Upper thoracic spinal fractures in trauma patients — a diagnostic pitfall
Introduction
The diagnosis of (upper) thoracic spinal fractures in patients with multiple, often severe, injuries can be difficult. These patients often suffer from coexisting neurological symptoms or head injuries, have multiple (limb) fractures and are often sedated or on respiratory support when first seen in a casualty department. Hence, a neurological evaluation is often unreliable, if possible at all. Furthermore, the requirement of a quick diagnostic work-up and the difficult circumstances surrounding these patients lead to radiographs which are often difficult to interpret, especially by junior staff. The upper thoracic spine is difficult to visualize, even in ideal circumstances. Thus, the combination of clinical and imaging difficulties render upper thoracic spinal fractures liable to being overlooked. Additional diagnostic tests, such as computed tomography or magnetic resonance imaging may not be possible due to pressing interventions for life-threatening complications [1]. Hence, these fractures are frequently not detected until later, which may lead to worsening of the neurological deficit [2].
Although a recent article in this journal drew attention to fractures of the thoracolumbar spine [3], only sparse literature exists with respect to upper thoracic spinal injuries. The main findings which have been described are: dislocation of the spine, loss of height of a vertebra, widening of the para-spinal line, widening of the mediastinum, left apical cap and displacement of the naso-gastric tube [4]. Especially these last three findings may be confused with a traumatic aortic rupture [4], [5], [6]. To complicate matters further, the type of injury associated with upper thoracic spinal fractures is also associated with aortic rupture.
In this study, we assessed the imaging findings and the outcome of a consecutive series of patients with upper thoracic spinal fractures, which were more serious than simple (Magerl A1 or A2) compression type injuries.
Section snippets
Materials and methods
Between January 1983 and December 1998, a series of 26 patients with high thoracic spinal lesions, excluding compression fractures (Magerl types A1 and A2), were identified. Follow-up data were available for 23 (88%) of these patients. Of these patients, 10 were initially seen and investigated in another hospital and subsequently transferred, while the remaining patients were all directly managed in our own trauma unit.
The case records were evaluated to assess the a etiology of the fracture,
Results
The patients studied consisted of 21 male and 2 female patients, varying in age between 16 and 52 yrs (mean 30.3 yr). The causes of their fractures were a traffic related accident (16 patients), a fall from a great height (4 patients) or miscellaneous (3 patients).
At initial examination, 14 patients had a complete neurological lesion (Frankel A), two had incomplete neurological lesions (Frankel B and Frankel C), while 7 patients had no neurological symptoms (Frankel E).
The fractures according
Discussion
The initial diagnosis of upper thoracic spinal fractures remains based on plain films and clinical awareness. In patients who have undergone significant injuring forces, which result in flexion and twisting of the thoracic spine, the diagnosis should be actively sought. This should consist of a careful inspection and palpation of the back, where gaps between spinous processes may be felt within soft tissue swelling. In spite of this, great difficulty may be encountered in obtaining the correct
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