Epidemiology

• Prevalence / Incidence : Thoracic and lumbar fractures account for 30% to 50% of all spinal injuries in trauma patients.

• Majority of thoracic and lumbar injuries occur within the region between T11 and L1, commonly referred to as the thoracolumbar junction

Thoracic and lumbar fractures account for 50% of all spinal traumatic fractures.

• Incidence. 4-5 per 100,000. 18 - 35 years. Male\ Female = 4:1 Neurologic injury 25% of cases.

• 65% of TL#s occurs between the T9&L2 vertebrae. (thoracolumbar Junction)

• Cervical - 7 vertebrae• Thoracic - 12 vertebrae• Lumbar - 5 vertebrae• Sacral - 5 fused vertebrae• Coccyx - 4 fused vertebrae

4

5

Functional spinal unit

Composed of: • 2 adjacent vertebrae • Facet joint• Inter vertebral disc • Intervening ligaments

7

This unit is responsible for Movement of spine

Thoracic Spine• Kyphotic Curve. • Ribs more stiffness, resist rotation.• T11,T12 have floating ribs;

No costotransverse articulations.

No sternal attachement.

•Facet orientation limited flexion/extension.•Canal is relatively small.

Lumbar Spine

• Lordotic Curve.• Large discs More mobility• Spinal canal wider.• Spinal cord ended at L1.• Facet orientation more flexion/extension.

ETIOLOGY• High energy trauma (RTA 50%)• Falls.• Sports accident.• Gunshot injury.• Osteoporosis• Tumors • Weak bone(malnutrition,renal,RA,DM,endocrine).

– 16% major chest injury– 10% major abdominal injury– 8% long bone/ pelvic fractures

Spinal fracture should be suspected in;1. Comatosed patient.2. High energy trauma.3. Evidence of neurological deficit.4. Multiple injuries:

Missed TL#s reach 5%, And reach 22% in cervical fractures.

The main causes are,• Poly trauma.• low level of suspicion.• Intoxication \ unconsciousness• Failure to take proper radiographs.• Failure to interpret the x ray.

CLASSIFICATION

Three column theory

ANTERIOR COLUMN

MIDDLE COLUMN

POSTERIOR COLUMN

Spinal Stability

• Categorized major spinal injury into 4 groups:

– 1. Compression Fracture– 2. Burst Fractures– 3. Flexion Distraction Injuries– 4. Fracture Dislocations

• 45% of TL#s.

• Anterior column failure

(Anterior or lateral flexion)

• Middle, Post. Column intact.

• Usually no Neurological deficits.

COMPRESSION (WEDGE) FRACTURE

Compression

Type A involves both endplates, type B involves the superior endplate, and type C involves the inferior endplate. In type D fractures, there is a compression fracture of the anteriovertebral body.

Compression Fracture

Compression Fractures

• Only anterior column injury• Middle? and post. OK• Ant. column less than 30%• No more than 10 deg kyphosis• No neuro injury

Burst fractures

• 15 % of TL#s• Anterior& middle column failure. (Axial compression)

• Most common at T/L junction• Neurological deficit.

Burst Fracture

Burst

Type A involves fractures of both endplates, type B involves fractures of the superior endplate, and type C involves fractures of the inferior endplate. Type D is a combination of a type A fracture with rotation. Type E fractures exhibit lateral translation.

Stable Burst

• Both ant and middle column involvement

• Minimal kyphosis• No neuro involvement• No laminar fracture

Unstable Burst• 3 column involvement• Possible neuro

involvement• Severe communition• Significant pedicle

widening• Look for laminar

fracture (asso. with root entrapment)

FLEXION-DISTRACTION = SEAT-BELT-TYPE = CHANCE #

• Posterior &middle columns failure. (hyperflexion then tension forces)

• Anterior column - partial damage. - functions like a hinge.

