Thoracolumbar spine trauma usually occurs as a result of high-energy trauma (e.g., road traffic accidents, falls from heights).
May occur spontaneously in patients with osteoporotic, neoplastic, or metabolic disorders of the spine.
Initial on-the-scene evaluation involves performing a primary survey with ABC assessment with C-spine immobilisation and haemorrhage control.
It is important to evaluate and assess thoracolumbar fractures for instability.
If the decision to operate is made, this should occur earlier rather than later.
Thoracolumbar fractures are breakages in the vertebrae of the spinal column in the thoracic and lumbar regions. They may be associated with disruption of the ligamentous complexes, and can result in instability or compression of neural structures. Thoracolumbar fractures are the usual outcome of thoracolumbar trauma. Other outcomes include traumatic disc prolapse, ligamentous injury, and epidural haematoma causing pressure on the spinal cord or nerve roots; these occur very rarely without a fracture. This topic focuses on thoracolumbar spine fracture.
History and exam
Key diagnostic factors
- presence of risk factors
- back pain
- acute numbness/paraesthesia
- muscle spasticity/clonus (hypertonicity) or hypotonia
- hyperreflexia or hyporeflexia
- Hoffman's sign
- positive Babinski's sign
- spinal deformity
- loss of anal sphincter reflex
Other diagnostic factors
- absence of bulbocavernosus reflex (S3-S4)
- signs of spinal shock (hypotonia or flaccidity that resolves within 24 hours)
- urinary incontinence
- painless urinary retention
- falling from a height
- motor vehicle crash
- age >65 years
- concomitant osteoporosis
- previous vertebral fracture
- underlying neoplastic lesion
- underlying metabolic or inflammatory disorders
- male sex
1st investigations to order
- thoracolumbar spine x-ray (anterior-posterior and lateral views)
Investigations to consider
- CT spine
- MRI spine
- CT myelography
- MRI with STIR sequence
at the scene: potential vertebral column injuries
- Musculoskeletal lower back pain
- Acute cervical spine trauma
- Degenerative cervical spine disease
- Clinical guidance for the effective identification of vertebral fractures
- Spinal injury: assessment and initial management
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