Spinal fractures are mostly seen in male young adults. Most of them are caused by indirect external forces, such as fracture of the hip or foot when falling from a high place, impact external force upward to the thoracolumbar segment; a few of them are caused by direct external forces, such as house collapse, automobile crush injury or firearm injury. Fractures of the thoracolumbar segment are common in the spine. Spinal fractures can be complicated by injury to the spinal cord or cauda equina, which can lead to paraplegia or even life-threatening in severe cases; improperly treated simple compression fractures can also leave chronic low back pain.
Symptoms and signs
1.History of serious trauma, such as fall from height, heavy impact on the low back, buried by soil and ore in a landslide event, etc.
2.After thoracolumbar spine injury, the main symptoms are local pain, difficulty in standing and turning over, retroperitoneal hematoma stimulates the abdominal ganglion, which slows down the intestinal peristalsis and often presents with abdominal pain, abdominal distension and even symptoms of intestinal paralysis.
Disease etiology
Violence is the main cause of thoracolumbar spine fractures.
Classification of thoracolumbar spine fractures
Simple dehiscence compression fracture
This is the result of injury to the anterior column of the spine. The force comes from a rotational force along the x-axis that causes the spine to flex forward, with few posterior structures affected, and the vertebrae are usually in the shape of a pinch. This type of fracture does not damage the middle column and the spine retains its zonal stability. This type of fracture is usually the result of a fall from height injury, foot or hip landing, and violent body flexion that produces compression of the anterior half of the vertebral body.
Stability Burst Fracture
This is the result of injury to the anterior and middle columns of the spine. The violence comes from axial compression of the Y-axis. The vertebral body of the thoracolumbar spine is subjected to the greatest force and is shattered by compression. Since there is no rotational force, the posterior column of the spine is not affected, thus retaining the stability of the spine, but the shattered vertebral body and intervertebral disc can protrude in front of the spinal canal, damaging the spinal cord and producing neurological symptoms.
Unstable blast fracture
This is the result of simultaneous injury to the anterior, middle and posterior columns. The violence comes from axial compression in the Y-axis and clockwise rotation, and possibly rotational forces along the Z-axis, causing the posterior column to fracture as well, resulting in post-traumatic kyphosis and progressive neurological symptoms due to spinal instability.
Chance fracture
This is a horizontal laceration of the vertebral body. In the past, it was thought that the violence came from the greatest force rotating along the X-axis, causing injury to the spine by hyperextension, such as falling from a height on one’s back and landing with the back obstructed by an object, causing hyperextension of the spine, rupture of the anterior longitudinal ligament, transverse splitting of the vertebral body, and rupture of the spinous processes by mutual extrusion, which can lead to posterior displacement of the previous vertebral body.
It is also believed that the fracture is a consequence of flexion of the spine, and the axis of flexion should be in front of the anterior longitudinal ligament, so it is considered to be the result of axial pulling of the spine from the Y-axis, as well as the involvement of rotational forces along the X-axis, which is also an instability fracture. These fractures are also unstable fractures. They are less common clinically;
Flexion-distraction type of injury
The flexion axis is posterior to the anterior longitudinal ligament, and the anterior column is partially injured by compressive forces, while the middle and posterior columns are injured by tension forces of pulling, while the middle and posterior columns are injured by tension forces of pulling, and the middle column is partially injured by tension forces of pulling, and the middle column is partially injured by rupture of the vertebral joint capsule, dislocation of the articular eminence, subluxation or fracture, and this injury often also has the involvement of rotational forces from the Y-axis, so this type of injury is often a potentially unstable fracture that The cause is a tear of the ligamentum flavum, the interspinous ligament and the supraspinous ligament.
Spinal Fracture – Dislocation
Also known as a mobility injury. The violence comes from the Z-axis, for example, in a car accident where the violence comes directly from the back of the back, or when working bent over and a heavy object falls directly on the back, the alignment of the vertebral canal has been completely broken under strong violence, and the vertebrae are displaced along the transverse plane in the plane of injury, usually all three columns are destroyed by shear forces, and the plane of injury is usually through the intervertebral disc, with the involvement of rotational forces, so the degree of dislocation is greater than a fracture When the articular eminence is completely dislocated;
The inferior articular process moves to the front of the superior articular process of the next vertebra and blocks each other, called articular process interlocking, which is an extremely serious spinal injury inevitable and has a poor prognosis. There are also some simple accessory fractures such as fracture of the vertebral plate with yellow protrusion fracture, which will not weigh down the instability of the spine, called stable fracture, especially transverse process fracture, which is often an avulsion fracture caused by violent contraction of the lumbar muscles after an impact on the back.
Classification of cervical spine fractures
Flexion-type injury
This is the result of an anterior column compression, posterior column distraction injury, which is violent via the sagittal plane of the Z-axis, producing either a purely soft tissue, or a purely bony, or a mixed injury, and is commonly seen clinically as
(1) anterior subluxation (hyperflexion type sprain): this is the result of posterior spinal column ligament rupture, there are complete and incomplete two, complete supraspinous ligament, interspinous ligament, and even spinal joint capsule and transverse ligament are torn, while incomplete is only supraspinous stale ligament and partial interspinous ligament tear, this injury can have 30%-50% ulnar spinal deformity This injury can have 30%-50% incidence of ulnar spinal deformity and quadriplegia, so it is an insidious cervical spine injury.
