Lumbosacral Spine Acute Bony Injuries Workup

Updated: Dec 11, 2018
  • Author: Federico C Vinas, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Workup

Laboratory Studies

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  • The evaluation of a patient with an acute lumbar spine fracture should include routine laboratory tests such as a complete blood cell (CBC) count, electrolyte evaluation, coagulation profile, and blood type and crossmatch. Spinal fractures are often associated with open fractures of the limbs, with significant blood loss and acute anemia.

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Imaging Studies

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  • The combination of plain radiographs, computed tomography (CT) scans, and magnetic resonance images (MRIs) allows definition of the bony and ligamentous injuries that have been inflicted. The information from these studies helps in the (1) classification of the injury, (2) identification of unstable injuries, and (3) selection of the proper instrumentation to adequately stabilize the unstable bony elements.

  • The initial radiographic examination in the emergency department is a complete spine radiograph series.

    • Analysis of plain radiographs should proceed in an organized sequence beginning with the alignment of both anteroposterior and lateral radiographs; identification of the margins of the vertebral bodies, spinolaminar line, articular facets joints, and interspinous distance; and the position of the transverse processes.

    • Abnormalities of alignment include disruption of the anterior or posterior vertebral body lines, disruption of the spinolaminar line, dislocation of the facets, and rotation of the spinous processes.

    • Kyphotic angulation is often 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 disc 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 are usually associated with widening of the interspinous distance.

  • Following the analysis of routine spine x-ray films, a CT scan is performed on areas of suspected bony injury.

    • CT scan images best define complex fractures and involvement of the posterior elements of the spine, as shown below.

      Axial computed tomography scan of an athlete who h Axial computed tomography scan of an athlete who had a hyperextension injury that resulted in disruption of the posterior spinal elements. This patient had compromise of the anterior and middle spinal columns, resulting in an unstable fracture.
    • The scan should include 1 full vertebra above and 1 full vertebra below the level of the fracture, with 3- to 5-mm thickness. Both bone and soft-tissue windows should be imaged.

    • Fractures oriented in a horizontal plane, such as Chance fractures and fracture-compression, may not be well visualized with axial scans. Therefore, sagittal and coronal reconstructions should be performed routinely in the evaluation of spinal fractures. 3-D reconstructions can be used to better define the extent of canal compromise and posterior element fractures, although this is not always necessary. See the images below.

      A computed tomography scan with sagittal reconstru A computed tomography scan with sagittal reconstructions allows better visualization of the compression fracture.
      Computed tomography scan with coronal reconstructi Computed tomography scan with coronal reconstruction of an athlete who had multiple compression fractures.
      Computed tomography scanning with 3-dimensional re Computed tomography scanning with 3-dimensional reconstruction facilitates the assessment of some complex fractures. In this case, the patient experienced a severe compression fracture.
  • MRI allows better visualization of the spinal cord and ligamentous structures. See the image below.

    • On T2-weighted images, high-signal intensity indicates edema. This can be seen in the vertebral body, ligaments, and thoracic spinal cord.

    • Ligament disruptions can sometimes be demonstrated with MRI. The anterior longitudinal ligaments are best seen on T1-weighted images, and the posterior longitudinal ligaments are best seen on T2-weighted images. Frequently, identifying disrupted ligaments is easier than identifying intact ligaments.

    • One disadvantage of MRI in unstable patients is the need for special, nonmagnetic mechanical ventilators and other MR-compatible life-support monitors. Some hemodynamically unstable patients may not be candidates for MRI. In addition, patients with multiple traumas frequently have external fixators used to stabilize pelvic fractures, which makes the process of obtaining an MRI difficult.

      Magnetic resonance image of a young female with a Magnetic resonance image of a young female with a severe unstable fracture of L4. The patient had a partial neurologic deficit and required urgent surgical fixation.
  • When a neurologic deficit is present and a contraindication to MRI is evident, myelography with a postmyelogram CT scan may be used to rule out neural compression. Nonfilling of nerve roots, hematomas, and cauda equina nerve root avulsions may be demonstrated with myelography.

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Other Tests

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  • Electromyography and nerve conduction studies

    • The examination of muscles with needle electrodes and nerve conduction studies are complementary techniques, usually performed together. [40]

    • Electromyography can show evidence of denervation in the lower-extremity muscles or abnormalities in the sphincter muscles.

    • Examination of the paraspinal muscles is also important to distinguish lesions on the spinal cord or cauda equina from lesions in the lumbar or sacral plexus.

    • Nerve conduction studies are an essential part of the evaluation of possible 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. Results from motor nerve conduction studies are 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 neurourologic dysfunction.

  • Evoked potentials

    • Somatosensory evoked potentials and nerve action potentials may be used to illustrate preoperative dysfunction and to confirm postoperative improvement.

    • Motor evoked potentials may be sensitive and specific to changes in neural function and may help to call "attention to the need for intraoperative corrections including widening decompressions, improving perfusion, and limiting deformity correction so that more severe neural compromise may be prevented." [41]

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