History

Patients with spinal injuries should be questioned about any transient paralysis or paresthesias involving the lower extremities. The history of the accident should include attention to mechanisms, including the following:

Whether the patient was the driver or the passenger
Whether the patient was restrained or unrestrained
What the vehicle's rate of speed was
What distance the patient fell (for injuries from falls from heights)
What weights were applied to the spine at the time of injury

If the patient is unable to relate the history, it may be obtained from emergency medical personnel on the scene or other witnesses. Schouten et al emphasize the importance of the initial assessment.^[11]

Physical Examination

The physical examination should initially include attention to the details relevant for all traumatized patients (ie, the ABCs [patent airway, spontaneous breathing, stable circulation], blood pressure, and pulse). In the spinal examination, specific attention should be paid to direct palpation for tenderness, deformity, or defects.

The unique finding in thoracolumbar dislocations is that of a fixed gibbus deformity at the level of injury. The patient is most appropriately placed in the lateral decubitus position with the knees flexed if any neurologic compromise is present. This maximizes the residual diameter of the narrowed spinal canal.

A thorough neurologic examination should include the following:

Graded motor function of the major muscles in the lower extremity (0-5)
Sensory examination to both sharp and dull stimuli
Reflex evaluation

In addition to the tendon reflexes, the bulbocavernosus and cremasteric reflexes and the perianal wink should be recorded. A rectal examination documenting the status of the patient's rectal tone must be routinely performed. Dermatomes can be assessed quickly, and landmarks, such as the umbilicus (T10), anterior knee (L3), dorsolateral foot (S1), and perianal region (S3-5), can be used.

Usually, an indwelling catheter is inserted into the bladder, and urine output is monitored.

Workup

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Media Gallery

Flexion distraction injury with facet dislocation.
Fracture dislocation.

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Author

J Allan Goodrich, MD Staff Physician, Orthopaedic Spine Surgeon, Doctor's Hospital

J Allan Goodrich, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Society of Lateral Access Surgery

Disclosure: Received income in an amount equal to or greater than $250 from: Globus medical<br/>Intellectual property Globus.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

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

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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