from an oblique frontal projection. AF indicates annulus fibrosis; DNR, dorsal nerve root; NP, nucleus pulposus; NRG, nerve root ganglion; SC, spinal cord; SN, spinal nerve; TP, transverse process; VB, vertebral body; and VNR, ventral nerve root.
Lumbar spine trauma. The normal lumbar spine consists of 5 vertebral bodies that are fully articulated and without associated ribs. The anterior lumbar vertebral bodies are slightly greater in vertical height than the posterior body, which results in a natural lordotic curve of the lower back.The last thoracic vertebral body (T12) has a rib facet. The first sacral segment (S1) is usually not fully articulated. The sacral joint (SJ) lies lateral to the sacrum.
Lumbar spine trauma. Lateral drawing of a lumbar vertebral body. The vertebral bodies of the lumbar spine are larger and thicker than those of the thoracic spine. The facet joints of the lumbar spine are oriented in a more anterior-posterior plane than those of the thoracic spine.
Lumbar spine trauma. Drawing of 2 lumbar segments viewed from an oblique angle. The outline of the facets and the pars interarticularis have the appearance of the "neck" of a Scottie dog.
Lumbar spine trauma. The structures of the lumbar spine can be considered as 3 columns. Trauma to the lumbar spine may result in injury limited to the anterior, middle, or posterior column, or it may involve multiple spinal columns, resulting in gross instability.
Lumbar spine trauma. Lateral drawing of the 3 spinal columns of the thoracolumbar junction. The anterior column (black dotted line) includes the anterior spinal ligament, the anterior annulus fibrosis, the intervertebral disc, and the anterior two thirds of the vertebral bodies. The middle column (red dotted line) includes the posterior aspect of the vertebral bodies, the posterior annulus fibrosis, and the posterior longitudinal ligament. The posterior column (thick blue dotted line) includes all of the spine posterior to the longitudinal ligament (thick blue dotted line).
Pathophysiology
Fractures of the lumbar spine occur any time the combined forces of compression, distraction, and rotation exceed the strength of the spinal column. The predominant force determines the nature of the fracture dislocation.
An example of a predominately distractive injury is a Chance fracture of the spine. A Chance fracture usually is a lower thoracic spinal or upper lumbar fracture with posterior ligament rupture. It represents a variant of the flexion distraction injury pattern. Usually, a minor anterior vertebral compression occurs, as shown in the images below.
Lumbar spine trauma. A Chance fracture or a modified compression fracture of the upper lumbar spine may occur when the weight of the upper body moves forward (red arrow) while the person's waist and upper body are fixed in position by the seatbelt or steering wheel of an automobile (pink arrows). The resulting fixed-position stress results in a fracture.
Lumbar spine trauma. Anterior view of a Chance fracture of the L2 vertebral body. The fracture line follows a horizontal plane through the L2 vertebral body and the transverse processes (arrows).
Lumbar spine trauma. Drawing of a Chance fracture of the thoracolumbar junction. The defect follows an irregular horizontal plane (arrows), which results in disruption of the anterior (black dotted line), the middle column (red dotted line), and the posterior column (blue dotted line).
Sagittal T2-weighted MRI of an L2 compression fracture. Relatively little deformity of the L2 vertebral body is shown, with less than 5° of kyphotic forward angulation. Compression fractures with little angulation often are associated with significant posterior ligamentous trauma (arrow).
In a Chance fracture, the anterior column fails in tension, whereas a flexion distraction fracture primarily involves compression of the anterior column and distraction of the middle and posterior columns. The distinction is principally the relative degree of posterior ligamentous injury versus anterior compression. Of patients with flexion distraction injuries, 50% have rupture of the interspinous ligament, ligamentum flavum, facet capsule, posterior annulus, and thoracodorsal fascia.
