Back Clinic Screening Tests. Screening tests are typically the first assessment completed and are used to determine if further diagnostic testing might be needed. Because screening tests are the first step towards diagnosis, they are designed to be more likely to overestimate the true incidence of a disease. Designed to be different from diagnostic tests in that they might demonstrate more positive results than a diagnostic test.
This can lead to both true positives as well as false positives. Once a screening test is found to be positive, a diagnostic test is then completed to confirm the diagnosis. Next, we will discuss the assessment of diagnostic tests. Many screening tests are available for physicians and advanced chiropractic practitioners to utilize in their practice. For some tests, there is quite a bit of research demonstrating the benefit of such tests on early diagnosis and treatment. Dr. Alex Jimenez presents appropriate assessment and diagnostic tools used in the office to further clarify and appropriated diagnostic assessments.
Spondylolisthesis occurs when a�vertebra of the spine slips forward over the vertebra below it. Spondylolisthesis can be categorized as: congenital spondylolisthesis, which means the disorder is present at birth; isthmic spondylolisthesis, which occurs when a defect occurs in a supportive vertebral structure of the spine; and degenerative spondylolisthesis, which is more common and is frequently associated with degenerative disc disease, or DDD, where the intervertebral discs lose hydration with age.
Development of Spondylolisthesis
The spinal column is exposed to directional pressures while it carries, absorbs, and also distributes most of the fat of the body throughout physical activities and during rest. To put it differently, while the spine is consuming and carrying body fat, additionally, it moves in different directions (e.g., rotate, bend forwards ). This mixture of functions causes unnecessary stress to be placed onto the vertebra and the supportive vertebral�structures of the spine, and it might result in one of these slipping forwards over the ones beneath it, ultimately developing into spondylolisthesis.
Grading spondylolisthesis
Doctors “grade” the severity of spondylolisthesis utilizing five descriptive categories. Even though there are several factors your physician notes when evaluating your spondylolisthesis, the grading scale (below) relies on how far forward a vertebral body has slid over the vertebra beneath it. Often, the doctor uses a lateral (side view) x-ray to examine and grade�spondylolisthesis. Grade I is a smaller slide than Grade IV or V.
Grade I: Less than 25% slip
Grade II: 25% to 49% slip.
Grade III: 50% to 74% slip.
Grade IV: 75% to 99% slip.
Grade V: The vertebra has fallen forward off the vertebra below it. This�grade is the most severe type of spondylolisthesis and is medically referred to as�spondyloptosis.
Who Might be at Risk
If a family member has spondylolisthesis, your risk for developing the disorder may be higher. Also, some physical activities can make you more vulnerable to developing spondylolisthesis. Gymnasts, linemen in football, and weightlifters, all put pressure and stress on their spine. Picture the movements gymnasts perform on a regular basis: they bend backward and twist through the air, landing quickly and absorbing the impact through their legs and back. Those motions can place strain on the spine, potentially causing spondylolisthesis.�The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Scoliosis Pain and Chiropractic
The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, other aggravated conditions can also cause back pain.�Scoliosis�is a well-known, health issue characterized by an abnormal curvature of the spine and it is subcategorized by cause as a secondary condition, idiopathic, or of unknown cause, or congenital. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain associated with scoliosis through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. Chiropractic care can help restore the normal curvature of the spine.
Scoliosis is a medical condition where an individual’s spine is diagnosed with an abnormal curve. The natural curvature of the spine is generally “S” shaped when viewed laterally, or from the side, and it should appear straight when viewed from the front or back. In many instances, the abnormal curvature of the spine with scoliosis increases over time, while in others, it remains the same. Scoliosis can cause a variety of symptoms.
Scoliosis affects approximately 3 percent of the population. The cause of most instances is unknown, however, it is believed to involve a mixture of environmental and genetic variables. Risk factors include having relatives with the same problem. It may also develop due to other health issues, such as Marfan syndrome, cerebral palsy, muscle spasms, and tumors like neurofibromatosis.� Scoliosis commonly develops between the ages of 10 and 20 and it commonly affects girls more than boys. Diagnosis is supported with X-rays. Scoliosis is classified as structural, in which the curve is fixed, or functional, in which the underlying spine is normal.
Treatment is based upon the level of curve, place, and trigger. Curves can be viewed periodically to record the progression of scoliosis. Bracing is frequently utilized to treat scoliosis. The brace must be fitted into the individual and used until the progression of scoliosis stops. Exercise is advocated towards the improvement of scoliosis. Other alternative treatment options, such as chiropractic care, can restore the natural curvature of the spine. The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Scoliosis Pain and Chiropractic
The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, other aggravated conditions can also cause back pain. Scoliosis is a well-known, health issue characterized by an abnormal curvature of the spine and it is subcategorized by cause as a secondary condition, idiopathic, or of unknown cause, or congenital. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain associated with scoliosis through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. Chiropractic care can help restore the normal curvature of the spine.
Rheumatoid arthritis, or RA, is a chronic health issue which affects approximately 1 percent of the population in the United States. RA is an autoimmune disorder that causes the inflammation and degeneration of the synovial tissue, specific cells and tissue which form the lining of the joints within the human body. Rheumatoid arthritis may and generally does affect every joint in the body, especially as people get older. RA commonly develops in the joints of the hands and feet, severely restricting an individual’s ability to move, however, those with significant disease in the spine are at risk of damage like paraplegia. Rheumatoid arthritis of the spine is frequent in three areas, causing different clinical problems.
The first is basilar invagination, also referred to as cranial settling or superior migration of the odontoid, a health issue where degeneration from rheumatoid arthritis at the base of the skull causes the it to “settle” into the spinal column, causing the compression or impingement of the spinal cord between the skull and the 1st cervical nerves. The second health issue, and also the most frequent, is atlanto-axial instability. A synovitis and erosion of the ligaments and joints connecting the 1st (atlas) and the 2nd (axis) cervical vertebrae causes instability of the joint, which may ultimately result in dislocation and spinal cord compression. In addition, a pannus, or localized mass/swelling of rheumatoid synovial tissue, can also form in this region, causing further spinal cord compression. The third health issues is a subaxial subluxation which causes the degeneration of the cervical vertebrae (C3-C7) and often results in other problems like spinal stenosis.
Imaging studies are crucial to properly diagnose patients with rheumatoid arthritis of the cervical spine. X-rays will demonstrate the alignment of the spine, and if there is obvious cranial settling or instability. It can also be difficult to demonstrate the anatomy at the bottom of the skull, therefore, computed tomography scanning, or CT scan, with an injection of dye within the thecal sac is arranged. Magnetic resonance imaging, or MRI, is beneficial to assess the severity of nerve compression or spinal cord injury, and allows visualization of structures, including the nerves, muscles, and soft tissues. Flexion/extension x-rays of the cervical spine are usually obtained to evaluate for signs of ligamentous instability. These imaging studies entails a plain lateral x-ray being taken with the patient bending forward and the other lateral x-ray being taken with the individual extending the neck backwards.�The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Neck Pain and Auto Injury
Whiplash is one of the most common causes of neck pain after an automobile accident. A whiplash-associated disorder occurs when a person’s head and neck moves abruptly back-and-forth, in any direction, due to the force of an impact. Although whiplash most commonly occurs following a rear-end car crash, it can also result from sports injuries. During an auto accident, the sudden motion of the human body can cause the muscles, ligaments, and other soft tissues of the neck to extend beyond their natural range of motion, causing damage or injury to the complex structures surrounding the cervical spine. While whiplash-associated disorders are considered to be relatively mild health issues, these can cause long-term pain and discomfort if left untreated. Diagnosis is essential.
