May 2006Ania Szary, Year III

Gillian Lieberman, MD

Radiological Evaluation of Thoracic

Spinal Trauma

Ania Szary, Harvard Medical School Year IIIGillian 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

OutlineImaging 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 ModalitiesBasis Views Pros Cons

Plain Film

Trauma: Initial imaging

APLateral

Fast PortableHigh resolution

PositioningLimited contrast

CT Spinal injury

PainNeurologic

deficit LOCDistracting

injuries

AxialSagittal

and coronal reformats

Evaluation of bony anatomy and pathology

Time efficient

Limited resolution of soft tissues

Motion and metal artifacts

MRI Same as CT

Ligament injury

Any plane Evaluation of soft tissues

MR compatible devices Metal artifactsTime consuming

Ania Szary, Year III

Gillian Lieberman, MDNormal Spinal Anatomy: Plain FilmABCS

Alignment

Bone integrity

Cartilage spaces

Soft tissues

PACS, BIDMC

Intervertebral Disc SpaceSpinous Process

Transverse ProcessPedicles

Articular Process

AP Lateral

Ania Szary, Year III

Gillian Lieberman, MD J.K. Plain Film

Deep Sulcus Sign

ET Tube

NG Tube

Fractures

T5 T6

Courtesy of Dr. Anne Catherine Kim

Widened Mediastinum

T5

Apical Cap

Ania Szary, Year III

Gillian Lieberman, MDNormal Spinal Anatomy: CT

Vertebral BodySpinal Cord

Costovertebral ArticulationSpinous ProcessApophyseal Joint

Transverse Process

PedicleLamina

PACS BIDMC

PACS BIDMC

AxialSagittal

Ania Szary, Year III

Gillian Lieberman, MD Normal J.K. Axial CT

Courtesy of Dr. Anne Catherine Kim

Chest tube

T6

•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

Ania Szary, Year III

Gillian Lieberman, MD J.K. CT Sagittal Reformat

T6

T5

Courtesy of Dr. Anne Catherine Kim

•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

Ania Szary, Year III

Gillian Lieberman, MD

Normal Spinal Anatomy: MRI

PACS, BIDMC

Anterior Longitudinal Ligament

Posterior Longitudinal Ligament and Dura Mater

Intervertebral Disc

Spinal Cord

CSF

Dura MaterLigamentum Flavum

Sagittal T2 Image

Ania Szary, Year III

Gillian Lieberman, MD

J.K. MRI

T5

Courtesy of Dr. Anne Catherine Kim

T6

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

Ania Szary, Year III

Gillian Lieberman, MD

Thoracic Spine and Cord InjuryThoracic fractures uncommon

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

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

MVA, falls, and violence Thoracic spinal canal narrow compared to spinal cord50% 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 ForcesDislocation – ligamentous disruptionCompromise spinal cord

Hyperflexion and HyperextensionCombination of intrinsic compression and tension forces

www.spineuniverse.comHyperflexion Hyperextension

Rotary

Shear

Ania Szary, Year III

Gillian Lieberman, MD

DDx of Thoracic FractureCompression fractures of indeterminate age

MetastasesOsteopenia

Sheuermann’s diseaseMulti-level anterior vertebral wedgingEnd plate irregularity

Kümmel’s diseaseDelayed vertebral collapseEtiology uncertain

Physiologic wedgingTrauma

Ania Szary, Year III

Gillian Lieberman, MD

DiscussionThoracic spine is a stable and rigid structureCompromise of stability increases risk for fractureThoracic injury is caused by combination of forcesSpinal cord injury is common with thoracic fracture Imaging modalites: plain film, CT, MRIRemember your ABCSConsider underlying pathologies for fracture

Ania Szary, Year III

Gillian Lieberman, MD

Acknowledgements

Gillian Lieberman, MDAnne Catherine Kim, MDPamela LepkowskiLarry Barbaras

Ania Szary, Year III

Gillian Lieberman, MD

ReferencesBrandser, 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.