A traumatic compression fracture in a young patient (after a motor vehicle accident) should be considered a possible Chance fracture. Most Chance fractures that involve the lumbar spine occur at the L1 vertebral level; however, a similar injury pattern may occur at the L2 level. Although traditionally considered seatbelt fractures, lumbar Chance fractures from motor vehicle accidents have been reported in pediatric patients who were wearing three-point restraints properly.5
Fractures associated with flexion are more common in the upper lumbar levels and less common in the lower lumbar and sacral areas. The lower lumbar spine (L4-S1) is stabilized by the large paraspinal muscles and the limited range of motion of the L5-S1 interspace. However, at the L1-L3 levels, a fulcrum of increased motion results in the potential for a combination of acute hyperflexion and rotation, as shown in the images below.
Lumbar spine trauma. Sagittal T2-weighted gradient-echo MRI demonstrates a compression fracture of the L1 vertebral body with a small bony fragment displaced into the spinal canal.
Lumbar spine trauma. Lateral radiograph demonstrates postoperative results after stabilization of an L1 compression fracture.
Because the spinal cord terminates at the T12-L1 level, lower thoracic and upper lumbar spinal injuries at this level most commonly cause bladder and bowel signs and decreased movement and sensation in the lower extremities.
A vertical compression force, as shown in the images below, may result in compression of the endplates of the vertebral bodies, or it may result in significant deformity and spinal canal compromise. The injury pattern may be primarily posterior, resulting in spinal cord injury. Significant anterior vertebral body injury can occur without causing spinal cord injury.
Lumbar spine trauma. Drawing of the primary force involved in compression burst injury of the lumbar spine. The vertical force is directed into the central portion of the lumbar endplate (arrow). The force results in both downward and axial displacement of fragments of the vertebral body endplate.
Lumbar spine trauma. Drawing of the mechanism of injury of the lumbar spine burst injury is compared with an axial CT image. The centrally applied vertical force results in radial expansion of the vertebral body endplate. The posterior margin of the endplate may be displaced into the spinal canal (arrow).
Lumbar spine trauma. Axial T1-weighted MRI in a patient with lumbar spine compression burst injury. A comminuted fracture of the lumbar spine endplate (arrow) results in spinal canal narrowing.
Distractive injuries more commonly occur in the upper lumbar spine resulting from fixation of the pelvis with violent pulling of the upper spine. Fixed neurologic injury is common if the distraction is significant, as shown in the image below.
Lumbar spine trauma. Sagittal T1-weighted MRI of the lumbar spine demonstrates a severe degree of compression of the L1 vertebral body (arrow). More than 60% of the vertical height of the L1 has been lost due to a compression failure of the L1 body.
Axial rotation occurs in the upper lumbar region. If the rotational forces are sufficiently great, a combined fracture and rotational subluxation occurs, as shown in the image below. Injury to the conus medullaris results.
Lumbar spine trauma. Two contiguous sagittal T2-weighted MRIs of the lumbar spine demonstrate a compression fracture of the L1 vertebral body. The anterior aspect of the L1 is compressed more than 60%. The posterior margin of the fracture encroaches into the spinal canal at the L1 level.
Pathologic fractures due to metastatic or metabolic bone disease can occur with relatively minor trauma, as shown in the image below. Compression of the lateral nerve roots or the conus medullaris results in variable degrees of weakness and pain.
Lumbar spine trauma. Sagittal reformatted CT image in a patient with lumbar vertebral body distraction (arrow). Distraction injury commonly is associated with injury to the conus of the distal spinal cord.
Fracture types
Traumatic compression fractures represent a primarily vertical load injury with anterior or lateral flexion causing failure of the anterior column. The middle column remains intact and may act as a hinge. These fractures are usually stable and rarely involve neurologic compromise.
The Denis classification system includes 4 types of compression fractures:
- Type A - Involvement of both endplates
- Type B - Involvement of the superior endplate
- Type C - Involvement of the inferior endplate
- Type D - Buckling of the anterior cortex with both endplates intact
A lumbar spine burst fracture results from hyperflexion, which produces wedge compression of one or more vertebral bodies. Because of the rigidity of the ribcage, most of these fractures occur at the L1 or L2 level. The lumbar spinal canal is relatively wide in relation to the lower spinal cord and the conus; thus, lower thoracic spinal cord injuries are commonly incomplete. Kyphosis greater than 30° requires internal stabilization to prevent further deformity. Dural laceration with impaled nerve roots can be anticipated at the time of surgery if a patient with neurologic damage has a burst fracture of a vertebral body combined with a laminar fracture at the same level.