A teardrop fracture is caused when the anteroinferior aspect of a cervical vertebral body is damaged due to flexion of the spine together with vertical compression. The fracture throughout the body is also associated with deformity of the human body and subluxation or dislocation of the facet joints. A teardrop fracture is generally associated with a spinal cord injury due to the displacement of the anterior portion of the body into the spine.
The flexion teardrop fracture shouldn’t be confused with a similar-looking vertebral fracture called “expansion teardrop fracture”. Both usually happen in the cervical spine, but as their names indicate, they result from other mechanisms (flexion-compression vs. hyperextension). Both are linked to a small fragment being broken apart from the anteroinferior corner of the affected vertebra. Flexion teardrop fractures normally involve instability in most elements of the backbone, commonly occur at the C4-C7 vertebra, and have a higher association with spinal cord injury (specifically anterior cord syndrome). In contrast, the extension-type fracture happens more commonly in C2 or C3, causes significantly less if any disturbance to the middle and posterior elements, and does not normally result in spinal cord injury (but it may co-occur with more harmful spinal injuries).
A flexion teardrop fracture is a common injury of the cervical spine,�or neck, which can be severe in nature. Its name�is characterized by the triangle-shaped fragment which typically fractures from the anteroinferior corner of�the vertebral body and that resembles a drop of water dripping from the vertebral body. The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work. Back pain attributes to the most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
A vertebral fracture is a common health issue which can often cause bone fragments to damage the spinal chord and nerve roots. Broken bones can occur due to trauma or injury from automobile accidents, slip-and-fall accidents, or sports injuries, among other causes. Depending on how severe the vertebral fracture is, individuals may have difficulty performing everyday activities. The purpose of the article below is to demonstrate and discuss vertebral fracture diagnosis imaging studies and their results.
Practice Essentials
Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomical and functional features that result in specific injuries. See the image below.
Figure 1: Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
Signs and Symptoms
Symptoms of vertebral fracture can include pain or the development of neural deficits such as the following:
Weakness
Numbness
Tingling
Neurogenic shock – In this, hypotension is associated with relative bradycardia as a result of autonomic hyporeflexia
Spinal shock – The temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury; initially results in hyporeflexia and flaccid paralysis; with time, the descending inhibitory influence is removed and hyperreflexive arches, even spasticity, may occur
An injury to the thoracic or lumbosacral cord would likely result in neural deficits at the trunk, genital area, and lower extremities. Specific syndromes, such as Brown-S�quard syndrome and anterior cord syndrome, may affect a compression part of the spinal cord.
See Overview for more detail.
Diagnosis
Laboratory Studies
Patients with vertebral or pelvic fractures resulting from a major trauma require serial hemoglobin determinations as an indicator of hemodynamic stability.
Other laboratory studies, including the following, aid in the evaluation of associated organ damage in patients with vertebral fracture:
Urinalysis or urine dip for blood – Can help to rule out associated kidney injury
Amylase and lipase levels – Elevated level of amylase or lipase may suggest pancreatic injury
Cardiac-marker levels – Elevated levels in the setting of chest trauma may indicate a cardiac contusion
Urine myoglobin and serum creatine kinase levels – Elevated level of urine myoglobin or serum creatine kinase in the context of a crush injury may indicate evolving rhabdomyolysis
Serum calcium level – In patients with metastatic disease to the bone and resultant pathologic fractures, a serum calcium determination is necessary; these patients may have hypercalcemia that requires medical attention
Pregnancy test – Should be obtained in females of childbearing age
Imaging Studies
Radiography – Plain radiographs are helpful in screening for fractures, but hairline fractures or nondisplaced fractures may be difficult to detect
Computed tomography (CT) scanning – CT scans can readily detect bony fractures and help with the assessment of the extent of fractures
Magnetic resonance imaging (MRI) – This is usually the study of choice for determining the extent of damage to the spinal cord; MRI is the most sensitive tool for detecting lesions of neural tissue and bone
See Workup for more detail.
Management
Nonsurgical Fracture Management
Minor fractures or those with column stability are treated without surgery. Nonoperative management of unstable spinal fractures involves the use of a spinal orthotic vest or brace to prevent rotational movement and bending.
Consideration should be given to the stabilization of patients with spinal cord injuries and paraplegia. These patients need to be stabilized sufficiently so that their upper body and axial skeleton are appropriately supported, which allows for effective rehabilitation.
Surgical Fracture Management
The goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. The following basic approaches are used for surgical management of the thoracolumbar spine:
Posterior approach – Useful for stabilization procedures that involve fixation of the posterior bony elements; the posterior approach is used when early mobilization is considered and decompression of the spinal canal is not a major consideration
Posterolateral approach – Often used for high thoracic fractures such as T1 through T4; it may be combined with a posterior stabilization procedure when limited ventral exposure is needed
Anterior approach – Allows access to the vertebral bodies at multiple levels; the anterior approach is most useful for decompression of injuries and spinal canal compromise caused by vertebral body fractures
The 4 basic types of stabilization procedures are as follows:
Posterior lumbar interspinous fusion – Least-invasive method; involves the use of screws to achieve stability and promote fusion
Posterior rods – Effective in stabilizing multiple fractures or unstable fractures
Z-plate anterior thoracolumbar plating system – Has been used for the treatment of burst fractures
Cage
See Treatment for more detail.
While automobile accidents, slip-and-fall accidents, and sports injuries can cause spinal injuries, osteoporosis has been described as the leading cause of non-traumatic vertebral fracture. Vertebral fractures can generally be overlooked due to non-specific presentation. Imaging diagnostics are essential in the case of trauma or injury to determine the presence of broken bones in the spine, among other health issues.
Dr. Alex Jimenez D.C., C.C.S.T.
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Background
Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomical and functional features that result in specific injuries. See Figure 1 above.
This article reviews the mechanisms and management of individual injuries in the thoracic and lumbar regions of the spine; information on cervical spine fractures is presented in Fracture, Cervical Spine.
For patient education resources, see the patient education article Vertebral Compression Fracture.
Epidemiology
Approximately 11,000 new spinal cord injuries occur each year, and approximately 250,000 people in the United States have a spinal cord injury. Approximately half the injuries occur in the thoracic, lumbar, and sacral areas; the other half occur in the cervical spine. The average age at injury is 32 years, and 55% of those injured are aged 16-30 years. Approximately 80% of patients in the US national database are male.
In a retrospective analysis of patients 55 years or older who had traumatic fracture to the lumbar spine, age 70 years or older was an independent predictor of mortality, whereas instrumented surgery and vertebroplasty or kyphoplasty were associated with decreased odds of death. [1]
Vehicular accidents account for approximately one third of reported cases, and approximately 25% of cases are due to violence. Other injuries are typically the result of falls or recreational sporting activities. The incidence of injuries due to violence has been increasing, while the incidence of injuries due to vehicular accidents has been declining.
