Rosen & Barkin's 5-Minute Emergency Medicine Consult (667 page)

Mechanism to suggest forces applied to lumbar region:

• MVA
  
• Fall
  
• Direct impact to lumbar region
  

• Midline lumbar tenderness or deformity
  
• Neurologic findings involving lumbar spinal nerves
  

• Consider abuse in cases of uncertain mechanism.
  
• Increase suspicion of bleeding consequences, such as spinal hematomas, in patients taking Coumadin or other anticoagulants.
  

Following criteria associated with higher risk of thoracolumbar (TL) spine injuries and should be imaged:

• TL pain or tenderness to palpation
  
• Decreased level of consciousness (Glasgow Coma Scale <14)
  
• Drug intoxication, altered pain perception
  
• Neurologic deficits (described above)
  
• Painful, distracting injuries
  
• Severe injury mechanism (e.g., rollover MVA, auto vs. pedestrian, fall >10 ft)
  
• Lumbar radiographs (described under Imaging)
  
• Careful neurologic exam including:
  
  • Assessment of rectal tone
    
  • Bulbocavernosus and cremasteric reflexes
    
  • Perineal sensation
    

• Standard multitrauma labs if indicated:
  
• CBC
  
• Chemistry panel
  
• Coagulation studies
  
• Urinalysis
  

• Lumbar radiography with minimum of anteroposterior and lateral views. Characteristics of
  unstable
  fractures include:
  
  • Widening of interspinous, interlaminar, or interpedicular distance
    
  • Kyphosis >20°
    
  • Translation >2 mm
    
  • Vertebral body height loss >50%
    
  • Articular process fracture
    
• Radiographs may not identify burst fractures in 25% of cases.
  
• If a fracture is identified, entire spine should be imaged to evaluate for associated injuries.
  
• Spinous process fracture, transverse process fracture, or simple transverse sacral fracture require lumbar flexion–extension films if patient is neurologically intact and there is no evidence of unstable injury.
  
• CT or MRI should be performed for further evaluation of suspected fractures or fractures identified on plain films to assess spinal cord integrity.
  

Consider postvoid residual urinary catheterization or ultrasound to identify urinary retention.

• Contusion
  
• Pathologic fracture (metastatic cancer)
  
• Osteoporosis
  
• Pelvic fracture
  
• Traumatic herniated disc
  
• Low posterior rib fracture
  
• Tuberculous spondylitis (Pott disease)
  
• Ankylosing spondylitis
  
• Osteogenesis imperfecta (pediatric)
  
• Congenital scoliosis with hemivertebra (mistaken for lateral wedge fracture)
  
• Child abuse
  
• Spinal hematoma
  
• Epidural abscess
  

TREATMENT

It is difficult to determine whether an injury is stable in the field; any patients with suspected spinal injuries should be immobilized to prevent further injury.

• Immobilization while tending to immediate life-threatening conditions
  
• Airway, breathing, and circulation management
  

• Maintain spinal immobilization.
  
• High-dose methylprednisolone protocol for any neurologic deficit (best in concert with specialist consultation)
  
• Consultation with orthopedic spine or neurosurgery service
  
• Appropriate analgesia
  
• The following stable injuries may be treated conservatively if CT confirms stability of injury and patient is neurologically intact:
  
  • Isolated spinous process, transverse process fracture
    
  • Chance fracture
    
  • Anterior wedge compression (<50%) fracture
    
  • Stable burst fracture
    
• Total contact orthotic devices may be useful; limited activities; sleep prone; avoid pillows and soft mattresses, which may worsen deformity.
  

• Narcotic pain medication in absence of contraindications
  
• High-dose steroid protocol: Methylprednisolone: 30 mg/kg IV load over 1 hr, then 5.4 mg/kg/h for the next 23 hr; initiate in ED within 8 hr of injury.
  

• Tylenol: 1 g (peds: 15 mg/kg) PO q4h PRN
  
• Motrin: 400–800 mg (peds: 10 mg/kg) PO q6h PRN
  
• Dilaudid: 1–2 mg (peds: 0.015 mg/kg) IV/IM q3h PRN
  
• Morphine: 2–10 mg (peds: 0.1–0.2 mg/kg) IV/IM q3h PRN
  
• Toradol: 30 mg IV or 60 mg IM (peds: 0.5 mg/kg IV or 1 mg/kg IM) q6h PRN:
  
  • Use half Toradol dose for patients >65 y
    

• Flexeril: 5–10 mg PO q8h PRN
  
• Soma: 350 mg PO q8h PRN
  
• Zofran: 4–8 mg IV/PO (peds: >4 y, 4 mg IV/PO) q8h PRN
  
• Compazine: 5–10 mg IV/IM/PO (peds: 2.5 mg PR/PO) q8h PRN
  
• Phenergan: 12.5–25 mg IM/PO/IV (peds: 0.5–1 mg/kg IM/PR) q8h PRN:
  
  • IV Phenergan NOT recommended due to reports of tissue necrosis
    

FOLLOW-UP

Patients with traumatic lumbar fractures should be admitted for stabilization procedures, parenteral pain control, management of possible ileus, and evaluation for associated injuries.

• Neurologically intact patients with stable injuries evaluated in conjunction with a spine surgeon
  
• Patients with simple compression (wedge) fractures with no neurologic deficit may be considered for outpatient management if adequate pain control and appropriate follow-up can be arranged.
  
• Simple transverse sacral fracture, isolated spinous process fracture, and isolated transverse process fracture may also be considered for outpatient management.
  
• The patient must be neurologically intact with a stable living situation; CT scan and flexion–extension films must confirm fracture stability.
  

Patients discharged with stable injuries should have primary care or orthopedic appointment in 1 wk to monitor for recovery and evaluate for potential complications.

Return to ED for new neurologic symptoms or pain not controlled by discharge medications. Otherwise, follow-up as described above.

• Lumbar fractures are rare in pediatrics. Aggressively pursue causative factor if mechanism is not evident.
  
• Older individuals may have underlying medical cause of lumbar pathology. Pursue alternative causes of pain, such as hematomas and infections. Be vigilant in patients taking anticoagulants.
  
• CT should follow compression fractures seen on plain films to assess for stability and potential canal involvement.
  
• Otherwise healthy, ambulatory patients with simple post MVA low back pain may be safely discharged without imaging if the exam is otherwise reassuring.
  

• Boran S, Lenehan B,Street J, et al. A 10-year review of sports-related spinal injuries.
  Ir J MedSci.
  2011;180(4):859–863.
  
• Hanck J, Muñiz A. Cervical spondylodiscitis, osteomyelitis, and epidural abscessmimicking a vertebral fracture.
  J Emerg Med
  .2012;42(3):e43–e46.
  
• Holmes JF, Panacek EE, Miller PQ, et al. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients.
  J Emerg Med
  . 2003;24:1–7.
  
• Petersilge C, Emery S. Thoracolumbar burst fracture: Evaluating stability.
  Semin Ultrasound CT MR
  . 1996;17:105–113.
  
• Tamir E, Anekstein Y, Mirovsky Y, et al. Thoracic and lumbar spine radiographs for walking trauma patients: Is it necessary?
  J Emerg Med
  . 2006;31:403–405.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Pediatric Trauma
  
• Spinal Cord Syndromes
  
• Trauma, Multiple
  

CODES

• 722.10 Displacement of lumbar intervertebral disc without myelopathy
  
• 805.4 Closed fracture of lumbar vertebra without mention of spinal cord injury
  
• 847.2 Sprain of lumbar
  

BASICS