The Thoracolumbar Injury Classification and Severity Score is a more recent attempt to place thoracolumbar spine trauma into a more comprehensive clinical context. The TLICS system identifies 3 major injury characteristics including injury morphology, posterior ligamentous complex integrity, and neurological status. Minor injury characteristics and individual variables (such as ankylosing spondylitis), multisystem trauma, and chest wall injuries are considered. The TLICS system has been demonstrated to be valid. The TLICS can be incorporated into clinical practice.6
Treatment
The principal treatment for unstable lumbar spine fractures is surgical fixation with spinal canal decompression as needed, as shown in the images below. The area of injury commonly includes the lower thoracic and upper lumbar spine. Instability is usually associated with kyphosis of 20° or more. The primary posterior approach is accomplished by means of the Harrington rod system. Adverse effects resulting from the locking of vertebral segments and incomplete reconstitution of the vertebral height have been reported.
Lumbar spine trauma. Axial CT images of an L2 compression burst fracture after posterior fusion with pedicle screws (yellow arrow) joined by a posterior bar (white arrow). The pedicle screws should be entirely within the bone of the body and pedicle of the vertebral bodies.
Lumbar spine trauma. Axial CT image after a lumbar myelogram. Contrast material is noted in the posterior paraspinal region outside of the thecal sac (yellow arrows). The pedicle screws were noted to follow a satisfactory course within the pedicles of the L4 and L5 vertebral bodies. The dural leak was later successfully repaired. SC indicates the spinal canal.
Lumbar spine trauma. Oblique view of 3-dimensional reconstruction of a multisection CT scan of the lumbar spine after posterior fusion of an L2 burst fracture. Note the fractures of the L2 vertebral body and the anterior endplate of the L4 body (white arrows). Pedicle screws have been placed in the L1, L2, and L3 (yellow arrows) vertebral bodies. By using multisection CT scanning, artifacts related to the pedicle screws are kept to a minimum.
Lumbar spine trauma. Sagittal 3-dimensional surface model of a CT scan of the lumbar spine after transpedicular fixation of the L4-5 interspace. Although the pedicle screws are in a satisfactory position within the pedicles of L4 and L5, a leak is present in the dura. Contrast material from an intrathecal injection has collected in the extradural space (arrows). Dural repair was later successful.
Lumbar spine trauma. Sagittal 3-dimensional and multiplanar reformatted CT images of a fixation of the thoracic-lumbar junction. A bone graft and fixation plate have been positioned across the T11-T12-L1 levels.
An alternative posterior approach involves pedicular fixation in which 2 segments are fused. The procedure results in both fracture reduction and fixation. The injured vertebra also is grafted through the pedicle. Clearance of bone fragments from within the spinal canal is an important goal for most surgical approaches to lumbar spine fractures. Patients with complete paraplegia can be expected to remain unchanged.
Preferred Examination
A general outline for the evaluation of acute multiple trauma involving the spine is shown below.
Lumbar spine trauma. Imaging methods that may be useful in the evaluation of the patient with an acutely injured lumbar spine.
At the least, standard anteroposterior (AP) and lateral radiographs should be obtained in all patients. A possible exception is the patient who is ambulating independently and complaining of back pain after a motor vehicle collision; in a retrospective study that included 1,110 such patients, Tamir et al found that no lumbar and thoracic spine radiographs were positive for a fracture or dislocation.7
Oblique views are useful if the AP and lateral views demonstrate scoliosis or a questionable defect of the posterior spinal elements. Flexion and extension views are helpful if subluxation is detected or if a chronic injury may be present. In all patients with compression fracture, the anterior height of the vertebral body is diminished, whereas the posterior height remains within normal limits. No subluxation of vertebral bodies is present. The anterior compression is less than 40% unless a burst fracture is present, as shown in the images below.
