Spinal Fractures.... your management?

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pinipig523

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Hey guys -

I just thought of this today...

Spinal fractures from trauma - what's your management and do you have a source that is your "go to" source for this, preferrably on the web?

I know that the first step is to evaluate whether it is stable or not.

I know that the following are generally stable:
- Solitary spinous process fracture
- No tear drop deformity
- Solitary transverse fracture that is NOT in the cspine (2/2 vertebral artery involvement)
- As long as they do not hit 2 of the 3 columns (anterior, posterior, spinous ligament)
- And usually if there's a NAME for it, then it is usually unstable.

Also, I know to look for anterior, central or brown sequard lesions.

So say you get an XR or CT that shows a fracture - do you go for the MRI right after despite what it looks like to evaluate the cord and columns? Or do you always consult nsurg? Are there cases where you don't consult nsurg or do you consult nsurg always regardless if it appears to be a stable fracture?
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if it's not an isolated spinous process fx or a mild lumbar compression fx, I just call up NSx and ask them what they suggest.
 
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Birdstrike said:
Transverse or spinous fxs = treat like rib fractures (one alone no big deal, 7 of them could hurt like hell! or be difficult to function with if you're 80)

Any other traumatic spine fracture of the body, pedicles, facets, other = CT the level above through level below and get on the phone with spine.

MRI acutely? Worried about ligamentous injury? SCIWORA? Signs of myelopathy.......

You're out of your comfort zone at this point. Pick up the phone.

Spine fractures are high risk enough, there's no need to be a cowboy.
Click to expand...

So you mean anything other than a solitary transverse (provided it is not in the cspine) or a spinous fracture - don't be a cowboy?

So if you see multiple spinous process fractures, you won't ct it or mr it to make sure there's nothing else causing instability? Multiple fractures may lead you to think there's more than meets the eye?

I mean, multiple rib fractures, greater than 3, usually go to the trauma unit for overnight obs because of higher incidence of pulm contusion etc...
 
I tend to be very conservative with traumatic back pain, in patients of all ages.

Even in young people. The permanent disability that may result from a missed injury in my opinion justifies an aggressive search for those injuries. That's why I'm very liberal with the CTs and the MRIs in traumatic back pain.

I'm certainly willing to forego imaging completely for those patients who in my opinion don't have any significant risk of anything (and you all know what I mean; you see the same kinds of patients).

If a patient has a story or an exam that warrants imaging, I usually end up CT-ing them and will MRI them if there's any hint of neuro compromise. I rarely just use plain films. They aren't sensitive enough for c-spine injuries and probably aren't sensitive enough for T and L spine injuries either.
 
For those of you that subscribe to the ACEP daily news briefing via email, you probably read the article that recommended upright images to rule out c-spine injuries. Apparently some have been missed by CT and MRI in supine patients and only became evident that they were unstable with upright films.
 
First, I'll subscribe to the school of thought presented by DeNiro in Ronin : "If there's any doubt, there's no doubt". However, I don't call spine on TP/SP fractures unless it is a TP in the cervical spine with foraminal involvement or pt. has neuro deficits (including parasthesias). If I see fractures on the plain film, it's rare that I won't get a CT scan to further delineate the injury and survey the rest of the spine. If the patient needs admitted for pain control for multilevel TP fxs (I haven't really seen multilevel SP fx's) then trauma may insist on a spine consult (we have one ortho spine doc, he answers on his personal cell, doesn't take call but has answered during the middle of the night and at major sporting events and is never less then collegial). Medicine admits most of our geriatric GLF patients with wedge compression fxs (without retropulsion) who need rehab placement without spine involved.
 
glorfindel said:
I tend to be very conservative with traumatic back pain, in patients of all ages.

Even in young people. The permanent disability that may result from a missed injury in my opinion justifies an aggressive search for those injuries. That's why I'm very liberal with the CTs and the MRIs in traumatic back pain.

I'm certainly willing to forego imaging completely for those patients who in my opinion don't have any significant risk of anything (and you all know what I mean; you see the same kinds of patients).

If a patient has a story or an exam that warrants imaging, I usually end up CT-ing them and will MRI them if there's any hint of neuro compromise. I rarely just use plain films. They aren't sensitive enough for c-spine injuries and probably aren't sensitive enough for T and L spine injuries either.
Click to expand...

Plain film vs. CT for C-spine injuries is much discussed ( I favor CT for any concern above I'm imaging you because you're too big a crybaby to be cleared by Nexus). However, iff you have adequate films and a board-certified radiologist reading them I don't think there's any literature support for a high miss rate on T&L spine plain films. Especially missing anything that's going to lead to a bad outcome down the road. Unstable T&L spine fractures tend to be pretty obvious on plain films, excepting perhaps the high T-spine injuries that can be obscured by overlying bone and soft tissue. Agree with CT'ing if high suspicion for injury and MRI for neuro deficit.
 
Arcan57 said:
Plain film vs. CT for C-spine injuries is much discussed ( I favor CT for any concern above I'm imaging you because you're too big a crybaby to be cleared by Nexus). However, iff you have adequate films and a board-certified radiologist reading them I don't think there's any literature support for a high miss rate on T&L spine plain films. Especially missing anything that's going to lead to a bad outcome down the road. Unstable T&L spine fractures tend to be pretty obvious on plain films, excepting perhaps the high T-spine injuries that can be obscured by overlying bone and soft tissue. Agree with CT'ing if high suspicion for injury and MRI for neuro deficit.
Click to expand...


I thought I read somewhere that T spine XR is good enough. I think that the LS spine XR is also good enough to give you a basic idea of any possible fractures too from my same reading source. I'll try to find it. Definitely Cspine needs CT.



Arcan57 said:
First, I'll subscribe to the school of thought presented by DeNiro in Ronin : "If there's any doubt, there's no doubt". However, I don't call spine on TP/SP fractures unless it is a TP in the cervical spine with foraminal involvement or pt. has neuro deficits (including parasthesias). If I see fractures on the plain film, it's rare that I won't get a CT scan to further delineate the injury and survey the rest of the spine. If the patient needs admitted for pain control for multilevel TP fxs (I haven't really seen multilevel SP fx's) then trauma may insist on a spine consult (we have one ortho spine doc, he answers on his personal cell, doesn't take call but has answered during the middle of the night and at major sporting events and is never less then collegial). Medicine admits most of our geriatric GLF patients with wedge compression fxs (without retropulsion) who need rehab placement without spine involved.
Click to expand...

Most wedge compression fractures are stable right? Unless you have 50% or greater height loss or tear drop deformity suggestive of columnar disruption.
 
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Birdstrike said:
Of course, that's a different animal than a 20-year-old guy, with 4 rib fractures from a slip and fall, in rural ED with negative CXR, 100% O2 sat, no other injuries or pain, soft belly, reliable with no other medical problems and after 6 hours of obs looks and feels ready to dehorn the devil himself. Do you ship that out for to spend the night in a Level I trauma unit? I don't know.
Click to expand...

This is why my answer to this question is "Texas".
Because in other states, if you're in that rural, and you have that patient, a positive for fx but negative for PTX, HTX, or whatever means "send them home," because the majority of trauma surgeons won't accept it in transfer. And if they come back in 8 hours SOB and have a 40% pneumo, you're on the hook for doing what's right 90%+ of the time. So you're stuck watching them in your ED, because you know the FP working the hospital at night isn't going to Obs them.
In Texas, you'll be ok.
 
Dr.McNinja said:
This is why my answer to this question is "Texas".
Because in other states, if you're in that rural, and you have that patient, a positive for fx but negative for PTX, HTX, or whatever means "send them home," because the majority of trauma surgeons won't accept it in transfer. And if they come back in 8 hours SOB and have a 40% pneumo, you're on the hook for doing what's right 90%+ of the time. So you're stuck watching them in your ED, because you know the FP working the hospital at night isn't going to Obs them.
In Texas, you'll be ok.
Click to expand...

McNinja - what do you mean in texas you'll be ok?
 
Birdstrike said:
Yes, but.....


(If you can handle some more unscientific and unsubstantiated, pure anecdote)

For a while a couple guys in my group were sending these home routinely after plain films without CT'ing ("stable" <20-30% vertebral compression fxs that seemed uneventful, with normal neuro exam).

A few showed up in the ortho guys offices with fractures that progressed and developed burst components. No neuro involvement, though.

Our group director put out the APB that we need to CT all compression fractures and call ORTHO (or quietly move along to Texas.)


( Oops! Now that it's been "published" on SDN, I guess the lawyers will say it's "standard of care" in all cases now. Sorry :p )
Click to expand...

Ah gotcha... CT them to look for burst components or other signs that may point to an unstable fracture such as seatbelt or rotational component or burst or retropulsion.

I would still argue that maybe an MRI is better because you can tell acute from chronic based on intensity.

After reading this thread and brushing up on fractures through some reading -

1. If unstable based on xr, call nsurg - you may end up giving steroids if neuro s/s are noted.
2. If xr shows fracture - you may need to get a CT before clearing a stable fracture.... there may be something about it that may be somewhat unstable (i.e. burst instead of simple grade 1 wedge fracture).
3. If unsure of acuity or chronicity and cannot be elicited per hx - get MR to look for increased intensity of acute fractures.
4. Unstable fractures include disruption of 2 of 3 Denis colums and those w/ names, those cervical fractures w/ tear drop, transverse fracture of c spine, multiple levels.
5. Old people w/ wedge fractures of T or LS spine may need admission and some may benefit from vertebroplasty.
 
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Hijacks are welcome in this thread... by me, at least.

What other professions spend 11+ years to reach the "top" of the ladder... and....... are told how to behave by those fools who spent 3-4 years in business school ?

Time to take the power back. *insert Rage Against The Machine* lyric here... although... Rage would have us all holding hands and singing and getting along with no regard for actual work or scholarship.

Meh. Someone help me out here, I'm going to bed.
 
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