Lesson of the week: Fractures of the thoracolumbar spine in major trauma patients

Abstract

Case reports Case 1—A driver who was not wearing a safety belt was ejected from a vehicle. His score on the Glasgow coma scale was 15 on arrival at the accident and emergency department. Avulsion fractures of C2 and C3 bodies were noted without neurological deficit. Additionally, an open fracture of the radius and ulna and fractures of the pelvic ring were diagnosed. The patient was “log rolled” (a procedure in which patients are rolled on to their side by a number of staff with minimal movement of the spine) to allow examination of his back. His responses were recorded as non-tender over the thoracolumbar spine and so radiographs were not taken. He made a steady recovery. He continued to complain of back pain after discharge. Radiographs taken three months after injury showed a healing wedge fracture of T12 with a clinically obvious kyphosis but no involvement of the spinal cord. Case 2—A young car driver who collided with a tree was brought to accident and emergency in haemorrhagic shock. He complained of abdominal pain. Diagnostic peritoneal lavage revealed fresh blood, indicating the need for emergency laparotomy. His level of consciousness was slightly reduced (Glasgow score 13) and his spine was non-tender on “log roll.” He had an emergency laparotomy and splenectomy. Four months later, because of persistent back pain, radiography of the thoracolumbar spine was done. A burst fracture of T12 without involvement of the spinal cord was identified in the radiographs. Case 3— A cyclist was hit by a car. She was fully alert and conscious (Glasgow score 15) in accident and emergency. Fractures of the pelvic ring, femur and tibia, and facial injuries were diagnosed. Back pain and spinal tenderness were absent. Computed tomography of the pelvis and abdomen was performed later and showed unexpected burst fractures of T7 and L1 requiring fixation. Bladder and bowel dysfunction and perineal sensory loss were present on discharge. Case 4— This man was hit by a falling object which broke the helmet he was wearing and fractured his left third, fourth, and fifth ribs, and clavicle. His level of consciousness was slightly reduced (Glasgow score 13) when seen in accident and emergency. He denied back pain and spinal tenderness. Following a slight deterioration in consciousness he was intubated and ventilated for computed tomography of the brain; a small frontal contusion was identified. He was found to be paraplegic with priapism when sedation was withdrawn. He was extubated in the intensive care unit. Magnetic resonance imaging identified fractures at T8 and T9 with compression of the spinal cord. Case 5— A motorcyclist collided with a car. She was in early haemorrhagic shock but fully conscious and oriented (Glasgow score 15) in accident and emergency. Facial fractures were noted. There was no spinal tenderness, bruising, or deformity when she was “log rolled.” She underwent emergency laparotomy and splenectomy for a ruptured spleen. She had low back pain before discharge. Some weeks later, radiographs showed severe burst fractures of T8 and T9 with retropulsion and canal narrowing. The patient had visible kyphosis but was neurologically intact apart from minor sensory loss on the left side. Case 6—A young man fell 7 metres. He was fully alert and oriented (Glasgow score 15) on arrival at accident and emergency. He had multiple lacerations to his head and neck and multiple tendon lacerations on both wrists; the right radial artery was severed. There was no spinal pain or tenderness on “log roll.” He underwent definitive tendon and wound repair under general anaesthesia and was admitted to the intensive care unit. When extubated two days later, he denied back pain but radiographs showed a crush fracture of L2 with retropulsion and 80%canal compromise which required fixation. There were no neurological sequelae. Acknowledgments Contributors: Lynne Dadley assisted in identifying the cases and suggested alterations to the manuscript. Gillian Bryce reviewed the manuscript and suggested changes. The problem was first highlighted to the group by Mike Clancy. SM is guarantor for the paper. The names of the members of the study group appear at the end of the paper