Flexion Distraction/chance/seat belt imjury

Types A and B occur at one level, either through bone (A) or ligament (B). Type C and D occur at two levels (motion segments). Type C denotes that the middle column failed through bone. Type D denotes that the middle column failed through ligament and disc.

Flexion Distraction Injury

Fracture-Dislocation

• Failure of all columns (compression, tension,

rotation, or shear). • anterior hinge is disrupted.• Dislocation.• Severe neurological deficit.

Flexion distraction• Easy to miss- may look

benign• Anterior column >

50% crushed• Middle column mainly

intact• Significant spinous

process widening• Unstable

Fracture Dislocations• Translation in lower

lumbar spine may be developmental (nly L3-S1 spondylolysthesis)

• Always abnormal in thoracic spine (ribs)

• Unstable• Normally- neuro deficit• Can be hidden at mid

thoracic spine• 3 column injury

Fracture Dislocation

Fracture Dislocation

Type A are bony one-level injuries. Type B are one-level ligamentous injuries. Type C injuries are two-level injuries that occur through bone and/or ligament.

Complete VS Incomplete

• Complete– No function below level of injury– Absence of sensation and voluntary

movement in S4/5 distribution

• Incomplete– Preservation of sensation in S4/5 distribution

and voluntary control of anal sphincter

Clinical Evaluation

E • Pre Hospital care : Strict precaution for immobilization in form

of spine board and cervical collar needed. Urgent transportation to adequately

equipped tertiary health centre. Resuscitation should begin immediately .

• In Hospital Care Primary survey: Airway Breathing Circulation Disability Exposure Glasgow Coma Scale

Secondary survey : Complete Spine examination– Thorough history– Inspect and palpate entire spine– Per anal examination : sphincter tone bulbocavernous reflex anal wink voluntary anal contraction sensory examination

RADIOLOGICAL ASSESMENT

X-RAYS Lateral View

• Alignment.

• Contour of bodies.

• Disc spaces.

• Angulation.

• Encroachment on canal.

• Loss of vertebral body height.

X-RAYS Lateral View

• Measurement of degree of vertebral body compression.

• Look at how the ant.& post. aspects of the body line up.

X-RAYS Lateral View

X-RAYS Lateral View

• Measure Kyphosis.

• Measure from closest intact endplates.

• Alignment• Symmetry/ Shape of

pedicles• Interpedicular distance• Position of spinous process• Contour of bodies

X-RAYS A-P view

X-RAYS A-P view• Lateral vertebral body height.

• Interpedicular distance. • Distance between the spinous

processes.

Treatment

Goals

1. Maximise neurological recovery .

2. Maintain or restore spinal alignment.

3. Obtain a healed and stable spinal column.

4. Prevent future deformity.

Spinal Cord Injury

Methylprednisolone

• 30mg/kg iv bolus over 15min. • 5.4 mg/kg/h infusion over 23 hrs (first 3 hours).

• 5.4 mg/kg/h for 47hrs (if > 3 – 8 hrs passed).

Proton pump inhibitor & LMW Heparin

Non-operative treatment

Bed Rest• Strict bed rest for 3- 4 weeks.• Avoid flexion, sit-ups, & spinal rotation.• Avoid weight bearing. • Bed rolling encouraged.

Bracing

• Treated with brace for 6-8 weeks.

• Wear on whenever upright.

• Ambulation & Transfers.

• Solid healing 8-12 weeks.

Braces

• TLSO brace• 1) Hyperextenxion brace :

JEWETT

• 2) Sagital control:• Taylor brace• Both flexion and extension

restricted

• TLSO : 3)Sagital Coronal control brace

• Knight-Taylor brace• Has lateral bars for coronal

control

Operative treatmentIndications:• Ant. vertebral height loss > 40%.• Canal compromise > 40%. • Kyphosis > 25 degrees.• Neural compression.

Aim• Neural Decompression.• Stabilization.• Solid fusion.

Surgical options

Anterior FixationPosterior Fixation

Vertebroplasty

Kyphoplasty

Anterior decompression and stabilisation