Ania Szary, Year III Gillian Lieberman, MD

May 2006

Radiological Evaluation of Thoracic Spinal Trauma

Ania Szary, Harvard Medical School Year III Gillian Lieberman, MD

Ania Szary, Year III Gillian Lieberman, MD

Patient J.K.
18 y.o. male s/p high speed MVA rollover and ejection transferred from OSH Unresponsive on arrival GCS 2 BP: 80/30

Ania Szary, Year III Gillian Lieberman, MD

Outline

Imaging modalities Anatomy of thoracic spine: plain film,CT, MRI J.K.: plain film, CT, MRI Thoracic spine and cord injury Mechanisms of spinal injury DDx of thoracic spinal fractures Conclusion

Ania Szary, Year III Gillian Lieberman, MD

Imaging Modalities
Basis Plain Film CT
Trauma:

Views
AP Lateral

Pros
Fast Portable High

Cons
Positioning Limited

Initial imaging

contrast

resolution
Limited

Spinal

Axial Sagittal

injury Pain Neurologic deficit LOC Distracting injuries Same as CT Ligament injury

and coronal reformats

of bony anatomy and pathology Time efficient

Evaluation

resolution of soft

tissues Motion and metal artifacts

MRI

Any

plane

Evaluation

of soft

MR

tissues

compatible devices Metal artifacts Time consuming

Ania Szary, Year III

Gillian Lieberman, MD

Normal Spinal Anatomy: Plain Film

AP

ABCS
Alignment Bone integrity Cartilage spaces Soft tissues
Intervertebral Disc Space Spinous Process Transverse Process Pedicles Articular Process

Lateral

PACS, BIDMC

Ania Szary, Year III Gillian Lieberman, MD

J.K. Plain Film

Fractures

Apical Cap

ET Tube
T5

T5 T6

Widened Mediastinum

NG Tube Deep Sulcus Sign

Courtesy of Dr. Anne Catherine Kim

Ania Szary, Year III Gillian Lieberman, MD

Normal Spinal Anatomy: CT

Sagittal Axial

PACS BIDMC

Vertebral Body Spinal Cord Transverse Process Spinous Process

Pedicle Lamina Costovertebral Articulation Apophyseal Joint

PACS BIDMC

Ania Szary, Year III Gillian Lieberman, MD

Normal J.K. Axial CT

Comminuted fracture of T6 vertebra Fracture of spinous and transverse process Associated paravertebral edema/hematoma Possible retropulsion of fragments into spinal canal Heterogeneity of spinal cord indicating injury vs artifact
T6

Chest tube

Courtesy of Dr. Anne Catherine Kim

Ania Szary, Year III Gillian Lieberman, MD

J.K. CT Sagittal Reformat

Anterior subluxation of T5 to T6 Disruption of posterior elements Prevertebral Edema Retropulsion of Fragments into spinal cord Fakeout of sternum due to misalignment during reformatting

T5 T6

Courtesy of Dr. Anne Catherine Kim

Ania Szary, Year III Gillian Lieberman, MD

Normal Spinal Anatomy: MRI

Sagittal T2 Image
CSF Spinal Cord Intervertebral Disc Anterior Longitudinal Ligament Posterior Longitudinal Ligament and Dura Mater Dura Mater Ligamentum Flavum
PACS, BIDMC

Ania Szary, Year III Gillian Lieberman, MD

J.K. MRI
Sagittal T2
Anterior subluxation of T5 to T6 Prevertebral Edema Retropulsion of Fragments into spinal cord Transection of spinal cord with associated hemorrhage and edema Posterior musculature hemorrhage
T5 T6

Courtesy of Dr. Anne Catherine Kim

Ania Szary, Year III Gillian Lieberman, MD

Thoracic Spine and Cord Injury

Thoracic fractures uncommon

Large overlapping facet joints limit flexion and extension Rib cage limits lateral movement and increases axial loading capacity

Associated with spinal fracture at other levels and pulmonary, rib, and aortic injury Spinal Cord injury

MVA, falls, and violence Thoracic spinal canal narrow compared to spinal cord 50% of thoracic fractures

Prompt radiologic evaluation vital for characterization and subsequent treatment

Ania Szary, Year III Gillian Lieberman, MD

Mechanisms of Injury

Compression ( ) and Tension ( )Forces

Fracture osseous disruption

Rotary and Shear Forces

Dislocation ligamentous disruption Compromise spinal cord

Shear

Hyperflexion and Hyperextension

Rotary

Combination of intrinsic compression and tension forces

Hyperflexion

Hyperextension
www.spineuniverse.com

Ania Szary, Year III Gillian Lieberman, MD

DDx of Thoracic Fracture

Compression fractures of indeterminate age

Metastases Osteopenia
Multi-level anterior vertebral wedging End plate irregularity Delayed vertebral collapse Etiology uncertain

Sheuermanns disease

Kmmels disease

Physiologic wedging Trauma

Ania Szary, Year III Gillian Lieberman, MD

Discussion

Thoracic spine is a stable and rigid structure Compromise of stability increases risk for fracture Thoracic injury is caused by combination of forces Spinal cord injury is common with thoracic fracture Imaging modalites: plain film, CT, MRI Remember your ABCS Consider underlying pathologies for fracture

Ania Szary, Year III Gillian Lieberman, MD

Acknowledgements

Gillian Lieberman, MD Anne Catherine Kim, MD Pamela Lepkowski Larry Barbaras

Ania Szary, Year III Gillian Lieberman, MD

References

Brandser, E. and El-Khoury, G. Thoracic and Lumbar Spine Trauma. Radiologic Clinics of North America. Vol 35 (3). May 1997. Dee, P. The radiology of Chest Trauma. Radiologic Clinics of North America. Vol 30 (2). March 1992. Emery, E. et al. Magnetic resonance imaging of posttraumatic spinal ligament injury. Journal of Spinal Disorders. Dec; 2(4):229-33.1989. Hanafee, W. and Crandall, P. Radiologic Clinics of North America. Vol IV (2) 1966 Pretroius, E. et al. Radiology Secrets, 2nd Edition. Philadephia. 2006. Novelline, R. Fundamentals of Radiology. Cambridge, MA. 2004. Pathria, M. and Petersilge, C. Spinal Trauma.Radiologic Clinics of North America. Vol 29 (4). July 1991.