Thoraco-Lumbar Radiography

1
Thoraco-Lumbar Radiography

• Moritz Haager
• March 4, 2004

2
Anatomy
3
Thoracic Spine
4
Lumbar Spine
5
Determinants of Stability

• T L spines are more stable than C-spine
• Strong ligaments
• Stabilization by ribs
• Bigger intervertebral discs
• Larger facet joints
• Less mobility
• Fractures dislocations tend to occur where
  curvature changes
• T11-12 (thoracolumbar junction)
• L5-S1 (lumbosacral junction)

6
Mechanisms of Injury

• Hyperflexion /- rotation
• Commonest
• Usually see anterior wedge s or Chance
• Shearing
• Ant or post translation
• Hyperextension
• Axial loading
• Compression or burst s

7
3 Column Model

• Anterior column
• Ant longitudinal lig
• Ant annulus fibrosis
• Ant vertebral body
• Middle column
• Post longitudinal lig
• Post annulus fibrosis
• Post vertebral body
• Posterior column
• Spinous processes
• Transverse processes
• Lamina
• Facet joints
• Pedicles
• Post ligamentous complex
• 2 or more columns disrupted unstable
• Most disruption of middle columns are unstable

8
Stable or Unstable?

• Radiographic findings suggestive of instability
• Vertebral body collapse w/ widening of pedicles
• gt 33 canal compromise on CT
• gt 2.5 mm translation b/w vertebral bodies in any
  plane
• Bilateral facet dislocation
• Abnormal widening b/w spinous processes or lamina
  and gt 50 anterior collapse of vertebral body

9
Stable or Unstable?

• Checklist for Instability
• Anterior elements disrupted 2 pts
• Posterior elements disrupted 2 pts
• Saggital plane translation gt 2.5 mm 2 pts
• Saggital plane rotation gt 5o 2 pts
• Spinal cord or cauda equina damage 2 pts
• Disruption of costovertebral articulations 1 pt
• Dangerous loading anticipated 2 pts
• 5 or more pts unstable until healed or surgically
  stabilized

10
Stable or Unstable?

• Risk of neurologic injury increases with
• gt 35 canal narrowing at T11-12
• gt 45 canal narrowing at L1
• gt 55 canal narrowing at L2 below

11
Approach to T L Spines

• A adequacy alignment
• All vertebrae need to be visible
• Ant post longitudinal lines
• Facet joints should lie on smooth curve
• Normal kyphosis lordosis
• All spinous processes should lie in straight line
• B bones
• Trace cortical margins of each vertebrae
• Difference b/w ant post body ht lt 2 mm
• Progressive increase in vertebral body ht moving
  down spine
• Wink sign interpedicular distance
• Dont forget to look at transverse processes

12
Approach to T L Spines

• C cartilage
• Progressive increase in disc space moving down
  spine (except L5-S1)
• Facet joint alignment
• S soft tissue
• Look at paraspinal stripe and prevertebral space

13
Case 1

• 38 yo female brought to ED after being backed
  over by car driven by boyfriend
• Intoxicated c/o back pain demonstrating the
  remarkable versatility of the F-word

14
Transverse process fractures of L2-4
Significance of transverse process fractures is
not the fractures in and of themselves but rather
the high incidence of associated
serious intraabdominal injury (20)
15
Case 2

• 46 yo male presents to ED after falling 12 feet
  off ladder while putting up Christmas lights c/o
  back pain

16
Anterolisthesis Of L4 on L5
17
CT demonstrates chronic anterolisthesis with no
intrusion into spinal canal
18
Case 3

• 50 yo male again 10-12 foot fall off ladder while
  putting up Christmas lights (dangerous hobby)

19
Mild ant wedging of T3 T4
20
Mild ant wedging of T3 T4
21
Case 4

• 21 yo belted passenger in rollover single vehicle
  MVA at highway speed

22
Widened paraspinal line suggesting hematoma
Laterally displaced T5 pedicle
Anterior wedging of T4 T5 w/ loss of 30-40 of
body ht
23
(No Transcript)
24
Case 5

• 29 yo driver offroading in pick-up truck rolls
  it at speed
• Not belted, ejected from vehicle and trapped
  underneath for 3 hrs

25
Paramediastinal soft tissue density widening
Suggestive of compression fractures
26
(No Transcript)
27
Case 6

• 22 yo male single vehicle rollover. Not
  restrained ejected through windshield at
  highway speeds

28
Posterior displacement
Involvement of pedicles laminar arch
Comminution anterior wedging of L2 w/ 50 loss
of body Ht
29
CT demonstrates severe burst w/ horizontal
plane extending posteriorly through pedicles and
transverse processes in keeping w/ a CHANCE
fracture
30
Case 7

• 58 yo roofer presents to ED unconscious after
  plunging 12 feet onto concrete through skylight

31
Schmorls node
Compression fracture of L3 w/ no obvious post
element involvement
32
(No Transcript)
33
(No Transcript)