The cost of a spinal cord injury that causes paraplegia is approximately $200,000 for the first year and $21,000 annually thereafter. The average lifetime cost of treating a patient with paraplegia is $730,000 for those injured at age 25 years and approximately $500,000 for those injured at age 50 years. The life expectancy for subjects with spinal cord injuries is shortened by 15-20 years compared with uninjured control subjects. The major causes of death are pneumonia, pulmonary embolism, and sepsis.
Etiology
Certain risk factors predispose the thoracic spinal cord to injury. The thoracic cord is the longest component of the spinal cord (12 segments), which results in an increased probability of injury compared to other spinal areas. The spinal canal and vertebral bodies are proportionately smaller than those of the lumbar region. Finally, the vascular supply is more tentative, with few collateral vessels, small anterior spinal arteries, and small radicular arteries. All of these factors make the thoracic cord more vulnerable to injury.
By comparison, the lumbar cord has a better vascular supply, including the large radicular vessel (usually at L2) known as the artery of Adamkiewicz. The lumbosacral enlargement is rather compact (5 lumbar spinal segments) and terminates in the conus medullaris. With a proportionately more generous spinal canal, the lumbar cord is less susceptible to direct traumatic injury or vascular insult.
Pathophysiology
Fractures of the thoracolumbar spine can be classified into 4 groups based on the mechanism of injury. The mechanism of injury is used interchangeably with the name of the fracture. These major fractures are presented in escalating order of severity.
Flexion-Compression Mechanism (Wedge or Compression Fracture)
This mechanism usually results in an anterior wedge compression fracture. As the name implies, the anterior column is compressed, with varying degrees of middle and posterior column insult. See Figure 1 above.
Ferguson and Allen have proposed a classification scheme that characterizes 3 distinct patterns of injury, as follows:
The first pattern involves anterior column failure while the middle and posterior columns remain intact. Imaging studies demonstrate wedging of the anterior component of the vertebral bodies. Loss of anterior vertebral body height is usually less than 50%. This is a stable fracture.
The second pattern involves both anterior column failure and posterior column ligamentous failure. Imaging studies demonstrate anterior wedging and may indicate increased interspinous distance. Anterior wedging can produce a loss of vertebral body height greater than 50%. This has an increased possibility of being an unstable injury.
The third pattern involves failure of all 3 columns. Imaging studies demonstrate not only anterior wedging, but also varying degrees of posterior vertebral body disruption. This is an unstable fracture. Additionally, the possibility exists for cord, nerve root, or vascular injury from free-floating fracture fragments dislodged in the spinal canal.
Axial-Compression Mechanism
This mechanism results in an injury called a burst fracture, and the pattern involves failure of both the anterior and middle columns. Both columns are compressed, and the result is loss of height of the vertebral body. Five subtypes are described, and each is dependent on concomitant, namely rotation, extension, and flexion. The 5 subtypes are (1) fracture of both endplates, (2) fracture of the superior endplate (most common), (3) fracture of the inferior endplate, (4) burst rotation fracture, and (5) burst lateral flexion fracture. [2]
McAfee classified burst fractures based on the constitution of the posterior column (stable or unstable). [3] In stable burst fractures, the posterior column is intact; in unstable burst fractures, the posterior column has sustained significant insult. Imaging studies of both stable and unstable burst fractures demonstrate loss of vertebral body height. Additionally, unstable fractures may have posterior element displacement and/or vertebral body or facet dislocation or subluxation. As with a severe wedge fracture, the possibility exists for a cord, nerve root, or vascular injury from posterior displacement of fracture fragments into the canal. Denis showed that the frequency rate of neurologic sequelae could be as high as 50%. [4] Current recommendations call for more detailed imaging studies to identify the possibility of canal impingement, which requires decompressive surgery.
Flexion-Distraction Mechanism
This mechanism results in an injury called a Chance (or seatbelt) fracture. This pattern involves failure of the posterior column with injury to ligamentous components, bony components, or both. The pathophysiology of this injury pattern is dependent on the axis of flexion. Several subtypes exist, and each is dependent on the axis of flexion and on the number and degree of column failure.
The classic Chance fracture has its axis of flexion anterior to the anterior longitudinal ligament; this results in a horizontal fracture through the posterior and middle column bony elements along with disruption of the supraspinous ligament. This is considered a stable fracture. Imaging studies show an increase in the interspinous distance and possible horizontal fracture lines through the pedicles, transverse processes, and pars interarticularis.
The flexion-distraction subtype has its axis of flexion posterior to the anterior longitudinal ligament. In addition to the previously mentioned radiographic findings, this type of injury also has an anterior wedge fracture. Because all 3 columns are involved, this is considered an unstable injury.
If the pars interarticularis is disrupted in either type of fracture, then the instability of the injury is increased, which may be radiographically demonstrated by significant subluxation. Neurologic sequelae, if they occur, appear to be related to the degree of subluxation.
Rotational Fracture-Dislocation Mechanism
The precise mechanism of this fracture is a combination of lateral flexion and rotation with or without a component of posterior-anteriorly directed force. The resultant injury pattern is failure of both the posterior and middle columns with varying degrees of anterior column insult. The rotational force is responsible for disruption of the posterior ligaments and articular facet. With sufficient rotational force, the upper vertebral body rotates and carries the superior portion of the lower vertebral body along with it. This causes the radiographic “slice” appearance sometimes seen with these types of injuries.
Denis subtyped fracture-dislocations into flexion-rotation, flexion-distraction, and shear injuries. [4] The flexion-rotation injury pattern results in failure of both the middle and posterior columns along with compression of the anterior column. Imaging studies may demonstrate vertebral body subluxation or dislocation, increased interspinous distance, and an anterior wedge fracture.
The flexion-distraction injury pattern represents failure of both the posterior and middle columns. The pars interarticularis is also disrupted. Imaging studies demonstrate an increased interspinous distance and fracture line(s) through the pedicles and transverse processes, with extension into the pars interarticularis and subsequent subluxation.
The shear (sagittal slice) injury pattern results in a 3-column failure. The combined rotational and posterior-to-anterior force vectors result in vertebral body rotation and annexation of the superior portion of the adjacent and more caudal vertebral body. Imaging studies demonstrate both the nature of the fracture and dislocation.
Each of these fractures is considered unstable. Neurologic sequelae are common.
Minor Fractures
Minor fractures include fractures of the transverse processes of the vertebrae, spinous processes, and pars interarticularis. Minor fractures do not usually result in associated neurologic compromise and are considered mechanically stable. However, because of the large forces required to cause these fractures, associated abdominal injuries may occur. In this context, the index of suspicion for associated injuries should increase and the physician should examine the patient for associated injuries.
