Injury, Int. J.

Care Injured 30 (1999) 471474

www.elsevier.com/locate/injury

Abdominal injuries associated with lumbar spine fractures in

blunt trauma
Reuven Rabinovici b,*, Philip Ovadia a, Guenther Mathiak a, Fizan Abdullah b
a
Department of Surgery, Jeerson Medical College, Philadelphia, PA 19107, USA
b
Section of Trauma and Surgical Critical Care, Yale University School of Medicine, 333 Cedar Street, LH 118, New Haven, CT 06520, USA
Received 16 June 1998; received in revised form 16 February 1999; accepted 8 March 1999

Abstract

Background: specic analysis of the relationship between abdominal injuries and lumbar spine fractures has not yet been
reported.
Methods: a retrospective review of 258 blunt trauma patients with lumbar spine fractures treated between 1991 and 1996.
Results: 26 patients sustained concomitant lumbar spine fractures and abdominal injuries. The mechanism of injury was
motor vehicle collision (73%), pedestrian-struck (11%), fall (8%) and assault (8%) resulting in ISS, RTS and mortality of 272
4, 6.5 2 0.4 and 8%, respectively. Forty-four lumbar spine fractures were identied (1.7/pt) in association with splenic (54%),
renal (41%), hepatic (32%) and small bowel (23%) injuries and no retroperitoneal involvement. Multilevel lumbar spine
fractures were associated with a higher organ injury/fracture ratio compared with single level fractures ( p < 0.01) including a
twofold higher incidence of solid organ (spleen, liver and kidney) injury ( p < 0.01). The level and type of fracture did not aect
the incidence of total and individual organ injury. Patients with abdominal injuries were more severely injured mainly due to
increased incidence of associated thoracic injuries although no signicant dierence in mortality was observed.
Conclusion: abdominal injuries occurred only in the minority of blunt trauma patients with lumbar spine fractures. These
injuries, which followed a similar distribution pattern as in blunt trauma in general, occurred most commonly due to motor
vehicle collisions and in association with multilevel vertebral fractures. No correlation with fracture type or level was
identied. # 1999 Elsevier Science Ltd. All rights reserved.

1. Introduction 2. Methods

Approximately 8000 to 10,000 spinal cord injuries
occur annually in the United States [1, 2], the majority
of which result from blunt trauma [3]. Of these, 15%
involve the lumbar spine [4]. The anatomical approxi-
mation of the lumbar spine and abdominal viscera
would appear to predispose to an increased incidence
of abdominal injuries in patients with lumbar spine
fractures. Nevertheless, this association has not yet
been conrmed and the character of these injuries has
not been reported.
* Corresponding author. Tel.: +1-203-785-2572; fax: +1-203-785-
3950.
E-mail address: reuven.rabinovici@yale.edu (R. Rabinovici)
All injured patients admitted to Thomas Jeerson
University Hospital, an urban, Level I Trauma and
Regional Spinal Cord Injury Centre, between January
1,1991 and December 31, 1996 were reviewed retro-
spectively to identify those who sustained blunt lumbar
spine fractures. Data were collected from the compu-
terized trauma registry (Lancet Technology,
Cambridge, MA) and from patient charts. Patients
were analyzed for abdominal injuries conrmed at op-
eration or by diagnostic studies, other associated inju-
ries, resultant neurological decit and in-hospital
mortality. Statistical analysis was performed using the
Chi-square and student's t test with a probability value
of less than 0.05 considered statistically signicant.

0020-1383/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 1 3 8 3 ( 9 9 ) 0 0 1 3 4 - 5
472 R. Rabinovici et al. / Injury, Int. J. Care Injured 30 (1999) 471474

Table 1
Demographics of patients with and without intra-abdominal injury. Percentages are per total number of patients in each group. P values refer to
patients with abdominal injury versus patients without abdominal injury. NS, not signicant

Total (n=258) Patients with abdominal injury (n=26) Patients without abdominal injury (n=232) P value

Male:female 2.0:1 1.6:1 2.0:1 NS

Age (years) 3821 3523 4021 NS
ISS 1520.7 2724 1220.6 < 0.01
RTS 7.5020.07 6.5220.4 7.6220.06 < 0.01
Neurological decit 36 (14%) 6 (23%) 30 (13%) NS
Motor vehicle accidents 76 (29%) 19 (73%) 57 (25%) < 0.01
Pedestrian-struck accidents 12 (5%) 3 (11%) 9 (4%) NS
Fall 147 (57%) 2 (8%) 145 (62%) < 0.01
Assault 23 (9%) 2 (8%) 21 (9%) NS
Deaths 8 (3%) 2 (8%) 6 (3%) NS

