Spine Injury: Lumbar, Emergency Medicine

Basics

Description

Flexion compression fracture:
- Wedge compression:
  - If <50% anterior compression of the vertebral body, injury considered stable
  - No ligamentous injury
  - No neurologic deficit
- Burst fracture:
  - Vertebral body fracture with retropulsion of bone into the neural canal
  - Kyphosis evident on lateral radiograph
  - Posterior ligamentous injury
  - Anterior compression, lower extremities, calcaneal fractures
  - Possible neurologic deficit
Flexion distraction (lap belt injury):
- Abdominal injuries likely
- Chance fracture:
  - Purely bony injury; fracture line through spinous process, pedicles, and vertebral body
  - No kyphosis evident on lateral radiograph
  - Often no neurologic deficit
- Facet dislocation:
  - Mostly soft tissue injury; no fracture
  - Complete disruption of posterior ligaments and intervertebral disc
  - Neurologic deficit may be present.
Flexion rotation:
- Unstable injury
- Neurologic deficit often present
Extension:
- Unstable, uncommon
- Disruption of anterior longitudinal ligament and intervertebral disc
- Neurologic sequelae rare but possible
Shear injuries (translational injuries):
- Anterior, posterior, or lateral translation of superior vertebral segment over the inferior segment
- Complete ligamentous disruption
- Neurologic deficit present
Simple fractures:
- Isolated spinous process fracture:
  - Ligamentous disruption
  - No neurologic deficit
- Isolated transverse process fracture:
  - Ligamentous disruption
  - Neurologic deficit possible; rare isolated root injury

Etiology

Blunt trauma with axial distraction, axial compression, or translational forces applied to lumbar region
Fall from height landing on the feet (associated calcaneal fractures) or on the buttocks
Motor vehicle accidents (MVA)

Rare reports of child abuse presenting as lower extremity flaccid paralysis owing to lumbar spine fracture.
Spinal cord terminates at L3 in newborn and recedes to T12 by adulthood; direct cord damage possible in children with high lumbar fractures.
End plate avulsion fractures: Adolescent injury usually at L4 " L5 or L5 " S1 level; ligament pulls off vertebral body end plate; associated neurologic findings.

Diagnosis

Signs and Symptoms

Pain or localized tenderness to palpation in lumbar midline
Ecchymosis or deformity overlying lumbar region; palpable deformity; paraspinal muscle spasm
Increased interspinous distance by palpation
Step-off (anterior or posterior displacement of spinous process) by palpation
Neurologic deficits referable to lumbar spinal nerves:
- Loss of bladder control
- Motor: Hip flexion (L1 " L4), leg extension (L3, L4), ankle dorsiflexion (L4, L5), toe extension (L5)
- Sensory: Inguinal crease (L1), medial thigh (L2 " L3), knee (L4), lateral calf (L5)
- Reflexes: Knee jerk (L2 " L4)
Pain may be masked by associated distracting injuries (e.g., pelvis, calcaneal fractures).
Patients with multiple injuries and altered mental status have an unreliable clinical exam and require imaging.

History
Mechanism to suggest forces applied to lumbar region:

MVA
Fall
Direct impact to lumbar region

Physical Exam

Midline lumbar tenderness or deformity
Neurologic findings involving lumbar spinal nerves

Consider abuse in cases of uncertain mechanism.
Increase suspicion of bleeding consequences, such as spinal hematomas, in patients taking Coumadin or other anticoagulants.

Essential Workup

Following criteria associated with higher risk of thoracolumbar (TL) spine injuries and should be imaged:

TL pain or tenderness to palpation
Decreased level of consciousness (Glasgow Coma Scale <14)
Drug intoxication, altered pain perception
Neurologic deficits (described above)
Painful, distracting injuries
Severe injury mechanism (e.g., rollover MVA, auto vs. pedestrian, fall >10 ft)
Lumbar radiographs (described under Imaging)
Careful neurologic exam including:
- Assessment of rectal tone
- Bulbocavernosus and cremasteric reflexes
- Perineal sensation

Diagnosis Tests & Interpretation

Lab

Standard multitrauma labs if indicated:
CBC
Chemistry panel
Coagulation studies
Urinalysis

Imaging

Lumbar radiography with minimum of anteroposterior and lateral views. Characteristics of unstable fractures include:
- Widening of interspinous, interlaminar, or interpedicular distance
- Kyphosis >20 °
- Translation >2 mm
- Vertebral body height loss >50%
- Articular process fracture
Radiographs may not identify burst fractures in 25% of cases.
If a fracture is identified, entire spine should be imaged to evaluate for associated injuries.
Spinous process fracture, transverse process fracture, or simple transverse sacral fracture require lumbar flexion " extension films if patient is neurologically intact and there is no evidence of unstable injury.
CT or MRI should be performed for further evaluation of suspected fractures or fractures identified on plain films to assess spinal cord integrity.

Diagnostic Procedures/Surgery
Consider postvoid residual urinary catheterization or ultrasound to identify urinary retention.

Differential Diagnosis

Contusion
Pathologic fracture (metastatic cancer)
Osteoporosis
Pelvic fracture
Traumatic herniated disc
Low posterior rib fracture
Tuberculous spondylitis (Pott disease)
Ankylosing spondylitis
Osteogenesis imperfecta (pediatric)
Congenital scoliosis with hemivertebra (mistaken for lateral wedge fracture)
Child abuse
Spinal hematoma
Epidural abscess

Treatment

Pre-Hospital

It is difficult to determine whether an injury is stable in the field; any patients with suspected spinal injuries should be immobilized to prevent further injury.