Fractures Secondary to Osteoporosis
Osteoporosis causes fractures of the vertebrae and fractures of other bones such as the proximal humerus, distal forearm, proximal femur (hip), and pelvis (see Osteoporosis). Women are at greatest risk. The prevalence rate for these fractures increases steadily with age, ranging from 20% for 50-year-old women to 65% for older women. Most vertebral fractures are not associated with severe trauma. Many patients remain undiagnosed and present with symptoms such as back pain and increased kyphosis. The presence of a significant vertebral fracture is associated with increased mortality. Patients with these fractures have a relative risk of death that is 9 times greater than healthy counterparts. Approximately 20% of women with vertebral fractures have another fracture of a different bone within a year. [5]
Efforts are currently underway to reliably predict who is at risk for these fractures. Bone densitometry is used to assess relative bone strength and fracture risk. Risk factors for osteoporosis fractures include postmenopausal age, white race, and low bone density prior to menopause. Predicting which patients are at risk using risk factor analysis or bone imaging allows for the administration of specific treatments that promote bone deposition or delay resorption. Prevention of fractures is critical and should include exogenous calcium and an appropriate exercise regimen. Many hormonal therapies are also available, including raloxifene (Evista) and calcitonin (Miacalcin).
In 2008, the American College of Physicians developed a guideline for the pharmacologic treatment of low bone density or osteoporosis to prevent fractures. [6]
Pathologic Fractures
Pathologic fractures are the result of metastatic disease of primary cancers affecting the lung, prostate, and breast. Kaposi sarcoma can also result in vertebral body fractures. Occasionally, cancer affects the spine itself or is the result of meningeal neoplasia. Pathologic fractures tend to affect the vertebral body at both the thoracic and lumbar levels. They cause kyphotic deformity and may result in compression of the cord or cauda equina. If the patient has neurologic deficits, consider emergent radiotherapy, steroid use, and surgical decompression and stabilization. See the image below.
Figure 2: Fluoroscopic view of a kyphoplasty procedure.
Fractures Secondary to Infection
Pott disease (tuberculosis spondylitis) results from the hematogenous spread of microbacteria to the spine (see Pott Disease (Tuberculous Spondylitis)). Other bacteria can be spread to the spine and cause osteomyelitis. As bacteria proliferate, vertebral damage occurs and primarily affects the vertebral bodies. As in the case of pathologic fractures, associated fractures and an increase in kyphotic deformity may be present. Treatment includes antibiotics. The presence of a neurologic deficit may prompt instrumentation and stabilization of the spine.
Patients with Special Considerations
Elderly patients usually have significant osteoporotic disease and degenerative bone disease. These patients may experience a significant fracture even from a relatively minor, low-energy mechanism of injury. Compression fractures in both the thoracic and lumbar regions are common. These patients also may have pathological fractures. Central cord syndrome is common for patients who develop neurologic deficits. For elderly patients with stable fractures, early mobilization is important to decrease morbidity and mortality.
Special consideration should be given to pediatric patients with significant trauma to the thoracic or lumbar spine. Because the skeleton is immature and the ligaments are elastic, significant force must be generated to cause a fracture, especially those associated with neurologic deficits. One entity that occurs in pediatric patients is spinal cord injury without radiographic abnormality. If injury and neurologic deficits are strongly considered, perform imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) scans. If the mechanism or circumstances are not consistent with the injury, consider abuse or neglect. Pediatric patients should be examined for additional injuries and bruises.
Patients in altered mental states pose a diagnostic challenge. In the absence of a reliable history and review of systems, findings from the physical examination and radiographic studies can help the physician assess vertebral injuries. In altered or intubated patients with other significant fractures such as pelvic fractures, multiple rib fractures, or scapular fractures, the physician should have a heightened index of suspicion for vertebral fractures. Once these patients have been stabilized, abdominal and chest radiographs may be supplemented with lateral views to reduce the likelihood of a missed vertebral fracture.
Diagnosis is essential in order for the healthcare professional to determine the best treatment approach for the patient’s vertebral fracture. Spinal injuries which go undiagnosed and are therefore left untreated can have an increased chance of fracture in another vertebra and it may subsequently heighten the risk of hip fracture. Early detection of vertebral fractures can further improve quality of life.
Dr. Alex Jimenez D.C., C.C.S.T.
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Presentation
Patient History
Details of the injury and mechanism of trauma are helpful in understanding the forces involved and the possible injury. Back pain in the setting of a major accident or a fall from a significant height (>10-15 ft) may increase the index of suspicion. The threshold for obtaining radiographic studies under these circumstances is lowered, and attention to spinal precautions and logrolling is increased. The concern is to not have iatrogenically induced deterioration of neurologic function or worsening of symptoms.
A major accident may involve significant vehicular damage, a head-on collision at high speed, vehicular rollover, or death at the scene. Accidents in which extrication, damage to the steering wheel or windshield, or passenger space intrusion occurred may produce spine injuries. Vehicular accidents involving motorcycles, bicycles, or pedestrians have a higher propensity for spine injuries. Questions about seatbelt use and airbag deployment are helpful in developing a high index of suspicion for vertebral injuries.
Symptoms include pain or the development of neural deficits such as weakness, numbness, and tingling. Even transient symptoms should be investigated. The morbidity of a spinal cord injury is so significant that even minor symptoms should be investigated.
Physical Examination
Patients with vertebral fractures secondary to trauma should be evaluated and treated in a systematic fashion as outlined by advanced trauma life-support protocols. At first, attention should be directed toward the patient’s airway, breathing, and circulation (ABC). Clinicians should adhere to cervical spine precautions. The patient can be logrolled off the spinal cord while radiographs are performed.
A neurologic examination should be performed as part of the expanded primary survey or secondary survey. The neurologic examination should include the cranial nerves, motor and sensory components, coordination, and reflexes. The physician should examine the pelvic areas, perineal areas, and extremities. A rectal examination is indicated, especially if the patient has weakness in the extremities. An injury to the thoracic or lumbosacral cord would likely result in neural deficits at the trunk, genital area, and lower extremities. Specific syndromes, such as Brown-S�quard syndrome and anterior cord syndrome, may affect a major part of the spinal cord (see Brown-S�quard Syndrome).
Associated Injuries
Patients with vertebral fractures typically experience significant force as the cause of injury. As such, they are likely to have associated injuries. Almost any organ can be affected, and the secondary survey should address these issues.
An altered patient may have an intercranial injury. Chest deformity, decreased breath sounds, low oximetry readings, or poor oxygen saturation are commonly associated with pulmonary injury. Consider cardiac injury if the patient has muffled heart tones, rhythm disturbances, or hemodynamic instability. Blunt or penetrating abdominal injury may be associated with spinal fractures; in these situations, conducting a neurologic examination and instituting spinal precautions is important until a spinal cord injury has been excluded. Orthopedic injuries require a significant force to fracture the bone and thus may be associated with vertebral fractures.
A correlation exists between fracture of the transverse process of L1 and same-side renal injury. Patients with calcareous injuries have approximately a 10% chance of associated lumbar vertebral injury. Patients involved in a motor vehicle accident while wearing a lap belt who sustained lumbar fractures are at significant risk for concomitant intra-abdominal injuries (eg, diaphragmatic, hollow viscus, or solid organ injuries).
