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    Thoracolumbarfractures 150817055817 Lva1 App6891

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    The document discusses thoracolumbar fractures, including their epidemiology, clinical evaluation, classification, radiographic evaluation, spinal stability, and treatment. It describes how thoracolumbar fractures most commonly occur between T11-L1, often due to axial loading or flexion/extension injuries. Clinical evaluation involves a thorough neurological exam to assess completeness of injury. Classification systems examine the fracture pattern and integrity of spinal columns. Imaging like CT and MRI help evaluate bone involvement and risk to the spinal cord. Treatment depends on the fracture type, stability, and neurological status.

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    Thoracolumbarfractures 150817055817 Lva1 App6891

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    35 views75 pages
    The document discusses thoracolumbar fractures, including their epidemiology, clinical evaluation, classification, radiographic evaluation, spinal stability, and treatment. It describes how thoracolumbar fractures most commonly occur between T11-L1, often due to axial loading or flexion/extension injuries. Clinical evaluation involves a thorough neurological exam to assess completeness of injury. Classification systems examine the fracture pattern and integrity of spinal columns. Imaging like CT and MRI help evaluate bone involvement and risk to the spinal cord. Treatment depends on the fracture type, stability, and neurological status.

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    The document discusses thoracolumbar fractures, including their epidemiology, clinical evaluation, classification, radiographic evaluation, spinal stability, and treatment. It describes how thoracolumbar fractures most commonly occur between T11-L1, often due to axial loading or flexion/extension injuries. Clinical evaluation involves a thorough neurological exam to assess completeness of injury. Classification systems examine the fracture pattern and integrity of spinal columns. Imaging like CT and MRI help evaluate bone involvement and risk to the spinal cord. Treatment depends on the fracture type, stability, and neurological status.

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    35 views75 pages

    Thoracolumbarfractures 150817055817 Lva1 App6891

    Uploaded by

    Pap Pip
    The document discusses thoracolumbar fractures, including their epidemiology, clinical evaluation, classification, radiographic evaluation, spinal stability, and treatment. It describes how thoracolumbar fractures most commonly occur between T11-L1, often due to axial loading or flexion/extension injuries. Clinical evaluation involves a thorough neurological exam to assess completeness of injury. Classification systems examine the fracture pattern and integrity of spinal columns. Imaging like CT and MRI help evaluate bone involvement and risk to the spinal cord. Treatment depends on the fracture type, stability, and neurological status.

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    of 75

    THORACOLUMBAR FRACTURES

    By
    Dr. Rishit J Soni
    2nd year Resident ,
    Dept Of Orthopaedics,
    C U Shah medical College,
    Surendranagar
    OUTLINE
    Epidemiology

    Clinical evaluation
    ATLS
    Neuro exam
    Neurogenic / spinal shock

    Classification of spinal cord injury


    Grading system
    Complete VS incomplete
    Incomplete cord syndromes
    OUTLINE
    Radiographic Evaluation
    Plain Xray
    CT
    MRI
    Mylography

    Spinal Stability

    Classification of Fractures

    Treatment of Specific Injuries


    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
    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
    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
    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.
    CLINICAL EVALUATION
    Complete Neurological Evaluation
    Motor function
    Sensory Testing
    Reflex Examination
    AMERICAN SPINE INJURY ASSOCIATION
    REFLEX EXAMINATION
    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
    RELEVANT ANATOMY OF SPINAL
    TRACKS
    INCOMPLETE CORD LESION
    Determined by anatomic location of tissue injury

    Prognosis better than complete injury.

    Important to determine zone of partial


    preservation.
    INCOMPLETE CORD LESION
    Arrangment of
    corticospinaltracks
    Nerve fibres to upper
    limb are centrally
    situated as compared
    to lower limb
    CENTRAL CORD SYNDROME
    MC type
    Usually by
    hyperextension
    Weakness :
    upper > lower
    Distal>proximal

    Variable sensory loss

    Sacral sparing
    Good prognosis
    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
    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
    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
    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
    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 atrophy
    Do Usg for noting post void residual
    urine level pre op : prognostic
    value(normal 50 to 100 ml)
    BLADDER DYSFUNCTION
    Innervation
    Sympathetic (L1-L2): contracts internal sphincter

    relaxes detrusors
    ParaSympathetic (S2 S3 S4):

    relaxes internal sphincter


    contracts detrusors
    Somatic(pudendal nerve S2 TO S4) : controls
    external sphincter
    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


    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
    RADIOGRAPHIC EVALUATION
    Trauma Series
    AP / Lat thoracic and
    lumbar spine
    Oblique view

    Flexion and extension view


    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
    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
    RADIOGRAPHIC EVALUATION
    MRI
    Indicated in cases of neurological deficit with
    inconclusive radiographs

    discherniations, epidural hematomas, or spinal cord


    edema easily visualised

    Both intrinsic and extrinsic cord injuries.

    Important tool in assessing the integrity of the PLC


    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.
    SPINAL STABILITY
    Holdsworth 1963

    2 column theory
    SPINAL STABILITY
    Denis 1983

    CT Scan

    3 column theory

    Stability based on
    integrity of middle
    coloumn
    SPINAL STABILITY

    Categorized major spinal injury into 4 groups:

    1. Compression Fracture
    2. Burst Fractures
    3. Flexion Distraction Injuries
    4. Fracture Dislocations
    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
    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.
    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.
    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.
    WHITE AND PUNJABI
    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
    AO CLASSIFICATION SYSTEM
    /MAGERL
    MCCORMACK GRADING

    Used in Burst fr
    Score more than 6
    indicative of use of
    longer posterior
    fixation or supplement
    with anterior .
    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
    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
    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
    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
    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
    POSTERIOR REALIGNMENT AND
    FIXATION
    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.
    ANTERIOR DECOMPRESSION AND
    STABILISATION
    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
    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
    BURST FRACTURE

    Failure of anterior and middle column


    Axial compression

    +/- failure of posterior column


    Compression or tensile force

    Most common at T/L junction


    BURST FRACTURE
    Stable :
    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.
    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.
    Neurological deficit :

    Complete injury
    Earlystabilization
    Neurological outcome not changed by
    decompression

    Incomplete injury
    Stabilization
    and decompression beneficial .
    Improvement may occur
    DECOMPRESSION
    Posterior
    Indirect (distraction and ligamentotaxis)
    Direct
    Transpedicle approach
    posterolateral appoach
    laminotomy/ laminectomy
    Anterior
    Partial / complete corpectomy
    FLEXION DISTRACTION INJURY
    Bone or soft tissue?
    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
    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
    GUN SHOT WOUNDS

    Rare injury
    Transabdominal bullets :
    higher source of
    contamination
    Complete injury more
    common than incomplete
    Retained bullets may

    cause to lead toxicity


    TREATMENT OVERVIEW
    COMPRESSION FRACTURE
    BURST FRACTURE
    FLEXION DISTRACTION INJURY
    FRACTURE DISLOCATION
    MINOR INJURY
    Thank You

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