Thoraco-Lumbar

Radiography
 Thoracic spine - Standard
views
AP and Lateral - Assess both views
systematically.
Images of the thoracic and lumbar spine
are often large and the bones should be
scrutinised in detail (see images below).
Note: The upper T-spine may not be
visible on the lateral view - if injury is
suspected here then a swimmer's view
may be helpful
 Who gets CT?
Dangerous mechanisms/high energy mechanisms:
-fall from elevation = or > 3 feet/5 stairs
-axial load to head (diving)
-MVC high speed (>100 km/h), ejection
-motorized recreational vehicles
-bicycle collision
 Who gets MRI?
Unexplained neurologic symptoms/signs
For visualizing soft tissues, neural elements and
unsuspected disk herniation
To differentiate cord edema x hemorrhage x infarction
To better characterize epidural hematoma
 Thoracic spine systematic
approach - Lateral and AP
Coverage - The whole spine is visible on both views
Alignment - Follow the corners of the vertebral bodies from one level to the
next
Bones - The vertebral bodies should gradually increase in size from top to
bottom
Spacing - Disc spaces gradually increase from superior to inferior - Note:
Due to magnification and spine curvature the vertebral bodies and discs at
the edges of the image can appear larger than those in the centre of the
image
Soft tissues - Check the paravertebral line (see AP image below)
Edge of image - Check the other structures visible
Anatomy
 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)
 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
T-spine normal anatomy - Lateral
(detail)
Alignment - Vertebral body alignment
is assessed by carefully matching the
anterior and posterior corners of the
vertebral bodies with the adjacent
vertebra
Bones - Gradual increase in vertebral
body height from superior to inferior
Spacing - Disc spaces gradually
increase in height from superior to
inferior
VB = Vertebral body
P = Pedicle
SP = Spinous process (ribs overlying)
F = Foramen - spinal nerve root exit
T-spine normal anatomy - AP
(detail)
Alignment - The vertebral bodies
and spinous processes (SP) are
aligned
Bones - The vertebral bodies and
pedicles are intact
Other visible bony structures
include the transverse processes
(TP), ribs, and the costovertebral
and costotransverse joints
Spacing - Each disc space is of
equal height when comparing left
with right. The pedicles gradually
become wider apart from superior
to inferior
Soft tissue - Note the normal
paravertebral soft tissue which
forms a straight line on the left -
distinct from the aorta
 L-spine systematic
approach – Lateral
Coverage - The whole L-
spine should be visible on
both views
Alignment - Follow the
corners of the vertebral
bodies from one level to
the next (dotted lines)
Bones - Follow the cortical
outline of each bone
Spacing - Disc spaces
gradually increase in
height from superior to
inferior - Note: The L5/S1
space is normally slightly
narrower than L4/L5
 L-spine systematic
approach - Normal AP
Alignment - The
vertebral bodies and
spinous processes are
aligned
Bones - The vertebral
bodies and pedicles are
intact
Spacing - Gradually
increasing disc height
from superior to inferior.
The pedicles gradually
become wider apart from
superior to inferior -
Note: The lower discs
are angled away from
the viewer and so are
less easily assessed on
this view
 L-spine normal
anatomy - Lateral
(detail)
Check the cortical
outline of each
vertebra
The facet joints
comprise the inferior
and superior articular
processes of each
adjacent level
The
pars interarticularis
literally means 'part
between the joints'
P=
Pedicle
SP =
Spinous process
Three column model – Anatomy
Anterior column = Anterior half of the
vertebral bodies and soft tissues
Middle column = Posterior half of the
vertebral bodies and soft tissues
Posterior column = Posterior elements
and soft soft tissues
 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
Three column model -
Fracture simulation
Injuries 1 and 2 affect one
column only and are
considered 'stable’
1 - Spinous process injury
2 - Anterior compression
injury
Injuries 3 and 4 affect two
or more columns and are
considered 'unstable’
3 - 'Burst' fracture
4 - Flexion-distraction
fracture - 'Chance' type
injury
Thoracolumbar spine - Systematic approach
Coverage - Adequate?
Alignment - Anterior/Posterior/Lateral
Bones - Cortical outline/Vertebral body height
Spacing - Discs/Spinous processes/Pedicles
