THORACOLUMBAR INJURIES

• Most injuries of the thoracolumbar spine occur in the transitional area – T11 to L2

• between the somewhat rigid upper and middle thoracic column and the flexible lumbar spine

• The spinal cord actually ends at L1 and below that level it is the lower nerve roots that are at risk.

Pathogenetic mechanisms fall into three main groups:

• low-energy insufficiency fractures arising from com -paratively mild compressive stress in osteoporotic bone;

• minor fractures of the vertebral processes due tocompressive, tensile or tortional strains;

• and high energy fractures or fracture-dislocations due to major injuries sustained in motor vehicle collisions, falls or diving from heights, sporting events, horse-riding and collapsed buildings

The common mechanisms of injury are:

• Flexion–compression• Lateral compression• Axial compression• Flexion–rotation• Flexion–distraction• Extension

ExaminationImaging= X-rays 1. anteroposterior x-ray may show loss of height or

splaying of the vertebral body with a crush fracture

2. The lateral view is examined for alignment, bone outline, structural integrity, disc space defects and soft-tissue shadow abnormalities

3. Plain x-rays, while showing the lower thoracic and lumbar spine quite clearly, are less revealing of the upper thoracic vertebrae because the scapulae and shoulders get in the way

• CT and MRI Rapid screening CT scans are now routine in many accident units.

• Not only are they more reliable than x-rays in showing bone injuries throughout the spine, and indispensable if axial views are necessary, but they also eliminate the delay, discomfort and anxiety so often associated with multiple attempts at ‘getting the right views’ with plain x-rays.

• In some cases MRI also may be needed to evaluate neurological or other soft-tissue injuries.

Treatment depends on:

• (a) the type of anatomical disruption;• (b) whether the injury is stable or unstable;• (c) whether there is neurological involvement

or not;• and (d) the presence or absence of

concomitant injuries

MINOR INJURIES• Fractures of the transverse

processesThe transverse processes can be avulsed with sudden muscular activityIsolated injuries need no more than symptomatic treatmentMore ominous than usual is a fracture of the transverse process of L5; this should alert one to the possibility of a vertical shear injury of the pelvis.

• Fracture of the pars interarticularis• should be suspected if a gymnast or athlete or

weight-lifter complains of the sudden onset of back pain during the course of strenuous activity.

• This is best seen in the oblique x-rays,• Bilateral fractures occasionally lead to

spondylolisthesis.• The fracture usually heals spontaneously,

MAJOR INJURIES

• Flexion–compression injury

• Axial compression or burst injury

• Jack-knife injury

• Fracture-dislocation

NEURAL INJURIES• NeurapraxiaMotor paralysis (flaccid), burning paraesthesia, sensory loss and visceral paralysis below the level of the cord lesion may be complete, but within minutes or a few hours recovery begins and soon becomes full.• Cord transectionMotor paralysis, sensory loss and visceral paralysisoccur below the level of the cord lesion; as with cord concussion, the motor paralysis is at first flaccid• Root transectionMotor paralysis, sensory loss and visceral paralysis occur in the distribution of the damaged roots

ANATOMICAL LEVELS

1. Cervical spineHigh cervical cord transection is fatal because all the respiratory muscles are paralysed. At the level of the C5 vertebra, cord transection isolates the lower cervical cord (with paralysis of the upper limbs)2. Between T1 and T10 vertebraeparalysis of the lower limbs and viscera3. Below T10 vertebra– sacral roots– lumbar roots

The sacral roots innervate:

• sensation in the ‘saddle’ area (S3, S4), a strip down the back of the thigh and leg (S2) and the outer two-thirds of the sole (S1);

• motor power to the muscles controlling the ankle and foot;

• the anal and penile reflexes, plantar responses and ankle jerks;

• bladder and bowel continence.

The lumbar roots innervate:

• sensation to the groins and entire lower limb other than that portion supplied by the sacral segment;

• motor power to the muscles controlling the hip and knee;

• the cremasteric reflexes and knee jerks.

DIAGNOSIS

• Complete cord lesions• Incomplete cord lesions– central cord syndrome– anterior cord syndrome– posterior cord syndrome– Brown-Séquard syndrome– High root lesions

FRANKEL GRADING

• Grade A = Absent motor and sensory function.• Grade B = Sensation present, motor power absent.• Grade C = Sensation present, motor power present• but not useful.• Grade D = Sensation present, motor power present• and useful (grade 4 or 5).• Grade E =Normal motor and sensory function.

MANAGEMENT OF TRAUMATICPARAPLEGIA AND QUADRIPLEGIA

• Skin= Every 2 hours the patient is gently rolled onto his or her side and the back is carefully washed (without rubbing), dried and powdered

• Bladder and bowel= intermittent catheterization under sterile conditions. and is changed twice weekly to prevent urethral and bladder complications,catheter blockage and infection

• Muscles and joints= The paralysed muscles, if not treated, may develop severe flexion contractures. These are usually preventable by moving the joints passively through their full range twice daily. Later, splints may be necessary.

Tendon transfers • If only deltoid and biceps are working (C5, C6) then a

posterior-deltoid to triceps transfer using interposition tendon grafts will replace the lost C7 function of elbow extension; this will enable the patient to orient his or her hand in space.

• If brachioradialis (C6) is working, this can be transferred to become a wrist extensor (since its prime function as an elbow flexor is duplicated by biceps). A primitive thumb pinch can be achieved by the Moberg procedure in which the thumb interphalangeal joint is fused and the basal joint of the thumb is tenodesed with a loop of the redundant flexor pollicis longus. On active extension of the wrist, the basal joint of the thumb is passively flexed.

• If extensor carpi radialis longus and brevis (C7) are both available, one of them can be transferred into the flexor pollicis longus to provide active thumb flexion (normally supplied by C8).

thoracolumbal fracture therapy

• - Konservatif • Postural reduction• NSAID• Braces• Electrical stimulation• Exercise• complementary or alternative medical

treatments = acupuncture, massage,atau dietary supplements

• Operatif • laminektomi• Internal fixation with plate

or wire, pedicle screw• anterior fusion or post

spinal fusion• vertebroplasty (an injection

of cement directly into the vertebral body)

• kyphoplasty (use of balloon to expand the compressed space prior to the injection of bone filler)