Lumbar spine trauma. Lateral radiograph demonstrates an L3 spinal compression fracture. Note the downward compression of the superior endplate of the L3 (yellow arrow). The anterior portion of the L3 vertebral body has been displaced forward (white arrow).
Lumbar spine trauma. Lateral radiograph of an L2 fracture demonstrates a pattern of downward compression (yellow arrow) and anterior fracture fragment displacement (white arrow).
After conventional radiography, CT is the primary means used to depict the posterior elements, which is necessary to exclude posterior instability and vertebral body deformity. CT scans are better in depicting the spinal canal and in estimating the degree of neural compromise. In a burst fracture, CT best demonstrates posterior spinal element involvement, as shown in the image below. A Chinese study comparing plain radiography with CT for assessing thoracolumbar burst or compression fractures found that although plain radiographs are qualitatively acceptable, especially with experienced observers, radiographs are inadequate for quantitative assessment—in particular, they tend to underestimate vertebral body comminution—and that treatment planning requires the addition of CT scanning.8
Lumbar spine trauma. A 35-year-old man presented to the emergency department after a motor vehicle accident. He complained of back pain without paresthesias or weakness of his lower extremities. Axial CT image demonstrates a compression fracture of the upper lumbar spine. Note the comminuted fracture pattern.
Axial CT scans fail to demonstrate subtle horizontally oriented injuries of the vertebral bodies, pedicles, or laminae. Also, axial CT scans may not depict minimal vertebral body compression fractures. The use of frontal and sagittal reformation, together with thin primary imaging sections, can overcome most of these limitations, as shown in the images below.
Lumbar spine trauma. A 35-year-old man presented to the emergency department after a motor vehicle accident. He complained of back pain without paresthesias or weakness of his lower extremities. Sagittal reformatted CT image demonstrates fracture of the anterior L1 vertebral body with a posterior fragment displaced into the spinal canal (black arrow). The fracture extended into the spinous process (yellow arrow). A second fracture in the L3 vertebral body is noted in the posterior aspect of the inferior endplate of the L3 (white arrow).
Lumbar spine trauma. Sagittal multiplanar reformatted CT scan demonstrates a compression fracture of the L1 vertebral body (white arrow). A large fragment of bone projects into the spinal canal (yellow arrow).
Many patients who present with lumbar spine injury have pulmonary, rib, or vascular injury. The expense and delay of obtaining routine CT scans of the lumbar spine are not justified. A review of the bone windows of thoracic and abdominal CT scans reveals most major deformities that are associated with Chance fracture, distraction injury, and burst vertebral fractures. More complex injuries can be studied later if necessary, but multisection CT studies can be reformatted to examine the lumbar spine in a lateral (sagittal) view. The use of MRI in spinal trauma should be linked to neurologic examination or unexplained severe spinal pain.
MRIs of the lumbar spine provide information that is not available with CT scans. Early in an injury, T1-weighted spin-echo (SE) axial and sagittal images may demonstrate the high signal intensity related to acute hemorrhage, including the rare complicating epidural hemorrhage. Both T2-weighted fast spin-echo (FSE) and fluid-attenuated inversion recovery (FLAIR) images demonstrate the high signal intensity associated with edema of bone marrow fat.
Gradient-echo T2-weighted images best outline the shape and structure of the vertebral body and the posterior spinal elements. These MRIs are superior to CT scans for the detection of a posttraumatic herniated disk, ligamentous edema, and spinal cord compression. Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) contrast enhancement should be used in patients with suspected metastatic disease and septic spondylosis, diskitis, or osteomyelitis, as shown in the image below.
Sagittal T2-weighted MRI of an L2 compression fracture. Relatively little deformity of the L2 vertebral body is shown, with less than 5° of kyphotic forward angulation. Compression fractures with little angulation often are associated with significant posterior ligamentous trauma (arrow).
Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.
Occult injury associated with lumbar vertebral body compression may be better assessed by using nuclear medicine bone scanning than with other techniques. Technetium-99m hydroxydimethylpyrimidine (HDP) is most commonly administered for this test. Chronic injuries demonstrate moderately increased activity, whereas acute fractures usually demonstrate a focally increased activity.
Limitations of Techniques
Radiographs may not clearly demonstrate the posterior spine elements, and excluding a Chance fracture can be difficult. Also, although most compression fractures in older patients are benign, a significant number of spontaneous compression fractures are related to metastatic disease. Follow-up imaging with contrast-enhanced MRI is indicated in all patients in whom a mass is noted and in all patients in whom a primary malignancy is suspected. Axial CT scans may fail to depict subtle horizontally oriented injuries of the vertebral bodies, pedicles, or laminae. Axial CT scans also may miss minimal vertebral body compression fractures. The use of frontal and sagittal reformation, together with thin primary image sections, can overcome most of these limitations. The resolution of MRIs used in the detection of spinal fractures is limited. Although gradient-echo and T1-weighted SE images outline fractures better, minimally displaced fractures are difficult to see.
Although nuclear medicine bone scans are sensitive to the processes that destroy or injure bone, a positive area of increased uptake on a bone scan is not specific for fracture. The fracture may not be detectable for as long as 72 hours after an injury. The resolution of fracture outlines is poor with nuclear medicine studies. Large osteophytes and intervertebral disk narrowing with vertebral endplate sclerosis may appear as areas of increased activity on standard nuclear bone scans. CT scans of the lumbar region may help in making the diagnosis if the results of a bone scan are positive. MRI is most effective in the identification of neoplasm and osteomyelitis.9
Differential Diagnoses
| Arachnoid Cyst | Osteoporosis, Involutional |
| Hemangioma, Bone | Septic Arthritis |
| Multiple Myeloma | Spondylolisthesis |
| Osteomalacia and Renal Osteodystrophy | Spondylolysis |
| Osteomyelitis, Chronic |
More on Lumbar Spine, Trauma |
 Overview: Lumbar Spine, Trauma |
| Imaging: Lumbar Spine, Trauma |
| Follow-up: Lumbar Spine, Trauma |
| Multimedia: Lumbar Spine, Trauma |
| References |
| Further Reading |
| Next Page » |
References
Hanson EH, Mishra RK, Chang DS, Perkins TG, Bonifield DR, Tandy RD, et al. Sagittal whole-spine magnetic resonance imaging in 750 consecutive outpatients: accurate determination of the number of lumbar vertebral bodies. J Neurosurg Spine. Jan 2010;12(1):47-55. [Medline].
Gross EA. Computed tomographic screening for thoracic and lumbar fractures: is spine reformatting necessary?. Am J Emerg Med. Jan 2010;28(1):73-5. [Medline].
Chen R, Song Y, Kong Q, Zhou C, Liu L. Analysis of 78 patients with spinal injuries in the 2008 Sichuan, China,earthquake. Orthopedics. May/2009;32(5):322. [Medline].
Dai LY, Wang XY, Jiang LS. Neurologic recovery from thoracolumbar burst fractures: is it predicted by the amount of initial canal encroachment and kyphotic deformity?. Surg Neurol. Mar 2007;67(3):232-7; discussion 238. [Medline].
Louman-Gardiner K, Mulpuri K, Perdios A, Tredwell S, Cripton PA. Pediatric lumbar Chance fractures in British Columbia: chart review and analysis of the use of shoulder restraints in MVAs. Accid Anal Prev. Jul 2008;40(4):1424-9. [Medline].
[Best Evidence] [Guideline] Patel AA, Dailey A, Brodke DS, Daubs M, Harrop J, Whang PG, et al. Thoracolumbar spine trauma classification: the Thoracolumbar InjuryClassification and Severity Score system and case examples. J Neurosurg Spine. March 2009;10(3):201-6. [Medline].