(2) Bilateral vertebral shoulder dislocation: due to the rupture of the ligament of the middle square column after transitional flexion, the violence causes the dislocated vertebral articulation to go beyond the anterior and superior compartment of the next segmental joint, the degree of vertebral dislocation should exceed at least 1/2 of the anterior and posterior diameter of the vertebral body, the subluxation of the vertebral body is displaced in front of the superior articulation of the next segment, some cases may have to fracture the articulation, but generally the fracture fragments are small and of little clinical significance. Most cases of this type have spinal cord injury.
(3) simple wedge (compression) fracture: more common. x-ray lateral film of the anterior edge of the vertebral body cortical insertion into the angle or the upper edge of the vertebral body rupture compression, the case is most often seen in osteoporotic pathological changes in addition to the vertebral fracture, there are varying degrees of posterior ligament structure rupture.
Injuries due to vertical compression
Violence is transmitted via the Y axis without hyperflexion or hyperextension forces, such as falling objects or diving from a height.
(1) Bilateral anterior and posterior arch fracture of the first cervical vertebra: also known as jefferson fracture, it is difficult to find the fracture line on X-ray, sometimes the C1 articular eminence is displaced outward bilaterally on orthopantomograph, and the widening of the anterior and posterior atlantoaxial diameter and the shadow of soft tissue swelling in front of the vertebra is seen on lateral radiograph. MRI can only show the damage to the spinal cord. The treatment is mainly non-surgical and can be done by continuous cranial traction followed by cephalothoracic cast immobilization for 3 months after 2 weeks.
(2) Blast fracture: It is a comminuted fracture of the lower cervical vertebrae, usually seen in C5 and C6 vertebrae, and the broken fracture fragments are convex into the spinal canal to varying degrees, so the incidence of paralysis can be as high as 80%, and can also be combined with cranio-cerebral injury, the vertebral fracture is comminuted, the fracture line is mostly vertical fracture fragments can come out into the spinal canal, and arch fractures may also be found.
Hyperextension injury
(1) hyperextension dislocation: most often occurs when driving a car at high speed, due to emergency braking or crashing, due to inertia, the head hit the windshield or the backrest of the seat in front, and force the head to transition supination followed by transition flexion to cause serious injury to the cervical spine, the pathological changes are rupture of the anterior longitudinal ligament, horizontal rupture of the intervertebral disc, avulsion fracture of the front lower edge of the upper vertebral body and rupture of the posterior longitudinal ligament, the result of the injury makes Cervical vertebrae move backwards with posterior spinal toxicity;
So that the spinal cord is sandwiched between the crumpled ligamentum flavum and the vertebral plate and cause injury around the central canal of the spinal cord, in some cases, especially in the elderly, the original posterior bone spur of the lower cervical vertebrae can impact the spinal cord, so that the plane of the affected Sun’s spinal cord does not match the plane of the fracture, and the characteristic sign of this disease is trauma marks on the frontal face.
(2) Injury pivotal arch fracture: the violence of this type of injury comes from the neck, so that the cervical spine transitional supination and extension, forming a strong shear force in the posterior part of the pivotal spine, so that the arch of the pivotal spine is unbearable and vertical fracture occurs, which used to be seen in the hanged person, so the name hanged person fracture. Currently, it occurs in traffic accidents on highways.
Fractures of poorly understood mechanisms
Dentate fracture: The mechanism of dentate fracture is not well understood. The violence may come from horizontal direction, from anterior to posterior, through the skull to the dentate, and there may be several kinds of compound violence. Dentate fractures can be divided into three types.
Type I, avulsion fracture of the tip of the dentate process.
Type II, transverse fracture of the base of the dentate process, above the body of the pivot vertebra.
Type III, a fracture of the upper part of the pivot body involving the superior articular process of the pivot vertebrae on one side becomes bilateral.
Type I is more stable, has fewer complications, and has a better prognosis; type II is more common, and because of the poor blood supply there, the non-healing rate is as high as 70%, so more people need surgery; type III fractures have good stability, good blood supply, high healing rate, and a better prognosis.
Diagnostic examination
1. The examination should include detailed history, mode of injury, posture at the time of injury, and any sensory and motor impairment after the injury.
2, pay attention to multiple injuries, multiple injury cases often combined with cranio-cerebral, thoracic and abdominal organ injuries, to deal with emergencies first, to save lives.
3, check the spine when the exposure surface should be sufficient, you must use your fingers to press the spinous process one by one from top to bottom, if you find local swelling and obvious local pressure pain located in the midline area, suggesting that the posterior column has been injured, thoracolumbar spinal fractures can often be felt in the posterior process deformity. Check for signs of spinal cord or cauda equina injury, and if there are signs of nerve injury, the mechanism should be told to the family or companion, and recorded on the history card in a timely manner.
4, imaging examination can help clarify the diagnosis, disadvantageous injury site, type and displacement, X-ray radiographs are the preferred method of examination, the elderly are sluggish, thoracolumbar spinal fractures often complain of lower back pain, simple lumbar spine radiographs will miss the lower thoracic fracture, so it must be indicated that the film site including the lower thoracic spine (T10-12), usually to take two front and side Usually, two front and two lateral films are taken, and if necessary, an oblique film is taken, on which the presence or absence of a fracture of the arch can be seen.
Since the anterior cervical hemithorax is an insidious injury with no obvious fracture, it is easy to neglect to diagnose it during the ordinary X-ray examination.