Data are presented as mean2S.E.M. where appropri-
ate.
3. Results
Out of 258 injured patients with lumbar spine frac-
tures only 26 (10%) suered abdominal injuries (Table
1). The mean age and gender distribution did not dier
between patients with or without associated abdominal
injuries. Patients with abdominal organ injury were
more severely injured, as evidenced by higher ISS and
lower RTS, were more often involved in motor vehicle
accidents and were less commonly admitted secondary
to falls than patients without abdominal pathology.
Thirty-six patients had neurological ndings. Of
these, 3 had complete conal injury, 3 suered incom-
plete conal injury and the remaining 30 sustained radi-
cular or cauda equina injury. Only 8 of the 256
reviewed patients (3%) died. Although trends toward
higher incidence of neurological decit and mortality
were observed in the abdominal injury group, statisti-
cal signicance was not reached.
In the 26 patients who suered both lumbar spine
fractures and abdominal injuries 44 vertebral fractures
were identied (Table 2). The most commonly injured
abdominal organs were the spleen (24 injuries), kidney
and adrenals (18), liver (14), and small intestine and
mesentery (10). Splenic and small bowel/mesentery
injuries tended to be associated with lower (L4, L5)
and middle (L3) rather than upper (L1, L2) vertebral
fractures (Table 2), whereas renal injury tended to
occur predominantly in conjunction with upper and
middle lumbar vertebral fractures. There was no dier-
ence in occurrence of liver injury among higher versus
lower lumbar spine fractures.
Analysis by type of vertebral fracture revealed no
dierence among body compression, burst and trans-
verse process fractures with respect to mean age, sever-
ity and mechanism of injury, frequency of injured
abdominal organs, incidence of neurological decit or
mortality (Table 3).
Patients who sustained multilevel vertebral fractures
(Table 4) were more severely injured, had a higher
organ injury/fracture ratio and a twofold higher inci-
dence of solid organ (spleen, liver, kidney) injury ( p <
0.01, data not shown) when compared with patients
who sustained a single level fracture. No dierences in
the incidence of neurological decit or mortality were
observed.
When compared with patients with lumbar spine

Table 2
Incidence of organ injury per fracture level. Percentages are per total
number of fractures in each level. No signicant statistical dierences
were identied among the groups

Level of fracture Spleen Kidney/adrenals Liver Small intestine

L1 (n=10) 4 (40%) 4 (40%) 5 (50%) 2 (20%)

L2 (n=9) 4 (45%) 6 (67%) 2 (22%) 1 (11%)
L3 (n=8) 5 (63%) 4 (50%) 1 (12%) 2 (25%)
L4 (n=9) 7 (78%) 2 (22%) 3 (33%) 2 (22%)
L5 (n=8) 4 (50%) 2 (25%) 3 (37%) 3 (37%)
Total (n=44) 24 (54%) 18 (41%) 14 (32%) 10 (23%) Fig. 1. Other injuries associated with blunt lumbar spine fractures. p
< 0.01 versus patients without intra-abdominal injury.
 R. Rabinovici et al. / Injury, Int. J. Care Injured 30 (1999) 471474 473

Table 3
Demographics of patients with lumbar spine fracture and abdominal injury by type of fracture. Percentages are per total number of fractures in
each group of fracture type

Type of fracture

body compression (n=17) burst (n=11) transverse process (n=16)

Age (years) 4025 2724 4427

ISS 2524 3125 3124
RTS 6.4820.4 5.9520.7 5.820.5
Neurological decit 2 (12%) 3 (27%) 1 (6%)
Motor vehicle accidents 12 (71%) 9 (82%) 10 (63%)
Pedestrian-struck accidents 1 (6%) 1 (9%) 2 (13%)
Fall 1 (6%) 1 (9%) 2 (13%)
Assault 3 (17%) - 2 (13%)
Deaths - 1 (9%) 1 (6%)
Organ injury/fracture ratio 1.47 1.63 1.31

fractures without abdominal injury, those who sus-
tained concurrent abdominal injury had a higher inci-
dence of thoracic, pelvic and closed head injuries while
the incidence of long bone, extra-lumbar spine and
facial fractures was similar (Fig. 1).
Information regarding the use of seat belts and pos-
ition in the car was available in 67 (88%) and 72
(95%) of the 76 patients involved in motor vehicle
accident, respectively. Only 45% of patients were wear-
ing seat belts at the time of injury. Sixty seven percent
of car accident victims were drivers, 20% front seat
passenger and 13% back seat passengers. No signi-
cant dierence in the use of seat belts and location in
the car were observed between patients with or without
abdominal injury. Information regarding the type of
seat belt used was unavailable.
4. Discussion
These data demonstrate that abdominal injuries
occur in only 10% of patients with lumbar spine frac-
tures which is similar to the incidence reported in
blunt trauma patients in general [5,6]. The 10% associ-
ation rate observed in the present study is the rst
reported relationship between lumbar spine fractures
and abdominal organ injury in the `blunt trauma'
patient as previous studies, which reported an inci-
dence of 465%, were less specic and correlated ab-
dominal injuries with combined thoracic and lumbar
spine fractures [712].
The low incidence of abdominal injuries in patients
with lumbar fracture is somewhat expected. This is
because most lumbar fractures result from exion,
axial loading, exion-distraction, and shear forces [13]
in contrast to abdominal injuries which are commonly
secondary to direct forces. On the other hand, a closer
association could be expected based upon the anatom-
ical proximity of the lumbar spine and abdominal vis-
cera as well as the signicant force required to fracture
lumbar vertebra [7].
As expected, patients who sustained vertebral frac-
tures and concurrent abdominal injury were more
severely injured than those without abdominal injury
possibly reecting the increased force necessary to pro-
duce multiple injuries. Seventy three percent of patients
with lumbar spine fractures and abdominal injuries
were injured in a motor vehicle collision. This percen-

Table 4
Demographics of patients with lumbar spine fracture and abdominal injury by number of levels of fracture. Percentages are per total number of
fractures in each group. P values refer to patients with single level versus multilevel fractures. NS, not signicant

