149

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

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Surg

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RM,

Scott

fractures

Belkin

SC,

Carter

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BL Computed

Assist

Tomogr

1979;

fracture-dislocationofthe thoracic ; a case report. J Bone Joint Surg

: fractures, dislocations, J Bone Joint Surg [Am]

and 1970;

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McManus F, C/inRadio/1986;

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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

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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

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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

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Wolpert

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et al 1979;

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Ennis

JT.

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CA, Greenberg IM. Complete dislocation without neurological deficit : a case report. 1977; 59-A:l34-5.

A, Mozes G. Complete without neurobogic deficit

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1987;

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