Tamir E, Anekstein Y, Mirovsky Y, Heim M, Dudkiewicz I. Thoracic and lumbar spine radiographs for walking trauma patients--is it necessary?. J Emerg Med. Nov 2006;31(4):403-5. [Medline].
Dai LY, Wang XY, Jiang LS, Jiang SD, Xu HZ. Plain radiography versus computed tomography scans in the diagnosis and management of thoracolumbar burst fractures. Spine. Jul 15 2008;33(16):E548-52. [Medline].
Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiol. May 2008;37(5):405-13. [Medline]. [Full Text].
Rutherford EE, Tarplett LJ, Davies EM, Harley JM, King LJ. Lumbar spine fusion and stabilization: hardware, techniques, and imaging appearances. Radiographics. Nov-Dec 2007;27(6):1737-49. [Medline]. [Full Text].
[Best Evidence] [Guideline] Deunk J, Brink M, Dekker HM, Kool DR, van Kuijk C, Blickman JG, et al. Routine versus selective computed tomography of the abdomen, pelvis, and lumbar spine in blunt trauma: a prospective evaluation. J Trauma. April;66(4):1108-17. [Medline].
Barrett TW, Schierling M, Zhou C, Colfax JD, Russ S, Conatser P, et al. Prevalence of incidental findings in trauma patients detected by computed tomography imaging. Am J Emerg Med. May/2009;27(4):428-35. [Medline].
Martin S, Raup G, Hunter S, Cho P. Surgical management of traumatic L2-L3 spondyloptosis. AORN J. Apr/2009;89(4):657-76. [Medline].
Sugrue PA, O'Shaughnessy BA, Nasr F, Koski TR, Ondra SL. Abdominal complications following kyphosis correction in ankylosing spondylitis. J Neurosurg Spine. February 2009;10(2):154-9. [Medline].
[Guideline] Zdeblick TA, Sasso RC, Vaccaro AR, Chapman JR, Harris MB. Surgical treatment of thoracolumbar fractures. Instr Course Lect. 2009;58:639-44. [Medline].
Amar AP, Larsen DW, Esnaashari N, et al. Percutaneous transpedicular polymethylmethacrylate vertebroplasty for the treatment of spinal compression fractures. Neurosurgery. Nov 2001;49(5):1105-14; discussion 1114-5. [Medline].
Zoarski GH, Snow P, Olan WJ, et al. Percutaneous Vertebroplasty for Osteoporotic Compression Fractures: Quantitative Prospective Evaluation of Long-term Outcomes. J Vasc Interv Radiol. Feb 2002;13(2):139-48. [Medline].
Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt CJ, et al. Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]. BMC Musculoskelet Disord. Nov 25 2008;9:156. [Medline].
Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, et al. Vertebroplasty, first 1000 levels of a single center: evaluation of the outcomes and complications. AJNR Am J Neuroradiol. Apr 2007;28(4):683-9. [Medline]. [Full Text].
Rashid F, Riccio SA, Munk PL, Malfair D, Heran MK. Vertebroplasty for vertebral compression fractures secondary to Cushing'ssyndrome induced by an ACTH-producing bronchial carcinoid tumour. Singapore Med J. Apr/2009;50(4):e147-50. [Medline].
van der Schaaf I, Fransen H. Percutaneous vertebroplasty as treatment for Kummell's disease. JBR-BTR. Mar-Apr/2009;92(2):83-5. [Medline].
Lo YP, Chen WJ, Chen LH, Lai PL. New vertebral fracture after vertebroplasty. J Trauma. Dec 2008;65(6):1439-45. [Medline].
Hiwatashi A, Ohgiya Y, Kakimoto N, Westesson PL. Cement leakage during vertebroplasty can be predicted on preoperative MRI. AJR Am J Roentgenol. Apr 2007;188(4):1089-93. [Medline]. [Full Text].
Musgrave DS, Vogt MT, Nevitt MC, Cauley JA. Back problems among postmenopausal women taking estrogen replacement therapy: the study of osteoporotic fractures. Spine. Jul 15 2001;26(14):1606-12. [Medline].
