Spinal column injuries in adults: Definitions, mechanisms, and radiographs
- Amy Kaji, MD, PhD
Amy Kaji, MD, PhD
- Associate Professor of Emergency Medicine
- David Geffen School of Medicine at UCLA
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editors
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
This topic review describes injuries to the cervical, thoracic, and lumbosacral spinal column, including fractures, dislocations, and subluxations of the vertebrae, and injuries to the spinal ligaments. The importance of recognizing and managing injuries to the spinal column is underscored by their association with spinal cord injury.
The management of spinal column injuries and other issues related to spinal cord injury are discussed elsewhere. (See "Evaluation and acute management of cervical spinal column injuries in adults" and "Acute traumatic spinal cord injury" and "Anatomy and localization of spinal cord disorders" and "Evaluation of cervical spine injuries in children and adolescents" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete".)
Among patients included in a large trauma registry, approximately 3 percent of those with blunt trauma sustain a spinal column injury, such as spinal fracture or dislocation, and 1 percent sustains a spinal cord injury . Spinal column injury rates reported in other studies range from 2 to 6 percent . The incidence is likely to be significantly higher in patients with head trauma and those who are unconscious at presentation. Fracture of the thoracolumbar spine, including spinous and transverse process fractures, may occur in as many as 8 to 15 percent of blunt trauma patients cared for at major trauma centers . Additional noncontiguous spine fractures are common in patients diagnosed with a spine fracture following high-energy blunt trauma [4,5]. A review of over 83,000 patients from the United States National Trauma Data Bank diagnosed with a spine fracture reported that 19 percent sustained a noncontiguous spine fracture.
A systematic review of 13 international studies found great variation (up to a threefold difference) in the rate of spinal column injury among nations, particularly between developed and developing nations [6,7]. Most studies demonstrate a bimodal age distribution where the first peak is found in young adults between 15 and 29 years of age and a second peak in adults older than 65 years of age. Mortality is significantly higher in elder patients . Spinal column injuries are more common in males. (See "Geriatric trauma: Initial evaluation and management".)
Note that statistics from trauma registries can be incomplete and inaccurate, depending on the inclusion criteria, and may underestimate the number of patients with spinal column injury. As examples, victims who die at the accident scene and patients whose neurologic deficits rapidly improve are often not included.
- National Spinal Cord Injury Association Resource Center. www.sci-info-pages.com/factsheets.html (Accessed on May 22, 2008).
- Greenbaum J, Walters N, Levy PD. An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med 2009; 36:64.
- Berry GE, Adams S, Harris MB, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma 2005; 59:1410.
- Nelson DW, Martin MJ, Martin ND, Beekley A. Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. J Trauma Acute Care Surg 2013; 75:135.
- Winslow JE 3rd, Hensberry R, Bozeman WP, et al. Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures. J Trauma 2006; 61:686.
- Chiu WT, Lin HC, Lam C, et al. Review paper: epidemiology of traumatic spinal cord injury: comparisons between developed and developing countries. Asia Pac J Public Health 2010; 22:9.
- van den Berg ME, Castellote JM, Mahillo-Fernandez I, de Pedro-Cuesta J. Incidence of spinal cord injury worldwide: a systematic review. Neuroepidemiology 2010; 34:184.
- Fassett DR, Harrop JS, Maltenfort M, et al. Mortality rates in geriatric patients with spinal cord injuries. J Neurosurg Spine 2007; 7:277.
- Spinal Cord Injury Information Network. www.spinalcord.uab.edu (Accessed on February 12, 2008).
- Stein DM, Kufera JA, Ho SM, et al. Occupant and crash characteristics for case occupants with cervical spine injuries sustained in motor vehicle collisions. J Trauma 2011; 70:299.
- Parenteau CS, Viano DC. Spinal fracture-dislocations and spinal cord injuries in motor vehicle crashes. Traffic Inj Prev 2014; 15:694.
- Clinical anatomy for emergency medicine, Snell, Rs, Smith, MS (Eds), Mosby, St. Louis 1993.
- Gardner, A, Grannum, S, Porter, K. Thoracic and lumbar spine fractures. Trauma 2005; 7:77.
- Savitsky E, Votey S. Emergency department approach to acute thoracolumbar spine injury. J Emerg Med 1997; 15:49.
- Guthkelch AN, Fleischer AS. Patterns of cervical spine injury and their associated lesions. West J Med 1987; 147:428.
- Clinical anatomy for emergency medicine, Snell Rs, Smith MS (Eds), Mosby, St. Louis 1993.
- Maroon JC, Abla AA. Classification of acute spinal cord injury, neurological evaluation, and neurosurgical considerations. Crit Care Clin 1987; 3:655.
- Harris JH Jr, Carson GC, Wagner LK, Kerr N. Radiologic diagnosis of traumatic occipitovertebral dissociation: 2. Comparison of three methods of detecting occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 1994; 162:887.
- Harris JH Jr, Carson GC, Wagner LK. Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 1994; 162:881.
- Powers B, Miller MD, Kramer RS, et al. Traumatic anterior atlanto-occipital dislocation. Neurosurgery 1979; 4:12.
- www.wheelessonline.com (Accessed on May 12, 2011).