Single level fractures (n=14) Multi level fractures (n=12) P value

Age (years) 3225 3825 NS

ISS 2124 3425 NS
RTS 7.8420.4 5.6320.6 < 0.01
Neurological decit 3 (22%) 3 (25%) NS
Motor vehicle accidents 12 (86%) 7 (58%) NS
Pedestrian-struck accidents 1 (7%) 2 (17%) NS
Fall 1 (7%) 1 (8%) NS
Assault - 2 (17%) NS
Deaths 1 (7%) 1 (8%) NS
Organ injury/fracture ratio 1.14 1.66 < 0.01
474 R. Rabinovici et al. / Injury, Int. J. Care Injured 30 (1999) 471474
tage is much higher compared with that observed in
the total group (29%) or in patients with lumbar spine
fracture without abdominal injury (25%).
The spleen, kidney, liver and small bowel were the
most commonly injured organs. This is similar to
injury distribution patterns reported in the literature
for `blunt trauma' in general [9,14,15,16] and in associ-
ation with other spinal injuries [7] although renal
involvement in this series is more frequent.
Interestingly, no other retroperitoneal organs including
the pancreas and duodenum were involved in spite of
their proximity to the lumbar vertebral column.
Renal injuries tended to be associated with high
lumbar spine fractures as might be anticipated from
renal anatomy and consistent with the view that such
injuries should be suspected in patient with blunt
trauma involving the lower chest and upper abdomen
[17,18]. The spleen (despite its anatomical proximity to
the upper lumbar vertebrae) and small bowel (despite
its coiling in the entire abdomen) tended to be injured
mainly in association with lower lumbar spine frac-
tures. Liver injuries were evenly distributed between
lower and upper lumbar spine fractures.
Multilevel vertebral fractures were associated with
higher organ injury/fracture ratio as compared to
single level fractures. This can be attributed to the
increased force required to produce multilevel vertebral
fractures. Surprisingly, there were no statistically sig-
nicant dierences in resultant neurological decit or
mortality between these two groups, possibly due to
the small number of cases involved. In addition, it is
important to note that the type of the lumbar spine
fracture did not aect the overall severity or incidence
of abdominal organ injury.
Investigation of the extra-abdominal injuries suered
by patients with lumbar spine fractures revealed that
those patients with abdominal organ injury were also
more likely to have thoracic, pelvic and closed head
injuries whereas long bone, facial and extra-lumbar
spinal fractures occurred with similar frequency as
compared with patients without trauma-induced ab-
dominal pathology.
The overall mortality of 3% is comparable to other
series reporting mortality in lumbar spinal cord inju-
ries [4,7,10] and is lower compared with higher spinal
cord injuries. The fact that most neurological injuries
were of the nerve root or cauda equina type which are
less disabling compared with higher spinal cord inju-
ries, contributes to the reduced mortality observed in
this group of patients.
While there was a trend towards higher mortality in
patients with concurrent abdominal injuries, statistical
signicance was not reached. A higher mortality would
be expected in the abdominal injury group, as abdomi-
nal injuries alone have a signicant risk of mortality
[15,19].
Since no signicant dierence in the percent of
injured patients wearing seat belts and location in the
car were observed between the abdominal injury and
the no abdominal injury groups, it is conceivable that
both parameters do not determine the risk of having
abdominal injuries in addition to lumbar fractures.
Nevertheless, because lap seat belts have been shown
to cause both abdominal and spinal injuries [9,19,20]
and since no data regarding the type of seat belt used
was available, no denitive conclusion can be drawn.
References
[1] Spack J, Istre GR. Acute traumatic spinal cord injury surveil-
lance, United States, 1987. MMWR 1988;37:285.
[2] DeVivo MJ, Philip RF, Maetz HM, Stover SL. Prevalence of
spinal cord injury. Arch Neurol 1980;37:707.
[3] DeVivo MJ, Rutt RD, Black KJ, Go BK, Stover SL. Trends in
spinal cord injury demographics and treatment outcomes
between and 1986. Arch Phys Med Rehab 1992;73:424.
[4] Burney RE, Maio RF, Maynard F, Karunas R. Incidence,
characteristics, and outcome of spinal cord injury at trauma
centers in North America. Arch Surg 1992;128:596.
[5] Nahum AM, Siegel AW. The changing panorama of collision
injury. Surg Gynaecol Obstet 1971;133:783.
[6] Reynolds BM, Balsam NA, Reynolds FX. Falls from heights. A
surgical experience of 200 consecutive cases. Ann Surg
1971;174:304.
[7] Sturm JT, Perry Jr. JF. Injuries associated with fractures of the
transverse processes of thoracic and lumbar vertebrae. J
Trauma 1984;24:597.
[8] LeGay DA, Petrie DP, Alexander DI. Flexion-distraction inju-
ries of the lumbar spine and associated abdominal trauma. J
Trauma 1990;30:436.
[9] Williams JS, Kirkpatrick JR. The nature of seat belt injuries. J
Trauma 1971;11:207.
[10] Anderson PA, Henley MB, Rivara FP, Maier RV. Flexion dis-
traction and chance injuries to the thoracolumbar spine. J
Orthop Trauma 1991;5:153.
[11] Green DA, Green NE, Spengler DM, Devito DP. Flexion-dis-
traction injuries to the lumbar spine associated with abdominal
injuries. J Spinal Disorders 1991;4:312.
[12] Saboe LA, Reid DC, Davis LA, Warren SA, Grace MG. Spine
trauma and associated injuries. J Trauma 1991;31:43.
[13] Denis F. The three-column spine and its signicance in the
classication of thoracolumbar injuries. Spine 1984;8:817.
[14] Strauch GO. Major abdominal trauma in 1971. Am J Surg
1972;125:413.
[15] Perry Jr JF. A ve-year survey of 125 acute abdominal injuries.
J Trauma 1965;5:53.
[16] Cox EF. Blunt abdominal trauma. Ann Surg 1983;4:467.
[17] Herschorn S, Kodama RT, Abara EO. Genitourinary trauma.
In: McMurtry RY, McLellan BA, editors. Blunt trauma.
Baltimore: Williams & Wilkins, 1990. p. 28395.
[18] Feliciano DV, Pachter HL. Hepatic trauma revisited. Curr
Problems Surg 1989;26:453.
[19] Woelfel GF, Moore EE, Cogbill TH, Van Way III CW. Severe
thoracic and abdominal injuries associated with lap-belt seat-
belts. J Trauma 1984;24:166.
[20] Arajarvi E, Santavirta S, Tolonen J. Abdominal injuries sus-
tained in severe trac accidents by seat belts wearers. J Trauma
1987;27:393.