deformity of the spinous processes; neurological examination was normal. Radiographs .... or gibbus because the posterior elements, in particular the spinous.
THORACIC
SPINE
TRANSLOCATION
WITHOUT A. H. R. W. SIMPSON,
D.
M. WILLIAMSON,
From
We report
Unstable
fractures,
spinal
cord injury. where there (Denis produce
1985
narrow of the
and
the
paraplegia.
recently
have
of these (CT),
assessing
seen but
injuries which
stability
this
specific
infrequent
the
of the but
accident
loss
and
Oxford
with
.*!-#{149}
the
neural
Radiographs
severe
deficit.
We
and
The
computed of choice and
sparing.
Case
1 . Radiographs
showing
fracture-dislocation
of T9 upon
Tb.
Ennis
discuss
the
management
of
injury.
REPORTS was involved a minor left
head
a fractured
side.
Clinical
showed
any
a fracture
in a road injury
and
spine showed no kyphus nor spinous processes; neurological
normal.
with
McManus
sustained on
shearing
associated
patients
diagnosis
consciousness, ribs
that
always
neurological
motorcyclist
and
of
stated
three no
important
1. A 17-year-old
humerus
of the of the
Centre,
R. HOUGHTON
region makes Bohlman in
was studied with is the investigation
CASE
brief
associated
are
(Lynch,
explained
problems
1970
region
translocation,
anatomy tomography
traffic
Orthopaedic
tG.
so in the thoracic spine around the neural elements
in
thoracic
complete
Case
frequently
S. J. GOLDING,
spine translocation without neurological deficit. In each case bilateral computed tomography, produced ‘floating arches’ which account for tomography demonstrates adequate canal dimensions, these patients treatment ofchoice at specialist spinal centres is operative stabilisation.
spinal canal in this cord almost inevitable.
We
1986);
are
Holdsworth
of
thoracic
this
fractures
INJURY
1983). Considerable violence is necessary to a fracture or dislocation of the upper thoracic
fractures
for
demonstrated
This is especially is the least space
spine ; the transection
with
three cases
Nuffield
of thoracic by the sparing of the cord. If computed may be treated conservatively, but the pedicular
CORD
with
clavicle, examination
other deformity examination was dislocation
at
A. H. R. W. Simpson, MA, FRCS, Orthopaedic Registrar D. M. Williamson, MA, FRCS, Senior Orthopaedic Registrar S. J. Golding, MA, FRCR, Director, Oxford Regional Computed Tomography Unit tG. R. Houghton, deceased, MA, FRCS, Orthopaedic Consultant Nuffield Orthopaedic Centre, Headington, Oxford 0X3 7LD, England. Correspondence
©
1989
British
0301-620X/90/l
JBoneJointSurgfBr]
80
should
be sent
to Mr A. H. R. W. Simpson.
Editorial Society of Bone 192 $2.00 1990; 72-B: 80-3.
and
Joint
Surgery
Fig. Case 1 . Axial CT images from on the left side of 18, separation the body ofT9 lying anterolateral
THE
2
T8 to T 10, showing an unstable fracture of the body of T9 from its arch, and to the body of TlO.
JOURNAL
OF BONE
AND
JOINT
SURGERY
THORACIC
T9/lO, with severe displaced anteriorly (Fig. 1). CT considerable
mala!ignment, and to the
confirmed separation
the right
the fracture of the body
SPINE
body of the
TRANSLOCATION
of T9 being body of T10
dislocation, of T9 from
then
mobilised The rods
the
patient
isolated fracture Ten days after instrumentation
in a jacket. were removed was
after
asymptomatic.
one
year
at which
Follow-up
CT
anteroposteriordiameterofthe
14.7 mm
spinalcanal
1 1.5 mm,
Ul!rich
was
in the distribution no long tract signs
confirmed
the
fracture-dislocation
of
showing an oblique comminuted fracture through levels, with displacement of the upper fragments left of the lower ones (Fig. 4). In view of the symptoms management of
of or
and the delay was continued.
injury
there
persistence
was
in diagnosis, By 1 5 weeks
full
clinical
of an asymptomatic
T6/7,
several to the minimal
conservative from the time
recovery thoracic
apart
from
kyphosis.
15
fractures smallest
>
and altered sensation thoracic nerve, but
time at
months after treatment showed healing of the with no significant stenosis at any level. The (normal
81
INJURY
disturbance.
CT
of the base of the injury the spine was and the patient
CORD
tenderness the seventh sphincter
showing its neural
arch (Fig. 2). There was also a left pleura! collection, consistent with a haemothorax. CT also demonstrated an unsuspected and unstable fracture at T8, with a transverse fracture of the pedicle and transverse process on the left, and an right pedicle of T7. reduced by Harrington
WITHOUT
et a! (1980).
.,,
‘i
;;L
Fig.
Fig. 3 Case 2. Lateral radiograph between T5 and T7, with T6 vertebral body.
Case
and AP tomogram severe compression
2. A 54-year-old
landing diagnosed
on the back fractures
lady
weeks
because of malalignment
and the However,
full
VOL.
off her
and a further
left thoracic
noted
that
chest pain; spine and
fracture was difficult soft tissue shadows
spine showed severe an angular kyphosis at this stage showed
72-B, No. 1, JANUARY
1990
there
radiograph
horse,
was
was
no
taken
this showed a left pleura!
to see because of the ofthe heart and aorta
extent of the injury was still radiographs and anteroposterior
of the thoracic at T7 with examination
later
persisting of the
collection. The dense overlying
thrown
kyphosis of the
of her left shoulder. A casualty officer of the left third and fourth ribs, both
clinically and radiologically, spinal tenderness. Seven
was
showing angular and displacement
not
apparent. tomograms
lateral displacement (Fig. 3). Clinical only minimal local
Case side,
2. Axial CT sections showing with preservation of the spinal
Case
3.
A
motorcycle injury,
23-year-old accident.
an
associated
open
with
and open fractures tibia. There were olecranon. After
She
4 the vertebral canal.
woman sustained
comminuted
arterial
was
fracture
occlusion
bodies
lying
involved a moderate of
requiring
the
side
by
in a head left
a vein
tibia
graft,
of the right distal femur and proximal also fractures of the left humerus and five days, she was transferred to this
centre with a gangrenous left leg which required belowknee amputation. The wounds on the right leg had been closed primarily and were now grossly infected. At this 5).
CT
stage,
showed
of T7, with superior fragments (Fig. 6). Although body
her
spinal
a severely
injury
was
comminuted
recognised
fracture
(Fig. of the
marked shortening of the spine, the passing to the right of the inferior the vertebral body had fractured from
A. H. R. W. SIMPSON.
82
the pedicles,
the arch
with the produced fracture
adjacent an acute through
haemothorax. In view injury weeks
was
intact
and
articulated
levels, so that kyphosis. There the T7/8 facet
of the
patient’s
uniting.
had
no
At review
symptoms
general
two
from
years
her
S. J. GOLDING,
G. R. HOUGHTON
normally
the shortening had was also an oblique joint and a right debility
was managed conservatively. after the injury showed that
were
D. M. WILLIAMSON.
the
Tomograms the spinal
after
spine,
at six fractures
injury
nor
spinal
the
any
patient
of spinal
stenosis.
DISCUSSION This
major
diagnose was
spinal
both
injury
can
clinically
initially
missed
be surprisingly
difficult
and radiologically in two
of our
to
: the diagnosis
three
cases.
Fig.
Clinical
examination often fails to reveal any step or gibbus because the posterior elements, in particular the spinous processes and supraspinous ligaments, have remained in alignment. radiograph,
Spinal tenderness performed primarily
5
Case 3. Lateral radiograph showing severe compression of the body T7 (arrow), and AP tomogram showing separation of the fragments the body ofT7, with the T6/7 and T7/8 discs almost level.
of of
may be absent. A chest for the soft tissues, does
not show this region of the spine well. However, Dorr, Harvey and Nickel (1982) reported a 36% incidence of haemothorax in patients with thoracic rotation and shear fractures, important
so the warning
There
presence sign.
is debate
translocations considered
of
on
the
a
haemothorax
stability
in the thoracic region. that a shearing fracture
of
is
an
acute
spinal
Holdsworth was a stable
(1970) injury,
but
Sasson and Mozes (1987) and Bohiman (1985) deem be highly unstable. The rib cage (Dorr et a! 1982) and the strong costovertebral ligaments confer significant it to
stability to the thoracic vertebral fractures and dislocations, and it is possible that the variable damage to these elements explains the divergence of viewpoints on stability. of ribs
Ifthere has been significant damage to a number in the region of the translocation, then the injury
is likely
to be unstable.
We consider
that
all such
be regarded as unstable. Many patients with spinal injuries multiple trauma and are often unconscious
injuries
should
the emergency suggest that
and
that
considered that there
there
any
reception area. If has been complete
paraplegia
is
that no further cord is no need to institute
an unstable radiographs
spine. should
Our never
have suffered on arrival in
plain cord
radiographs transection
irrevocable,
it
may
damage is possible the handling routine
cases demonstrate be used to infer
the
Fig. 6
that state
be and for
plain of the
spinal cord. Complete fracture-dislocation
dislocation ofthe cervical of the lumbar region
ical sparing have been reported Pitman and Greenberg 1977), sparing after severe displacement
is more
remarkable
dimensions
of the
because cord
and
and major neurolog-
(Jacobs 1977; Pitman, but the neurological in the thoracic region
of the
spine with
canal
the
less in this
favourable region.
We
Case 3. Series of CT sections showing the fragments lying around those ofT6, and an unstable fracture posterior elements remain in line.
could
find
only
two
reports
of similar
of the body of T7 at T8. Note that the
injuries
and Offierski 1979; Sasson and Mozes neither ofthese was CT available to delineate pattern and canal dimensions accurately. Since its introduction, as the investigation of choice spinal fracture. It gives a delineation of the fracture, stenosis and stability can be THE
JOURNAL
(Gertzbein 1987), but in the fracture
CT has become established for patients with suspected precise and comprehensive so that the degree of spinal predicted accurately (Faerber OF BONE
AND
JOINT
SURGERY
THORACIC
SPINE
TRANSLOCATION
WITHOUT
CORD
operative in
83
INJURY
stabilisation.
case
In our series,
3 precluded
internal
the systemic
fixation,
CT
adequate canal dimensions and a satisfactory was obtained by bed rest and ‘log-rolling’ until case
2 the
spinal
patient
had
fracture
has
and,
a severe
resulted
already
kyphosis.
in
an
been
although In case
with
the
asymptomatic,
I operative
outcome
shown
outcome union. In
mobilised
at present
excellent
sepsis
had
stabilisation
and
allowed
early
mobilisation.
Conclusions.
If
computed
adequate dimensions result can be obtained
ment,
but if the necessary
patient’s be
tomography
throughout by skilled
condition
the
treatment
attempted
expertise
permits, of choice.
in any party
form have been related directly
canal
a good manage-
is available
operative
only at specialist
No benefits commercial article.
demonstrates
the spinal conservative
and
stabilisation
This
should,
spinal
centres.
the may
of course,
received or will be received or indirectly to the subject
be
from a of this
REFERENCES Bohlman HH. Current concepts dislocations of the thoracic [Am] 1985; 67-A:l65-9.
Diagram remain
showing in line.
Fig.
7
how
the ‘floating
Denis
F. The ofacute
arches’
three column thoracolumbar
LD, Harvey
Dorr
ofspine Faerber
EN,
Lynch
demonstrated
cord
sparing.
et a! 1986).
a pattern
of injury
In essence,
bilateral
several
levels
remain
in continuity
severely
In each
had
displaced
allowed
whilst (Fig.
the
of our
which
pedicular
bodies
to
fractures
of the
on three-dimensional that this technique posterior
elements
two-dimensional images. reformatted three-dimensional any
further
For
diagnostic
the
and Offierski conclusions
VOL.
72-B,
two
CT may
which
reconstrucalso reveal
are not
seen
SM,
of
spinal
1979 ; Sasson were reached
No. 1, JANUARY
1990
and as
Mozes regards
opposite need for
JC,
Hunter
Fink
dimensional Spine update neurosurgeons. Foundation, Jacobs
Review
fractures.
Complete injury
article
ofthe
spine.
and
Joint
Surg
in the classification 1983 ; 8:817-31.
review
ofthe
early stability
7:545-50.
RM,
Scott
fractures
Belkin
SC,
Carter
J Comput
BL Computed
Assist
Tomogr
1979;
fracture-dislocationofthe thoracic ; a case report. J Bone Joint Surg
: fractures, dislocations, J Bone Joint Surg [Am]
and 1970;
frac52-A:
D,
trauma. Pitman
MI,
cervical
McManus F, C/inRadio/1986;
Pitman spine
JointSurg[Am]
Ulirich
IJ, Zinreich SJ, Chafetz N, McClendon DR. ThreeCT imaging of the lumbar spine. In : Genant HK, ed. 1987 : perspectives for radiologists, orthopaedists and San Francisco : Radiology Research and Education 1987:237-45.
RR. Bilateral fractures of the pedicles through the fourth and fifth lumbar vertebrae with anterior displacement of the vertebral bodies: case report. J Bone Joint Surg [Am] 1977 ; 59-A :409-10.
Lynch
(Gertzbein 1987) the
F.
ture-dislocations
Sasson
previously
OfllerskiC.
VL. Clinical
1982;
without spinal cord 1979; 6l-A:449-5l.
Holdsworth
on
In our experience, however, views have failed to yield reported
Nickel Spine
of
J Bone
1534-51.
in its
information.
cases
spine [Am]
became
remained
connect relationship to the posterior elements and was therefore not compromised. Hunter et a! (1987) suggest that complex mala!ignment involving displacement and rotation of fragments is best appreciated tions and suggest
GertzbeinSD,
at
elements
had
3.657-61.
the
fractures
posterior cord
CT
explained
the vertebral
7). The
cases
spine and its significance spinal injuries. Spine
Wolpert
tomography
et al 1979;
JPJr,
injuries.
review : Treatment and lumbar spine.
Ennis
JT.
Computed
tomography
in spinal
37:71-6.
CA, Greenberg IM. Complete dislocation without neurological deficit : a case report. 1977; 59-A:l34-5.
A, Mozes G. Complete without neurobogic deficit
fracture-dislocation : a case
report.
of the thoracic Spine
1987;
CG, Binet EF, Sanecki MG, Kieffer SA. Quantitative of the lumbar spinal canal by computed tomography. 1980; 134:137-43.
of
the
J Bone spine
12:67-70. assessment Radio/ogy