- THIEBAUT F, WACKENHEIM A, VROUSOS C. [DEFINITION OF ANTERO-POSTERIOR DISPLACEMENT OF THE ODONTOID PROCESS OF THE AXIS WITH THE AID OF THE BASILAR LINE]. Acta Radiol Diagn (Stockh) 1963; 1:811.
- Clark, WM, et al. Twelve significant signs of cervical spine trauma. Skeletal radiology 1979; 3:201.
- Atlas FRX/Jefferson Fracture. www.wheelessonline.com/ortho/atlas_frx_jefferson_fracture (Accessed on February 15, 2008).
- Hockerberg, RS, Kaji, AH. Spinal column injuries. In: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th, Marx, J, Hockberger, R, Walls, R (Eds), Mosby, Philadelphia 2006.
- Koivikko MP, Kiuru MJ, Koskinen SK, et al. Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004; 86:1146.
- Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol 1989; 152:319.
- Makan P. Neurologic compromise after an isolated laminar fracture of the cervical spine. Spine (Phila Pa 1976) 1999; 24:1144.
- Zmurko MG, Tannoury TY, Tannoury CA, Anderson DG. Cervical sprains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clin Sports Med 2003; 22:513.
- Woodring JH, Goldstein SJ. Fractures of the articular processes of the cervical spine. AJR Am J Roentgenol 1982; 139:341.
- Chapman JR, Anderson PA. Thoracolumbar spine fractures with neurologic deficit. Orthop Clin North Am 1994; 25:595.
- Montesano, PX. Anterior approach to fractures and dislocations of the thoracolumbar spine. In: Operative Orthopaedics, Chapman, M (Eds), Lippincott Williams & Wilkins, Philadelphia 1988. p.1905.
- Kuklo TR, Polly DW, Owens BD, et al. Measurement of thoracic and lumbar fracture kyphosis: evaluation of intraobserver, interobserver, and technique variability. Spine (Phila Pa 1976) 2001; 26:61.
- Bolesta, MJ, Rechtime, GR. Fractures and dislocations of the thoracolumbar spine. In: Rockwood and Green's Fractures in Adults, Bucholz, RW, Heckman, JD (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. p.1405.
- Panjabi MM, Oxland TR, Kifune M, et al. Validity of the three-column theory of thoracolumbar fractures. A biomechanic investigation. Spine (Phila Pa 1976) 1995; 20:1122.
- Vollmer DG, Gegg C. Classification and acute management of thoracolumbar fractures. Neurosurg Clin N Am 1997; 8:499.
- Vaccaro, AR, Lehman, RA, Jr, Jurlbert, RJ et, al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976) 2005; 15:2325.
- Patel AA, Dailey A, Brodke DS, et al. Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine 2009; 10:201.
- Holmes JF, Miller PQ, Panacek EA, et al. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med 2001; 8:866.
- Galli, R, Spaite, D, Simon, R. Emergency Orthopedics: The Spine, Appleton and Lange, Norwalk 1989.
- Ballock RT, Mackersie R, Abitbol JJ, et al. Can burst fractures be predicted from plain radiographs? J Bone Joint Surg Br 1992; 74:147.
- Dai LY. Imaging diagnosis of thoracolumbar burst fractures. Chin Med Sci J 2004; 19:142.
- Campbell SE, Phillips CD, Dubovsky E, et al. The value of CT in determining potential instability of simple wedge-compression fractures of the lumbar spine. AJNR Am J Neuroradiol 1995; 16:1385.
- Anderson PA, Rivara FP, Maier RV, Drake C. The epidemiology of seatbelt-associated injuries. J Trauma 1991; 31:60.
- Inaba K, Munera F, McKenney M, et al. Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: a review of the literature. J Trauma 2006; 60:915.
- Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury 2003; 34:426.
- Krueger MA, Green DA, Hoyt D, Garfin SR. Overlooked spine injuries associated with lumbar transverse process fractures. Clin Orthop Relat Res 1996; :191.
- Paley D, Gillespie R. Chronic repetitive unrecognized flexion injury of the cervical spine (high jumper's neck). Am J Sports Med 1986; 14:92.
- Tisot RA, Avanzi O. Laminar fractures as a severity marker in burst fractures of the thoracolumbar spine. J Orthop Surg (Hong Kong) 2009; 17:261.
- MECHANISMS OF INJURY
- CERVICAL SPINAL COLUMN INJURY
- Cervical spinal column injury classification
- Atlanto-occipital dislocation
- Atlanto-axial dislocation
- C1 (Atlas) fractures
- - Burst (Jefferson)
- - Posterior arch
- C2 (Axis) pedicle fractures
- - Odontoid fractures
- Anterior wedge
- Flexion teardrop
- Extension teardrop
- Spinous process fractures
- Burst fractures
- Laminar fractures
- Facet dislocations
- - Bilateral
- - Unilateral
- Ligamentous injuries and SCIWORA
- THORACIC AND LUMBAR (TL) SPINAL COLUMN INJURY
- TL spinal column injury classification
- Compression fractures
- Burst fractures
- Flexion-distraction (lap belt) injuries
- Translational spinal column injury
- Other TL fracture patterns
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS