Spine Trauma- When to Operate · Spine Trauma-When to Operate Indications for surgery Unstable...
Transcript of Spine Trauma- When to Operate · Spine Trauma-When to Operate Indications for surgery Unstable...
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Spine Trauma-
When to Operate
Andrea Halliday, M.D.
Oregon Neurosurgery
Specialists
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Spine Trauma-When to Operate
Indications for surgery
Unstable spinal injury
Preservation or improvement in neurologic
function
The return of the patient to an optimal level of
functioning as soon as possible
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Spine Trauma-When to Operate
Some surgeons believe that non-operative
treatment is the treatment of choice
All surgeons agree that an absolute indication
for emergent surgery is a progressive neurologic
deficit in the presence of a surgically correctable
compressive lesion or instability
An unstable ligamentous injury is an absolute
indication for surgery but is not emergent unless
there is a progressive neurologic deficit.
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Spine Trauma-When to Operate
Relative indications for surgery include
The ability to accelerate the rehabilitation
process, decreasing morbidity and decreasing
the cost of care
The prevention of a progressive spinal
deformity which may result in chronic pain,
loss of function or a neurologic deficit
The ability to reduce complications from
prolonged immobilization
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Delayed Spinal Deformity
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Spine Trauma-When to Operate
The integrity of the ligaments contributes
significantly to spinal stability
In all areas of the spine, complete ligamentous
injury results in progressive spinal deformity and
the risk of neurologic injury
AO dislocation
Bilateral facet dislocations
Ligamentous Chance fractures
Rupture of the transverse ligament
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Transverse Ligament Rupture
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Atlanto-occipital Dislocation
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Bilateral Jumped Facets
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Ligamentous Chance Fracture
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Spine Trauma-When to Operate
The controversial areas in terms of spinal
stability are cases of partial ligamentous
disruption or bony disruption without
significant loss of sagittal or coronal
alignment
The indications for surgical treatment of
burst fractures is probably the most
controversial.
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Spine Trauma-When to Operate
No one classification system for stability is
agreed upon.
One widely used approach is to expand
the three column theory proposed by
Denis to include the following:
If a column has primarily bony injury, the
fragments are in close apposition and the
coronal and sagittal alignment are satisfactory
then the column should heal in a brace.
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L1 Burst Fracture
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Spine Trauma-When to Operate
Non-operative management may consist of bed
rest and/or the use of an orthosis.
Most patients are unable to tolerate long term
bed rest and bed rest carries the risk of
pneumonia, DVT, constipation, skin breakdown
and de-conditioning.
Some orthoses are difficult to tolerate. Halo
devices in the elderly are often problematic as
they affect the patient’s balance.
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Odontoid Fracture
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Spine Trauma-When to Operate Each region of the
spine has different
biomechanical
properties that affect
the decision whether
or not to operate.
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Spine Trauma-When to Operate
The cervical spine, due to its unique anatomy, is viewed as two distinct regions, the upper cervical (occiput to C2) and the lower cervical (C3-T1).
The upper cervical spine is very mobile with the majority of flexion/extension occurring between the occiput and C1 and the majority of rotation occurring C1 and C2.
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Spine Trauma-When to Operate
The lower cervical spine is lordotic and
more stable than the upper cervical spine
however, the space for the neural
elements is smaller.
Therefore any acute sagittal displacement
may result in significant neurologic
compromise.
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Spine Trauma-When to Operate
There are two generally agreed upon
indications for acute neurosurgical
intervention in cervical spine trauma:
A neurologically incomplete patient with a
deteriorating neurologic examination and an
associated facet dislocation un-reducible by
traction
A neurologically deteriorating patient with
spinal cord compression.
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Spine Trauma-When to Operate
The STASCIS trial published in 2/2012 was a non-randomised multicentre trial of patients with acute cervical SCI undergoing early (24 hours) vs. late surgery.
The key finding was that 19.8% of patients undergoing early surgery showed a > grade 2 improvement in ASIA score compared with 8.8% in the late decompression group.
However, the early surgery group was younger with greater neurologic deficit and the chance of a 1 grade ASIA improvement was not statitically significant.
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Spine Trauma-When to Operate
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Spine Trauma-When to Operate
The thoracic spine is very stable due to the
articulating rib cage, sternum and clavicles.
Most injuries to the thoracic spine are a result of
axial loading with flexion.
Indications for operative intervention often
include loss of anterior vertebral body height
greater than 50% with loss of the posterior
ligamentous structures, fracture-dislocations or
flexion distraction injuries.
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Thoracic Fracture-Dislocation
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Spine Trauma-When to Operate
The thoraco-lumbar junction is a transition
zone from the stiff thoracic spine to a
mobile lumbar spine rendering this section
of the spine vulnerable to injury.
This anatomic zone accounts for
approximately 50% of all vertebral body
fractures and 40% of all spinal cord
injuries.
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Spine Trauma-When to Operate
As with other areas of the spine the
indication for operative intervention largely
depends on the patient’s neurologic
status, the degree of bony comminution
and the integrity of the posterior
ligamentous complex.
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Spine Trauma-When to Operate
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As mentioned earlier operative indications for lumbar burst fractures are controversial.
A high degree of vertebral comminution, reflecting an inability to resist axial loads, is a relative indication for surgery.
The presence of an incomplete neurologic deficit with residual canal compromise is a relative indication for surgery.
Spine Trauma-When to Operate
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Spine Trauma-When to Operate
Advantages to non-operative management
of burst fractures
Preservation of motion segments
Less invasive
Potentially less expensive
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L4 Burst Fracture
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Spine Trauma-When to Operate
Fracture-dislocations and three column
shear injuries result in disruption of all
three columns of the spine.
Because these injuries are grossly
unstable, surgical stabilization is
necessary.
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Three Column Shear Injury
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Spine Trauma-When to Operate
In summary, the absolute indication for emergent surgery is a progressive neurologic deficit in the presence of a surgically correctable compressive lesion or instability.
An absolute indication for surgery is an unstable ligamentous injury but surgery is not emergent in the absence of a progressive neurologic deficit.
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Spine Trauma-When to Operate
An absolute indication for surgery is a
neurologic deficit in the setting of a
surgically correctable compressive lesion.
The timing of surgery when the neurologic
injury is stable is controversial.
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Spine Trauma-When to Operate
The relative indications for surgery are:
The ability to accelerate the rehabilitation
process or the inability to tolerate non-
operative management.
The prevention of a progressive spinal
deformity which may result in chronic pain,
loss of function or a neurologic deficit.
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Spine Trauma-
When to Operate
Thank you