- Age: 32
- Gender: Male
- Medical history: None
- Initial presentation: Heavy bar landed on patients’ back, after which the patient fell on the floor and hit his head.
- Examination: Head injury and lumbal swelling. Pain at thoracic spine. Decreased sphincter tension. Tingling sensation was present in both legs after the accident, but had already disappeared at time of examination.
- Examination: Normal auscultation and normal percusion
Anteroposterior (AP) view X-spine
Lateral view X-spine
MRI of spine
S. Spijkers & M. Maas
Checklist Röntgen & CT (Lumbar spine)
- Coverage – The whole L-spine should be visible on both views
- Alignment – Follow the corners of the vertebral bodies from one level to the next
- Bones – Follow the cortical outline of each bone
- Spacing – Disc spaces gradually increase in height from superior to inferior – Note: The L5/S1 space is normally slightly narrower than L4/L5
- Alignment – The vertebral bodies and spinous processes are aligned
- Bones – The vertebral bodies and pedicles are intact
- Spacing – Gradually increasing disc height from superior to inferior. The pedicles gradually become wider apart from superior to inferior
Checklist MRI (Lumbar spine)
- Alignment: look at the normal lordosis, look at the posterior marginal line. Any vertebrae out of line?
- Vertebra: Quality of the marrow signal.
- Conus: Position and caliber of the conus. Terminates at L1/L2
- Cauda equina: Stenosis of the central spinal canal, compression of the cauda equina
- Discs: bulge wider that it is deep, or deeper than it is wide, evaluate all the discs
For spinal injuries the TLICS or Thoracolumbar Injury Classification and Severity Scale is a widely accepted method to identify and score the injury based on morphology, integrity of the PLC (posterior ligamentous complex) and neurological status. Each subgroup can receive a score of 1-4 respectively 0-3 for both the PLC and neurological status. This score than indicates the severity of the injury. A common interpretation is that a score of less than four requires no surgery, a score of precisely four may requires surgery (which may be the surgeons choice) and a score above four always requires surgery.
The answers of question two are the four subdivisions of morphology. Further scoring in PLC and neurological status is not included in this exercise.
The scoring for our case is as follows. The unstable burst fracture with PLC damage of L3 is scored five points. The ventral compression fracture of T11 is scored one point, as there is no PLC damage present. No neurological abnormalities were present at the time of the examination and thus, as the fracture with the highest amount of point is choses, this patient was scored 5 points, which implies need for surgery.
- Khurana, B., Sheehan, S., Sodickson, A., Bono, C. and Harris, M. (2013). Traumatic Thoracolumbar Spine Injuries: What the Spine Surgeon Wants to Know. RadioGraphics, 33(7), pp.2031-2046.
- Robertson, P. (2015). Thoracolumbar injury classification and severity score (TLICS) | Radiology Reference Article | Radiopaedia.org. [online] Radiopaedia.org. Available here