[Best Evidence] [Guideline] Dai LY, Ding WG, Wang XY, Jiang LS, Jiang SD, Xu HZ. Assessment of ligamentous injury in patients with thoracolumbar burst fractures using MRI. J Trauma. June, 2009;66(6):1610-5. [Medline].
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone Joint Surg Am. 2009;91:1033-41. [Medline].
Karger B, Teige K, Fuchs M, Brinkmann B. Was the pedestrian hit in an erect position before being run over?. Forensic Sci Int. Jun 15 2001;119(2):217-20. [Medline].
Higashitani K, Kondo T, Sato Y, et al. Complete transection of the pancreas due to a single stamping injury: a case report. Int J Legal Med. Oct 2001;115(2):72-5. [Medline].
Fager CA. Professional liability and potential liability. Neurosurgery. Jun 1985;16(6):866-72. [Medline].
Clark P, Letts M. Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg. Oct 2001;44(5):337-45. [Medline].
Diaz JJ Jr, Cullinane DC, Altman DT, Bokhari F, Cheng JS, Como J, et al. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma. Sep 2007;63(3):709-18. [Medline].
Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the lumbar spine. Spine. Feb 15 2002;27(4):432-8. [Medline].
Holmes JF, Miller PQ, Panacek EA, et al. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med. Sep 2001;8(9):866-72. [Medline].
Kaufmann TJ, Jensen ME, Schweickert PA, et al. Age of fracture and clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol. Nov-Dec 2001;22(10):1860-3. [Medline].
Kossmann T, Jacobi D, Trentz O. The use of a retractor system (SynFrame) for open, minimal invasive reconstruction of the anterior column of the thoracic and lumbar spine. Eur Spine J. Oct 2001;10(5):396-402. [Medline].
Nolla JM, Gomez-Vaquero C, Fiter J, et al. Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures. Ann Rheum Dis. Jan 2002;61(1):73-5. [Medline].
Oskouian RJ Jr, Johnson JP. Vascular complications in anterior thoracolumbar spinal reconstruction. J Neurosurg. Jan 2002;96(1 Suppl):1-5. [Medline].
Ryu KS, Park CK, Kim MC, Kang JK. Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures. J Neurosurg. Jan 2002;96(1 Suppl):56-61. [Medline].
Schellinger D, Lin CS, Hatipoglu HG. Potential value of vertebral proton MR spectroscopy in determining bone weakness. AJNR Am J Neuroradiol. Sep 2001;22(8):1620-7. [Medline].
Shaw CK, Li YM, Wang LY, et al. Prediction of bone fracture by bone mineral density in Taiwanese. J Formos Med Assoc. Dec 2001;100(12):805-10. [Medline].
Theodorou DJ, Theodorou SJ, Duncan TD, et al. Percutaneous balloon kyphoplasty for the correction of spinal deformity in painful vertebral body compression fractures. Clin Imaging. Jan-Feb 2002;26(1):1-5. [Medline].
Thompson NS, Date R, Charlwood AP, et al. Seat-belt syndrome revisited. Int J Clin Pract. Oct 2001;55(8):573-5. [Medline].
Vaccaro AR, Silber JS. Post-traumatic spinal deformity. Spine. Dec 15 2001;26(24 Suppl):S111-8. [Medline].
Yen D, Kuriachan V, Yach J, Howard A. Long-term outcome of anterior decompression and spinal fixation after placement of the Wellesley Wedge for thoracic and lumbar spinal metastasis. J Neurosurg. Jan 2002;96(1 Suppl):6-9. [Medline].
Further Reading
Related eMedicine topics
Lumbar Spine Fractures and Dislocations
Lumbar Compression Fracture
Keywords
Chance fracture, pathologic fracture, burst fracture, insufficiency fracture, spondylolysis deformity, spondylolisthesis, lumbar spine trauma, lumbar spine injury, lumbar spine fracture