Hemodynamic Instability
In the setting of a spinal cord injury with a neurologic deficit, close attention should be paid to the hemodynamic status of the patient. In the case of neurogenic shock, hypotension is associated with relative bradycardia as a result of autonomic hyporeflexia. The thoracic sympathetic chain is disrupted, which removes sympathetic tone and leaves unopposed vagal tone. This should be distinguished from hemorrhagic shock, in which a patient is tachycardic, hypotensive, and similarly unresponsive and flaccid. Thus, attention to the heart rate and a mechanism for exsanguination may help differentiate between these forms of shock.
Patients who are on beta-blockers may remain bradycardic despite being in hemorrhagic shock. A bedside ultrasound evaluation is a noninvasive screen for free fluid in the peritoneum. The more invasive peritoneal tap and lavage is the classic method of assessment for free fluid. Both types of shock require aggressive fluid and hemodynamic resuscitation.
Spinal shock refers to the temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury. It initially results in hyporeflexia and flaccid paralysis. With time, the descending inhibitory influence is removed and hyperreflexive arches�even spasticity may occur. For patients with spinal shock, pressures may be used after obtaining the proper fluid balance.
Indications
Patients with vertebral fractures who are neurologically intact should be assessed for the need for emergent decompressive surgery. Once the patient is hemodynamically stable and life-threatening injuries have been controlled, attention should be directed to neurologic injuries. The second consideration is obtaining a mechanically stable weight-bearing construct that allows for mechanical stability. This facilitates future ambulation and rehabilitation.
Patients with incomplete neurologic injuries need to be assessed for emergent decompressive surgery. For these patients, surgery may help maximize salvage of neurologic function. The surgeon can combine decompressive and stabilization procedures of the spine.
A study by Baldwin et al assessed conservative treatment of thoracolumbar spinal fractures. [7] Given the shortage of neurosurgeons at many trauma centers in the United States, Baldwin et al designed a treatment protocol that used radiologic criteria to screen for potentially stable fractures and to guide treatment without spinal consultation. Using both prospective and retrospective evaluation, the study determined that use of a treatment protocol for stable thoracolumbar fractures appeared safe and could help conserve resources.
Surgery for patients with complete neurologic deficit and paraplegia for more than 2-3 days is controversial. Decompressive procedures have little merit. Spinal stabilization is helpful in achieving mechanical stability and allows for more effective rehabilitation.
Relevant Anatomy
Basic Vertebral Anatomy
The vertebral column has 2 major roles: (1) a structural, weight-bearing role as the centerpiece of the axial skeleton and (2) a role as the conduit for the spinal cord. The vertebral column has 31 vertebrae. The typical vertebral body consists of a ventral segment, the body, and a dorsal part, the vertebral arch. The vertebral arch consists of a pair of pedicles and laminae and encloses the vertebral foramen. The intervertebral disks form the fibrocartilaginous articulation of the vertebral bodies. The vertebral bodies are stabilized anteriorly by the anterior longitudinal ligament and posteriorly by the posterior longitudinal ligament. The spinal canal is formed by the longitudinal apposition of the vertebral bodies, arches, disks, and ligaments. The spinal cord, meninges, and nerve roots course in the spinal canal.
Thoracic Region
The thoracic region of the spine has a relatively high stability because of the stabilizing effects of the ribs and the rib cage. This region extends from the first thoracic vertebra (T1) down to the level of tenth thoracic vertebra (T10). Additional stabilizing effects are provided by the almost-vertical orientation of the articulating processes and the shinglelike oblique arrangement of the spinal processes. A significant force is required to cause a fracture or dislocation in this region. The low thoracic region has false ribs at levels T11 and T12; thus, this region of the spine is less stable. This region can be considered the transition zone between the thoracic and lumbar regions because it resembles the lumbar region in stability and mechanisms of injury.
Lumbar and Low Thoracic Regions
The lumbar and low thoracic vertebrae are larger and wider, which is an adaptation required for their weight-bearing role as supports for the upper body and axial skeleton. In contrast to the mid and upper thoracic regions, the lumbar and low thoracic areas lack the stabilizing effect of the rib cage. The spinous processes are more horizontal, which provides increased mobility but less mechanical stability. The lumbar and low thoracic areas have greater mobility, which allows for flexion, extension, and rotation of the upper skeleton in relation to the pelvis and lower extremities.
As a result of increased mobility, the low thoracic and lumbar regions are more susceptible to injury. The transition area between the low-mobility thoracic region (T1 through T10) and the highly mobile lumbar area (approximately T11 through L2) is susceptible to injury. In adults, the spinal cord ends at the lumbosacral enlargement and conus medullaris at approximately the vertebral level of L1. Consequently, injuries to the low thoracic spine and L1 can result in significant paralysis and paraplegia of the lower body because they injure the lumbosacral enlargement of the spinal cord. In contrast, the mid and low lumbar regions are more forgiving because the individual nerve roots of the cauda equina course in this region and they are smaller, more flexible, and more resistant to injury compared with the lumbosacral enlargement.
Three-Column Model of the Spine
In 1983, Denis proposed the 3-column model of the spine, which described both the functional units that contribute to the stability of the spine and the destabilizing effect of injuries to the various columns. Denis defines the anterior column as containing the anterior longitudinal ligament, the anterior half of the vertebral body, and the related portion of the intervertebral disk and its annulus fibrosus. The middle column contains the posterior longitudinal ligament, the posterior half of the vertebral body, and the intervertebral disk and its annulus. The posterior column contains the bony elements of the posterior neural arch and the ligamental elements, which include the ligamentum flavum, the interspinous ligaments, and the supraspinous ligaments. The joint capsule of the intervertebral articulations is also part of the posterior column. Disruption of 2 or more columns results in an unstable configuration.
Contraindications
Hemodynamically unstable patients should not be taken for operative treatment of vertebral fractures until their condition has stabilized. Patients with advanced age and those with significant comorbid conditions (eg, significant coronary artery disease, peripheral vascular disease, advanced pulmonary disease) are poor candidates for any surgery, including vertebral fracture stabilization surgery. Patients with stable fractures can be observed for the development of deformity and then assessed for surgical treatment.
In conclusion, a vertebral fracture can differ tremendously from a broken arm or leg. Because a fracture in the vertebra can cause bone fragments to damage the spinal chord or nerve roots, it’s essential to receive a proper diagnosis of the extent of the spinal injury. Imaging diagnostics can help doctors determine the health issues. The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Imaging diagnostics are an essential element in the evaluation of spine trauma. Over the last few decades, the rapid evolution of imaging technology has tremendously changed the assessment and treatment of spinal injuries. Imaging diagnostics utilizing CT and MRI, among others, are helpful in the acute and the chronic settings. Spinal cord and soft-tissue injuries are best evaluated by magnetic resonance imaging, or MRI, whereas computed tomography scanning, or CT scans, best evaluate spinal trauma or spine fracture. The purpose of the article below is to demonstrate the significance of imaging diagnostics in spine trauma.
