Thoracolumbar fractures
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THORACOLUMBAR FRACTURES
By Dr. Rishit J Soni2nd year Resident ,Dept Of Orthopaedics,C U Shah medical College,Surendranagar
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OUTLINE Epidemiology
Clinical evaluation ATLS Neuro exam Neurogenic / spinal shock
Classification of spinal cord injury Grading system Complete VS incomplete Incomplete cord syndromes
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OUTLINE Radiographic Evaluation
Plain Xray CT MRI Mylography
Spinal Stability
Classification of Fractures
Treatment of Specific Injuries
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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
The thoracolumbar junction is a transition zone between the relatively stiff thoracic spine, stabilized by the costovertebral articulations, and more mobile lumbar spine
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Mechanism : axial loading(compression) flexion extension (lumbar jack injuries) shear axial rotation Multiple injury: multiple level involvement can
occur . High Suspicion For Abdominal and thoracic
injury
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CLINICAL EVALUATIONE
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 .
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In Hospital Care Primary survey: Airway Breathing Circulation Disability Exposure Glasgow Coma Scale
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Secondary survey : Complete Spine examinationThorough history Inspect and palpate entire spinePer anal examination : sphincter tone bulbocavernous reflex anal wink voluntary anal contraction sensory examination
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Neurogenic shock : Heamodynamic instability that occurs with
rostral cord injury related to loss of sympathetic tone to the peripheral vasculature and heart. The consequences of which are bradycardia, hypotension and hypothermia due to absent thermoregulation.
Spinal Shock It is temporary dysfunction of spinal cord
with loss of reflexes and sensory as well as motor function caudal to the level of injury manifested by
Absence of anal wink and bulbocavernous reflexes.
It is a temporary phenomenon and recovers within 24-48 hours even in severe injury.
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CLINICAL EVALUATION Complete Neurological Evaluation
Motor function Sensory TestingReflex Examination
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AMERICAN SPINE INJURY ASSOCIATION
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REFLEX EXAMINATION
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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
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RELEVANT ANATOMY OF SPINAL TRACKS
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INCOMPLETE CORD LESION Determined by anatomic location of tissue
injury
Prognosis better than complete injury. Important to determine zone of partial
preservation.
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INCOMPLETE CORD LESION Arrangment of
corticospinaltracks Nerve fibres to
upper limb are centrally situated as compared to lower limb
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CENTRAL CORD SYNDROME MC type Usually by
hyperextension Weakness :
upper > lower Distal>proximal
Variable sensory loss
Sacral sparing Good prognosis
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ANTERIOR CORD SYNDROME Loss of motor, pain
and temperature below level of injury
Preserved proprioception and light touch
Results d/t hyperflexion injury in which bone/disc fragment compress ant spinal artery or cord
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POSTERIOR CORD SYNDROME Affects dorsal column Loss of proprioception,
vibratory sense below level
Preserve other sensory and motor function
Rare syndrome caused by extension injury
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BROWN SEQUARD SYNDROME Hemisection of
spinal cord Loss of ipsilateral
motor and propioception
Loss of contralateral pain and temperature
Associated with facet joint dislocation, lamina /pedicle fracture
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CONUS MEDULLARIS SYNDROME Injury to sacral cord and lumbar roots
At level of T11 to L1
Manifestation :Sphincter dysfunction -Areflexic bowel and bladder -Saddle anaesthesia -Variable lumbar roots
involvement
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CAUDA EQUINA SYNDROME Injury to the lumbosacral nerve
roots within spinal canal below L1 Presents with -Low back pain -Lower limb weakness -Sphincter dysfunction -Areflexic bowel and bladder -Saddle anaesthesia -calf atrophyDo Usg for noting post void residual
urine level pre op : prognostic value(normal – 50 to 100 ml)
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BLADDER DYSFUNCTION Innervation Sympathetic (L1-L2): contracts internal
sphincter relaxes detrusors ParaSympathetic (S2 S3 S4): relaxes internal
sphincter contracts detrusorsSomatic(pudendal nerve S2 TO S4) : controls
external sphincter
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AUTOMATIC BLADDER If Lesion above S2
Loss of higher centre control,bladder function controlled by spinal reflexes
Frequency and incontinence, bladder small and sensitive to small changes in volume
AKA : UMN Type bladder / Cord Bladder
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AUTONOMOUS BLADDER If Lesion below S2
Loss of even spinal control,bladder fumntion controlled by local myoneural reflexes
Flaccid ,atonic bladder with Overflow incontinence
AKA : LMN Type bladder / Atonic /Isolated Bladder
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RADIOGRAPHIC EVALUATION Trauma Series AP / Lat thoracic and
lumbar spine Oblique view Flexion and extension
view
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Indicators of PLC disruption • Abnormal sagital or coronal plane translation
>2.5mm• Relative Increased inter spinous distance• > 50% loss of vertebral body height• > 30 degree of kyphosis
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RADIOGRAPHIC EVALUATION CT
provide finer detail of the bony involvement in thoracolumbar injuries
All cases of suspected injury to posterior elements or posterior vertebral body.