Initial Stabilization/Therapy

Immobilization while tending to immediate life-threatening conditions
Airway, breathing, and circulation management

Ed Treatment/Procedures

Maintain spinal immobilization.
High-dose methylprednisolone protocol for any neurologic deficit (best in concert with specialist consultation)
Consultation with orthopedic spine or neurosurgery service
Appropriate analgesia
The following stable injuries may be treated conservatively if CT confirms stability of injury and patient is neurologically intact:
- Isolated spinous process, transverse process fracture
- Chance fracture
- Anterior wedge compression (<50%) fracture
- Stable burst fracture
Total contact orthotic devices may be useful; limited activities; sleep prone; avoid pillows and soft mattresses, which may worsen deformity.

Medication

Narcotic pain medication in absence of contraindications
High-dose steroid protocol: Methylprednisolone: 30 mg/kg IV load over 1 hr, then 5.4 mg/kg/h for the next 23 hr; initiate in ED within 8 hr of injury.

First Line

Tylenol: 1 g (peds: 15 mg/kg) PO q4h PRN
Motrin: 400 " 800 mg (peds: 10 mg/kg) PO q6h PRN
Dilaudid: 1 " 2 mg (peds: 0.015 mg/kg) IV/IM q3h PRN
Morphine: 2 " 10 mg (peds: 0.1 " 0.2 mg/kg) IV/IM q3h PRN
Toradol: 30 mg IV or 60 mg IM (peds: 0.5 mg/kg IV or 1 mg/kg IM) q6h PRN:
- Use half Toradol dose for patients >65 y

Second Line

Flexeril: 5 " 10 mg PO q8h PRN
Soma: 350 mg PO q8h PRN
Zofran: 4 " 8 mg IV/PO (peds: >4 y, 4 mg IV/PO) q8h PRN
Compazine: 5 " 10 mg IV/IM/PO (peds: 2.5 mg PR/PO) q8h PRN
Phenergan: 12.5 " 25 mg IM/PO/IV (peds: 0.5 " 1 mg/kg IM/PR) q8h PRN:
- IV Phenergan NOT recommended due to reports of tissue necrosis

Follow-Up

Disposition

Admission Criteria
Patients with traumatic lumbar fractures should be admitted for stabilization procedures, parenteral pain control, management of possible ileus, and evaluation for associated injuries.
Discharge Criteria

Neurologically intact patients with stable injuries evaluated in conjunction with a spine surgeon
Patients with simple compression (wedge) fractures with no neurologic deficit may be considered for outpatient management if adequate pain control and appropriate follow-up can be arranged.
Simple transverse sacral fracture, isolated spinous process fracture, and isolated transverse process fracture may also be considered for outpatient management.
The patient must be neurologically intact with a stable living situation; CT scan and flexion " extension films must confirm fracture stability.

Issues for Referral
Patients discharged with stable injuries should have primary care or orthopedic appointment in 1 wk to monitor for recovery and evaluate for potential complications.

Followup Recommendations

Return to ED for new neurologic symptoms or pain not controlled by discharge medications. Otherwise, follow-up as described above.

Pearls and Pitfalls

Lumbar fractures are rare in pediatrics. Aggressively pursue causative factor if mechanism is not evident.
Older individuals may have underlying medical cause of lumbar pathology. Pursue alternative causes of pain, such as hematomas and infections. Be vigilant in patients taking anticoagulants.
CT should follow compression fractures seen on plain films to assess for stability and potential canal involvement.
Otherwise healthy, ambulatory patients with simple post MVA low back pain may be safely discharged without imaging if the exam is otherwise reassuring.

Additional Reading

Boran S, Lenehan B, Street J, et al. A 10-year review of sports-related spinal injuries. Ir J MedSci. 2011;180(4):859 " 863.
Hanck J, Mu ±iz A. Cervical spondylodiscitis, osteomyelitis, and epidural abscessmimicking a vertebral fracture. J Emerg Med. 2012;42(3):e43 " e46.
Holmes JF, Panacek EE, Miller PQ, et al. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003;24:1 " 7.
Petersilge C, Emery S. Thoracolumbar burst fracture: Evaluating stability. Semin Ultrasound CT MR. 1996;17:105 " 113.
Tamir E, Anekstein Y, Mirovsky Y, et al. Thoracic and lumbar spine radiographs for walking trauma patients: Is it necessary? J Emerg Med. 2006;31:403 " 405.

Codes

ICD9

722.10 Displacement of lumbar intervertebral disc without myelopathy
805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury
847.2 Sprain of lumbar
733.13 Pathologic fracture of vertebrae

ICD10

M51.26 Other intervertebral disc displacement, lumbar region
S32.009A Unsp fracture of unsp lumbar vertebra, init for clos fx
S33.5XXA Sprain of ligaments of lumbar spine, initial encounter
M84.48XA Pathological fracture, other site, init encntr for fracture
S32.000A Wedge compression fracture of unsp lumbar vertebra, init
S32.001A Stable burst fracture of unsp lumbar vertebra, init

SNOMED

426646004 Compression fracture of lumbar spine (disorder)
209565008 lumbar sprain (disorder)
202708005 Prolapsed lumbar intervertebral disc (disorder)
270508006 Pathological fracture of lumbar vertebra (disorder)
207959006 Closed fracture lumbar vertebra, wedge (disorder)
281934008 Burst fracture of lumbar vertebra (disorder)

Home

Erectile Dysfunction

Doctor123.org