Cervical Spine Fracture Evaluation
Practice Essentials
Approximately 5-10% of unconscious patients who present to the ED as the result of a motor vehicle accident or fall have a major injury to the cervical spine. Most cervical spine fractures occur predominantly at two levels: one-third of injuries occur at the level of C2, and one-half of injuries occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction C1 or C2. [1, 2, 3, 4, 5, 6, 7, 8]
Anatomy
The normal anatomy of the cervical spine consists of 7 cervical vertebrae separated by intervertebral disks and joined by a complex network of ligaments. These ligaments keep individual bony elements behaving as a single unit. [7]
View the cervical spine as three distinct columns: anterior, middle, and posterior. The anterior column is composed of the anterior longitudinal ligament and the anterior two-thirds of the vertebral bodies, the annulus fibrosus and the intervertebral disks. The middle column is composed of the posterior longitudinal ligament and the posterior one-third of the vertebral bodies, the annulus, and intervertebral discs. The posterior column contains all of the bony elements formed by the pedicles, transverse processes, articulating facets, laminae, and spinous processes.
The anterior and posterior longitudinal ligaments maintain the structural integrity of the anterior and middle columns. The posterior column is held in alignment by a complex ligamentous system, including the nuchal ligament complex, capsular ligaments, and the ligamenta flava.
If one column is disrupted, other columns may provide sufficient stability to prevent spinal cord injury. If two columns are disrupted, the spine may move as two separate units, increasing the likelihood of spinal cord injury.
The atlas (C1) and the axis (C2) differ markedly from other cervical vertebrae. The atlas has no vertebral body; however, it is composed of a thick anterior arch with two prominent lateral masses and a thin posterior arch. The axis contains the odontoid process that represents fused remnants of the atlas body. The odontoid process is held in tight approximation to the posterior aspect of the anterior arch of C1 by the transverse ligament, which stabilizes the atlantoaxial joint. [9, 7]
Apical, alar and transverse ligaments provide further stabilization by allowing spinal column rotation; this prevents posterior displacement of the dens in relation to the atlas.
In pediatric patients, the spine is more flexible, and therefore, neural damage occurs much earlier than musculoskeletal injury in young patients. Because of this high flexibility, fatal consequences can occur with sometimes even minimal structural damage. Compared to adults, children have a different fulcrum because of a relatively large head, the vertebrae are not completely ossified, and the ligaments are firmly attached to articular bone surfaces that are more horizontal, making the pathophysiology of injury in children different from that in adults. [6, 10]
�
The neck consists of seven bones, or the cervical vertebrae, which support the head and connect it the body. A cervical fracture is commonly referred to as a broken neck. Cervical spine fractures often occur due to trauma or injury, such as from automobile accidents or slip-and-fall accidents. Imaging diagnostics have advanced to be able to help healthcare professionals diagnose cervical spine health issues.
Dr. Alex Jimenez D.C., C.C.S.T.
�
Evaluation of injury
When a cervical spine injury is suspected, neck movement should be minimized during transport to the treating facility. Ideally, the patients should be transported on a backboard with a semirigid collar, with the neck stabilized on the sides of the head with sandbags or foam blocks taped from side to side (of the board), across the forehead.
If spinal malalignment is identified, place the patient in skeletal traction with tongs as soon as possible (with very few exceptions), even if no evidence of neurologic deficit exists. The specific injury involved and capabilities of the consulting staff guide further management.
Place tongs one finger width above the earlobes in alignment with the external auditory canal. The consultant applies the tongs for traction under close neurologic and radiograph surveillance. Care must be taken while managing the airway in patients with potential cervical spine injuries. Video-assisted intubation should be considered to limit cervical spine motion during the process of securing the airway. [11, 12, 13, 1]
Cervical spine injuries are best classified according to several mechanisms of injury. These include flexion, flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and imprecisely understood mechanisms that may result in odontoid fractures and atlanto-occipital dislocation. [1, 14, 4, 5, 15, 7, 16]
Radiographic evaluation is indicated in the following: [2, 2, 17, 18, 15, 19, 20]
Patients who exhibit neurologic deficits consistent with a cord lesion
Patients with an altered sensorium from head injury or intoxication
Patients who complain about neck pain or tenderness
Patients who do not complain about neck pain or tenderness but have significant distracting injuries
A standard trauma series is composed of 5 views: cross-table lateral, swimmer’s, oblique, odontoid, and anteroposterior. Approximately 85-90% of cervical spine injuries are evident in the lateral view, making it the most useful view from a clinical standpoint.
The advent of readily available multidetector computed tomography has supplanted the use of plain radiography at many centers. Recent literature supports CT as more sensitive with lower rates of missed primary and secondary injury. [14]
Thoracic Spinal Trauma Imaging
Computed Tomography
Findings
Thin-section axial CT performed by using a bone algorithm is the single most sensitive means by which to diagnose fractures of the thoracic spine. Routine helical CT scans of the thoracic spine are valuable because multisection CT scanners can generate high-resolution spinal images, even during a primary multisystemic trauma evaluation. [21, 22, 28, 29]
The CT images below display various thoracic spinal traumatic injuries.
Figure 1: Lateral 3-dimensional maximum intensity projection CT scan of multiple upper thoracic and lower cervical spinous process fractures. The force necessary to fracture the spinous processes of the upper thoracic spine may also involve the lower cervical spine.
Figure 2:�Three-dimensional CT scan of complex mid-face fractures including a Le Fort I injury in a patient who had fractures of the upper thoracic and lower cervical spinous processes. Sudden deceleration of the face and skull resulted in severe stress forces on the spinous processes.
Figure 3:�Axial CT scan of a T12 compression fracture demonstrates a fracture line through the anterior body of the T12 (white arrow), posterior displacement of the T12 vertebral endplate (black arrow) into the spinal canal, and a fracture of the left transverse spinous process.
Figure 4:�Axial and sagittal CT images of an acute lower thoracic spine compression fracture. Note the paraspinal hematoma (white arrows) and the slight narrowing of the spinal canal at the level of the compression fracture (double yellow arrows).
Figure 5:�Three-dimensional CT scan of the thoracic spine demonstrates a compression fracture.
Figure 6:�Sagittal CT scan of the thoracic and lumbar spine demonstrates a complete distraction fracture at the L1-2 interspace (arrow).
Figure 7:�Axial CT image of an unstable fracture of the thoracic spine. Note the association of compression of the vertebral body with laminar and pedicle fractures. Injury to the anterior, middle and posterior columns results in an unstable fracture.
Figure 8:�Coronal multiplanar reformatted CT images of an unstable thoracic spinal fracture. The association of both anterior compression and lateral subluxation (arrows) indicates instability.
Figure 9:�Volume maximum intensity projection CT image of the entire thoracic spine demonstrates spinous process fractures of the C7 through T7 vertebra. Although spinous process fractures of the T1 may occur in a manner similar to a clay shoveler’s fracture of the C6 or C7, middle and lower thoracic spinous process fractures most likely occur due to a combination of forward flexion and axial rotation. Note the lack of findings of compression vertebral body fractures.
Figure 10:�Three-dimensional surface CT image of the cervical spine. Note the spinous process fractures of the C6, C7, and T1. CT examination of both the cervical and the thoracic spine was obtained as a single study using a multisection CT scanner. All images were obtained by using a 3-mm reconstruction with 1.5-mm collimation. Scanning times were 0.5 seconds per rotation. These 3-dimensional images were reconstructed by using an independent imaging workstation. In complex cases, reconstructed images are very useful in consultation with treating physicians.