Associated abdominal ,pelvic and thoracic injury ruled out of respective Ct cans
Axial images readily demonstrate the degree of canal compromise from retropulsed fragments
empty or naked facet sign : facet dislocation
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RADIOGRAPHIC EVALUATION MRI
Indicated in cases of neurological deficit with inconclusive radiographs
disc herniations, epidural hematomas, or spinal cord edema easily visualised
Both intrinsic and extrinsic cord injuries.
Important tool in assessing the integrity of the PLC
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TERMS Compression : wedge-type fractures of the anterior
and middle aspects of the vertebral body. no involvement of the posterior vertebral body
Burst : Has compression of posterior part of
body also. Has associated retropulsed bony fragment in canal.
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SPINAL STABILITY Holdsworth 1963
2 column theory
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SPINAL STABILITY Denis 1983
CT Scan
3 column theory
Stability based on integrity of middle coloumn
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SPINAL STABILITY
Categorized major spinal injury into 4 groups:
1. Compression Fracture 2. Burst Fractures 3. Flexion Distraction Injuries 4. Fracture Dislocations
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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.
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BURSTType 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.
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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.
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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.
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WHITE AND PUNJABI
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MCAFEE SYSTEM 6 categories: wedge-compression fractures stable burst fractures :intact posterior
coloumn unstable burst fractures Chance fractures(flexion distraction injury) :
flexion around axis anterior to ALL flexion-compression injuries: flexion around
axis posterior to ALL translational injuries
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AO CLASSIFICATION SYSTEM /MAGERL
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MCCORMACK GRADING
Used in Burst fr Score more than 6
indicative of use of longer posterior fixation or supplement with anterior .
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TREATMENT Modaility :
Non operativeve : Analgesics Braces physiotherapy. steroids :Most benefit occurs in the first 8 hours, and
additional effect occurs within the first 24 hours Methylprednisolone bolus 30 mg/kg, then infusion 5.4
mg/kg/h Infusion for 24 hours if bolus given within 3 hours of injury Infusion for 48 hours if bolus given within 3 to 8 hours after
injury No benefit if methylprednisolone started more than 8 hours
after injury
Operative : posterior stabilisation anterior decompression and stabilisation
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BRACES
TLSO brace 1) Hyperextenxion
brace : JEWETT
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2) Sagital control: Taylor brace Both flexion and
extension restricted
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TLSO : 3)Sagital Coronal control brace
Knight-Taylor brace Has lateral bars for
coronal control
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POSTRIOR SURGERY:PRIMARILY FOR REALIGNMENT AND STABILIZATION Advantages : avoids the morbidity of anterior
exposure in patients who potentially have concomitant pulmonary or abdominal injuries.
shorter operative times decreased blood loss functional outcomes are similar to
those following anterior surgery Disadvantages: no direct approach to site of
pathology
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Initially hooks and wires were used
Pedicle screws wit rods most commonly useds with rods for stabilisation now.