Soft tissues – Paravertebral
Edge of image
Basic thoracolumbar spine injury classification
1 column - Anterior compression (or isolated spinous process injuries)
2 column - Burst injuries
3 column - Flexion-distraction 'Chance-type' injuries
1 Column - Anterior compression injury
Anterior compression injury is a common fracture pattern
which results from traumatic hyper-flexion with
compression. Although considered 'stable' the greater the
loss of height anteriorly the greater the risk of middle
column involvement. X-ray may underestimate the extent of
injury and so if there has been high risk injury or other
suspicion of instability then CT should be considered.
Anterior compression
injury - L-spine – Lateral
(Same patient as image
below)
A poorly defined dense
(white) fracture line is visible
with a detached fracture
fragment (asterisk)
L1 has lost height anteriorly
and there is disruption of the
anterior column only
2 column - 'Burst' fracture
'Burst' fractures result from high force
vertical compression trauma. Posterior
displacement of vertebral body fracture
fragments into the spinal canal leads to a
high risk of spinal cord or nerve root
damage.
3 column - Flexion-distraction fracture
Flexion-distraction injuries are associated with high force
deceleration injuries and are most common at the thoracolumbar
junction. Also known as 'Chance-type' fractures (after the radiologist
who first described them) these injuries are unstable and carry a
high risk of neurological deficit and abdominal organ injury.
The 'fracture' line may pass through the disc rather than the
vertebral body, and so there may not be visible bone injury of the
anterior column.
Flexion-distraction / 'Chance'
fracture - Lateral
Osteoporotic 'insufficiency'
injuries
Thoracolumbar spine injuries are very
common in patients with osteoporosis.
Common fracture patterns include 'wedge'
injuries and 'biconcave' fractures.
Thoracic spine - 'Wedge'
compression fracture
Lumbar spine - Biconcave
fracture
Other fracture
 Stable or Unstable?
Radiographic findings suggestive of instability
 Vertebral body collapse w/ widening of pedicles
 > 33% canal compromise on CT
 > 2.5 mm translation b/w vertebral bodies in any
plane
 Bilateral facet dislocation
 Abnormal widening b/w spinous processes or lamina
and > 50% anterior collapse of vertebral body
 Stable or Unstable?
Checklist for Instability
 Anterior elements disrupted 2 pts
 Posterior elements disrupted 2 pts
 Saggital plane translation > 2.5 mm 2 pts
 Saggital plane rotation > 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
 Stable or Unstable?
Risk of neurologic
injury increases with
 > 35% canal
narrowing at T11-12
 > 45% canal
narrowing at L1
 > 55% canal
narrowing at L2 &
below
 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 < 2 mm
 Progressive increase in vertebral body ht moving
down spine
 Wink sign & interpedicular distance
 Don’t forget to look at transverse processes
 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
 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
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%)
 Case 2
46 yo male presents to ED after falling 12
feet off ladder while putting up Christmas
lights c/o back pain
Anterolisthesis
Of L4 on L5
CT demonstrates chronic anterolisthesis with no intrusion into
spinal canal
 Case 3
50 yo male again 10-12 foot fall off ladder
while putting up Christmas lights
(dangerous hobby)
Mild ant wedging of
T3 & T4
Mild ant wedging of
T3 & T4
 Case 4
21 yo belted passenger in rollover single
vehicle MVA at highway speed
Widened paraspinal
line suggesting
hematoma

Laterally displaced
T5 pedicle
Anterior wedging of T4 & T5
w/ loss of 30-40% of body ht
 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
Paramediastinal
soft tissue density
& widening

Suggestive of
compression
fractures
 Case 6
22 yo male single vehicle rollover. Not
restrained – ejected through windshield at
highway speeds
 Posterior displacement

Involvement of pedicles &

laminar arch

Comminution &
anterior wedging
of L2 w/ 50% loss
of body Ht
CT demonstrates severe burst #
w/ horizontal plane extending
posteriorly through pedicles
and transverse processes in keeping
w/ a CHANCE fracture
 Case 7
58 yo roofer presents to ED unconscious
after plunging 12 feet onto concrete
through skylight
Schmorl’s
node

Compression fracture of L3
w/ no obvious post element
involvement