Figure 11:�Scout view image from a spiral CT scan shows a complete subluxation fracture (curved blue lines) of the lower thoracic spine. Such an injury combines lateral displacement with rotational injury (arrow).
Figure 12: Fracture dislocation of the lower thoracic spine. Axial CT image demonstrates the large distance that the lower thoracic spine has been displaced.
Figure 13:�Axial CT myelogram in a patient with a gunshot wound to the thoracic spine. While a fracture is obvious, the injury also resulted in a dural tear with a freely leaking cerebrospinal fluid space (white arrow). The midline fracture of the vertebral body is noted in the lower image (black arrow).
Figure 14:�Axial CT image demonstrates a complex fracture of the T12 with rotation subluxation. Air was introduced into the epidural space during the injury.
Figure 15:�Sagittal multi-planar CT image of a burst fracture following fixation. The image has been cut in the sagittal plane. Surgical repair of unstable thoracic spine fractures, such as this burst fracture, usually involves placement of an interposition graft (double black arrow) together with a lateral plate held in position by screws placed into the vertebral body above and below the injury. A residual fragment of the burst fracture is seen anteriorly (white arrow). The double white arrow illustrates the restored spinal canal.
Figure 16:�Shaded-surface 3-dimensional CT image of a burst fracture following fixation. The image has been cut in the sagittal plane. Surgical repair of unstable thoracic spine fractures, such as this burst fracture, usually involves placement of an interposition graft (double black arrow) together with a lateral plate held in position by screws placed into the vertebral body above and below the injury. A residual fragment of the burst fracture is seen anteriorly (white arrow).
Figure 17: Shaded-surface 3-dimensional CT image of a gunshot wound to the thoracic spine. Although the bullet passed into the interspace, causing a fracture of the vertebral body, the bullet stopped within the spinal canal. Note the outline drawn around the bullet (arrow).
Figure 18:�Shaded-surface 3-dimensional CT scan of a gunshot wound to the thoracic spine. In other cases, the bullet may enter the spinal canal superior to the final position in the canal. The passage of the bullet within the spinal canal (yellow arrow) destroys the spinal cord and also may result in a fracture of the vertebral body. Note that the bullet has been darkened (blue arrow).
Figure 19:�Axial CT image in a man with known pulmonary tuberculosis and back pain. Note the left-sided paraspinal abscess (arrow).
Figure 20:�Sagittal shaded-surface 3-dimensional reconstruction CT scan of the lower thoracic spine. The spinal image has been cut in the midsagittal plane to demonstrate posterior displacement of the thoracic spinal vertebral body (arrow) and downward displacement of the superior endplate. Note the general wedge shape of the vertebral body.
Because of its superior contrast definition and the absence of superimposed structures, good-quality CT imaging depicts more thoracic spinal injuries than do conventional radiographic studies. However, the percentage of clinically important fractures that are seen on CT scans but not on radiographs is lower with thoracic than with cervical spinal fractures. Most of the fractures missed on radiographs were spinous process fractures, transverse processes fractures, and fractures in large patients. Because axial CT is performed with patients in a neutral position, bony distraction of the fracture fragments and subluxations of the spinal articulations may not be as significant on CT images as on they are on acute trauma-series radiographs. [22, 25, 28, 29, 30, 31, 32]
The level of a burst fracture and the percentage of spinal canal stenosis have been correlated with associated neurologic deficits. A significant correlation exists between neurologic deficit and the percentage of spinal canal stenosis. The higher the level of injury, the greater the probability of neurologic deficit. This association may be related to the smaller canal diameter in the upper thoracic spine. The severity of neurologic deficit cannot be predicted.
In patients with Chance-type fractures, CT scans often show a burst-type fracture with posterior cortex buckling or retropulsion, and serial transaxial CT images often show a gradual loss of definition of the pedicles. [23]
The thoracic spine, located between the cervical and lumbar vertebrae, consists of 12 vertebrae levels. Thoracic spinal trauma, including spinal cord injuries along the middle of the spine, can generally be severe, however, with early treatment, long-term prognosis is good. Therefore, imaging diagnostics for thoracic spinal trauma are essential. Many healthcare professionals can provide patients with these services.
Dr. Alex Jimenez D.C., C.C.S.T.
�
Degree of Confidence
The confidence level for the diagnosis of a thoracic spinal fracture with 2-mm axial sections (possible with a multisection CT unit) is greater than 98% and reportedly 99%.
Because axial CT is performed with the patient in a neutral position, a bony distraction of the fracture fragments and subluxations of the spinal articulations may not be as significant on CT images as on acute trauma-series radiographs.
False Positives/Negatives
False-positive results may occur in patients with a Schmorl node, which is a chronic internal herniation of the vertebral disk into the thoracic vertebral body endplate and failure of the fusion of the anterior vertebral endplate epiphysis, resulting in a limbus vertebra. False-negative CT studies may occur in chronic stress injuries and severe generalized osteoporotic endplate fractures.
It has been reported that among trauma patients who had a chest and/or abdominal CT, fractures of the thoracic spine are frequently underreported. Sagittal reformats of the spine obtained from thin sections, and morphometric analysis using electronic calipers help to identify fractures that might otherwise not be identified. [25]
In conclusion, imaging diagnostics of�spinal trauma or spine fracture are essential towards the assessment and treatment of patients. Magnetic resonance imaging, or MRI, is helpful in the evaluation of spinal cord and soft-tissue injuries whereas computed tomography scanning, or CT scans, is helpful in the evaluation of spinal trauma or spine fracture. The understanding of imaging technology has tremendously enhanced advances in treatment.� The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Imaging diagnostics of the spine consist from radiographies to computed tomography scanning, or CT scans, in which CT is utilized in conjunction with myelography and most recently with magnetic resonance imaging, or MRI. These imaging diagnostics are being used to determine the presence of abnormalities of the spine, scoliosis, spondylolysis and spondylolisthesis. The following article describes various imaging modalities and their application in the evaluation of common spinal disorders described.
Achondroplasia
Achondroplasia is the most common cause of rhizomelic (root/proximal) short-limb dwarfism. Patients are of normal intelligence.�
It shows multiple distinct radiographic abnormalities affecting long bones, pelvis, skull, and hands.
Vertebral column changes may present with significant clinical and neurological abnormalities.�
Achondroplasia is an autosomal dominant disorder with about 80% of cases from a random new mutation. Advanced paternal age is often linked. Achondroplasia results from a mutation in the fibroblast growth factor gene (FGFR3) which causes abnormal cartilage formation.
All bones formed by endochondral ossification are affected.
Bones that form by intra-membranous ossification are not normal.
Thus, skull vault, iliac wings develop normally vs. the base of the skull, some facial bones, vertebral column, and most tubular bones are abnormal.
�
Dx: is usually made at birth with many features becoming apparent during the first few years of life.
Radiography plays an important part of clinical diagnosis.
Typical features include: shortening and widening of tubular bones, metaphyseal flaring, Trident hand with short, broad metacarpals and proximal and middle phalanges. Longer Fibular, Tibial bowing, markedly short humeri often with dislocated Radial head and elbow flexion deformity.