Sites 1) thoracic :
immediately lateral to middle of facet joint along superior third of transverse process
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2) lumbar vertebrae: Intersection of line
bisecting the transverse process and line passing along lateral aspect of facet joint
Other methods mamillary process
pars interarticularis
method
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POSTERIOR REALIGNMENT AND FIXATION
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ANTERIOR SURGERY Indicated for decompression of the neural
elements. It provides direct visualization of the anterior
thecal sac and is the most reliable method of spinal canal decompression
Higher morbidity Decompression followed by void filling with
autograft/ allograft / cage insertion Fixation by plates and screws/ rods -screw-
staple construct.
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ANTERIOR DECOMPRESSION AND STABILISATION
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COMBINED APPROACH Advantages: maximization of canal clearance, immediate circumferential stability
optimized fusion rates. Disadvantage superadded morbidity of two procedure Usually opted as 2 stage procedure : post ct
scan shows increased deformity or has residual neurological deficit
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COMPRESSION FRACTURE
<10% vertebral height loss :no need external support.
<30% to 40% height loss and <20 degrees to 25 degrees kyphosis : Jewett brace for 6 to 8 weeks.
In fractures below T5, a plaster jacket or TLSO can be used.
In higher fractures, a cervical component should be added to the brace.
50% height loss or >30 degrees kyphosis suggests PLC disruption, and posterior stabilization is recommended.
An MRI scan should be used to examine the integrity of the PLC
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BURST FRACTURE
Failure of anterior and middle column Axial compression
+/- failure of posterior column Compression or tensile force
Most common at T/L junction
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BURST FRACTUREStable : No PLC injury without neurologic deficit Radiographic criteria for non operative less than 25 degrees to 30 degrees of kyphosis, less than 50% height loss, absence of interspinous process widening, less than 50% canal compromise MRI evidence of discontinuity or continuity of the
PLC TLSO( hyperextension) Brace applied for 3 months X-ray and clinical follow-up examinations are
scheduled at 2 weeks, 1 month, 2 months, and 3 months. At the 3-month follow-up, x-rays are made out of the brace to ensure stable alignment.
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UNSTABLE BURST FRACTURE Need operative stabilization Posterior instrumentation and fusion: PLC disruption in neurologically intact
patients. <50% height loss: short-segment
stabilization >greater than 50% or extensive
comminution: pedicle screws are placed two levels above and below the fractured vertebra.
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Neurological deficit : Complete injury
Early stabilizationNeurological outcome not changed by
decompression
Incomplete injuryStabilization and decompression
beneficial . Improvement may occur
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DECOMPRESSION Posterior
Indirect (distraction and ligamentotaxis)Direct Transpedicle approach
posterolateral appoach laminotomy/ laminectomy Anterior
Partial / complete corpectomy
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FLEXION DISTRACTION INJURY Bone or soft tissue?
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SEAT BELT / CHANCE INJURY
Associated with intra-abdominal pathology. Purely Osseous injuries can be treated
nonoperatively If the injury is ligamentous or
osseoligamentous, surgical stabilization is indicated
Single-segment posterior fusion is usually adequate.
Surgeons should check that the pedicles at adjacent levels are intact prior to surgery.
If not : longer fixation is required In about 15% of cases, there is associated
burst fracture configuration. In about 5% of cases, there is an associated
herniated disc : Anterior decompression
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FRACTURE DISLOCATION High energy trauma There is a high incidence of complete
neurologic deficit Goal:
Stabilization for early mobilization
Long posterior pedicle screw constructs are best for thoracolumbar fracture-dislocations.
Up to 50% dural tears have been noted. Short-segment spinal fixation may not
provide adequate stabilization
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GUN SHOT WOUNDS
Rare injury Transabdominal bullets :
higher source of contamination
Complete injury more common than incomplete
Retained bullets may cause to lead toxicity
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TREATMENT OVERVIEW
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COMPRESSION FRACTURE
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BURST FRACTURE
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FLEXION DISTRACTION INJURY
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FRACTURE DISLOCATION
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MINOR INJURY
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Thank You