Spine: characteristic narrowing of L1-L5 interpedicular distance on AP views. Lateral view shows shortening of pedicles and vertebral bodies, �bullet shaped vertebrae� can be a characteristic feature. Early degenerative changes and canal narrowing occur. The horizontal sacral inclination is an important feature.
Pelvis is broad and short with characteristic �champagne glass� pelvis appearance.
Femoral heads are hypoplastic, but hip arthrosis is normally not observed even in older patients likely due to reduced leverage and lightweight (50kg) of patients.
Management of Achondroplasia
Recombinant human growth hormone (GH)�is currently being used to augment the height of patients with achondroplasia.
Most complications of Achondroplasia are related to the spine: vertebral canal stenosis, thoracolumbar kyphosis, narrowed foramen magnum and others.
Laminectomy extending to pedicles/lateral recess with foraminotomies and discectomies can be performed.
Cervical manipulations are contraindicated.
Imaging diagnostics play a fundamental role in the diagnosis the of scoliosis, an abnormality of the spine which is believed to occur due to an underlying health issue, although most cases of scoliosis are idiopathic. More over, radiographies, CT scans, and MRI, among others, can help monitor the changes of the deformity of the spine associated with this spinal manifestation. Chiropractors can provide imaging diagnostics to patients with scoliosis before proceeding with treatment.�
Dr. Alex Jimenez D.C., C.C.S.T.
�
Scoliosis
Scoliosis is defined as the abnormal lateral curvature of the spine >10-degree when examined by Cobb�s method of mensuration.
Scoliosis can be described as postural and structural.
Postural scoliosis is not fixed and can be improved by lateral flexion to the side of the convexity.
Structural scoliosis has multiple causes ranging from: ? Idiopathic (>80%) ? Congenital (wedge or hemivertebra, blocked vertebra, Marfan syndrome, skeletal dysplasias) ? Neuropathic (neurofibromatosis, neurological conditions like tethered cord, spinal dysraphism, etc.) ? Scoliosis d/t Spinal neoplasms ? Post-traumatic etc.
Idiopathic scoliosis is the most common type (>80%).
Idiopathic scoliosis can be of 3-types ( infantile, juvenile, adolescent).
Idiopathic adolescent scoliosis if patients >10y.o.
Infantile scoliosis if <3 y.o. M>F.
Juvenile scoliosis if >3 but <10-y.o.
Idiopathic Adolescent scoliosis is the most common with F:M 7:1 (adolescent girls are at particular risk).
Etiology: unknown thought to be the result of some disturbance of proprioceptive control of the spine and spinal musculature, other hypotheses exist.
Most seen in the thoracic region and most commonly convex to the right.
Dx: full spine radiography with gonadal and breast shielding (preferably PA views to protect breast tissue).
� Curves that are 50-degrees or greater and rapidly progressing will require operative intervention to prevent severe deformity of the thorax & ribs leading to cardiopulmonary abnormalities. � �? If curvature is < 20-degree, no treatment is required (observation). � �? For curves that are >20-40-degrees bracing may be used (orthosis).
Milwaukee (metal) brace (left).
Boston brace polypropylene lined with polyethylene (right) often preferred because it can be worn under clothing.
Bracing wearing is required for 24-hours for the duration of the treatment.
Note Cobb�s method of mensuration to record spinal curvature. It has some limitations: 2D imaging, not able to estimate rotation, etc.
Cobb�s method is still a standard evaluation performed in Scoliosis studies.
Nash-Moe method: determines pedicle rotation in scoliosis.
Risser index is used to estimate spinal skeletal maturity.
Iliac growth apophysis appears at ASIS (F- 14, M-16) and progresses medially and expected to be closed in 2-3-years (Risser 5).
Scoliosis progression ends at Risser 4 in females & Risser 5 in males.
During radiographic evaluation of scoliosis, it is crucial to report if Risser growth apophysis remains open or closed.
Spondylolysis and spondylolisthesis are health issues which can result in back pain. Spondylolysis is believed to be caused by repeated microtrauma leading to stress fractures in the pars interarticularis. Patients with bilateral pars defects can develop spondylolisthesis, where the degree of slippage of the adjacent vertebrae can progress gradually over time. Patients with suspected spondylolysis and spondylolisthesis may initially be evaluated with pain radiography. Chiropractic care can also help provide imaging diagnostics for these health issues.
Dr. Alex Jimenez D.C., C.C.S.T.
�
Spondylolysis & Spondylolisthesis
Spondylolysis defect in pars interarticularis or osseous bridge between superior and inferior articular processes.
Pathology stress fracture of the pars, believed to be after repeated microtrauma on extensions Men > Women, affects 5% of the general population especially in athletic adolescents.
Clinically postulated that adolescent back pain cases may be related to this process.
Typically spondylolysis remains asymptomatic.
Spondylolysis can be present with or w/o spondylolisthesis.
Spondylolysis is found in 90% at L5 with the remaining 10% in L4.
Can be uni or bilateral.
In 65%�of�cases, spondylolysis is associated with spondylolisthesis.
Radiographic Features: break in the Scotty dog collar around the neck on oblique lumbar views.
Radiography has low sensitivity compared to SPECT. SPECT is associated with ionizing radiation, and MRI is currently a preferred method of imaging diagnosis.
MRI can help to show reactive marrow edema next to pars defect or w/o defect so-called pending or potential to develop spondylolysis.
Types of Spondylolisthesis
Type 1 – Dysplastic, rare and found in congenital dysplastic malformation of the sacrum allowing anterior displacement of L5 on S1. Often no pars defect.
Type 2 – Isthmic, most common, often the result of a stress fracture.
Type 3 – Degenerative from the remodeling of articular processes.
Type 4 – Traumatic in an acute posterior arch fracture.
Type 5 – Pathologic due to bone disease locally or generalized.
Grading of spondylolisthesis is based on the Myereding Classification. This classification refers to the overhanging part of the superior body in relation to anterior-posterior part of the inferior body.
Grade 1 – 0-25% anterior slip
Grade 2 – 26-50%
Grade 3 – 51%-75%
Grade 4 – 76-100%
Grade 5 – >100% spondyloptosis
Note degenerative spondylolisthesis at L4 and retrolisthesis at L2, L3.
This abnormality develops due to degeneration of facets and disc with decreased local stability.
Rarely progresses beyond Grade 2.
Must be recognized in the imaging report.
Contributes to vertebral canal stenosis.
Canal stenosis is better delineated by cross-sectional imaging.
The inverted Napoleon hat sign -�seen on the frontal lumbar/pelvic radiographs at L5-S1.
Represents bilateral spondylolysis with marked anterolisthesis of L5 on S1 often with spondyloptosis and marked exaggeration of the normal lordosis.
Spondylolysis resulting in this degree of spondylolisthesis is more often congenital and/or traumatic in origin and less often degenerative.
The “brim” of the hat is formed by the downward rotation of the transverse processes, and the “dome” of the hat is formed by the body of L5.
In conclusion,�imaging diagnostics for the spine are recommended for patients with specific abnormalities of the spine, however, their increased use can help determine�their best treatment option. Understanding the abnormalities of the spine described above can help healthcare professionals and patients create a treatment program to improve their symptoms. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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