spinal trauma helpful hints - briz brain & spine · •low-velocity trauma causing sci presents...

Paediatric spine research group

Dr Geoffrey Askin

Orthopaedic Spinal Surgeon, Lady Cilento Children’s and

Mater Hospitals, Brisbane

Spinal Trauma – helpful hints


Spinal Fractures

• Annual incidence of 64 per 100,000

• Neurological deficit in 10-20%

• Over a third will have additional injuries

• 54% of all patients with spinal fractures are able to return to previous level of employment

this doesn’t include pathological #’s


3 components to spinal injury

• Vertebral injury (to the bone) can heal

• Neurological injury (to the spinal cord , cauda equina or nerve roots) - may or may not improve

• Ligament/disc injury – often heals in lengthened state


4 parameters determine the injury

morphology • Patient age

• Velocity ( energy) of

trauma

• Direction of forces

• Health of bone


Paediatric injuries

• Spinal fractures rare in children (<5%)

• Pts <15 yrs account for < 10% of all SCI

• 60 -80% of Paediatric spinal injuries occur in C spine (cf. 30-40% in adults)


Anatomic variations

• < 8 year old - high head to body ratio

• (disproportionately large head and a small body )


Anatomic variations

•Increased intrinsic elasticity

–Shallow facet joints

–ligaments and joint capsules are more

stretchable

–Absent uncinate process

–Weak nuchal muscles

•Anterior wedging of

vertebral bodies


Paediatric injuries


Paediatric injuries

<8 years high velocity

upper C-spine – 80%

ligament injuries - unstable

often paralysed

>8 years sub - axial

often low velocity

rarely paralysed

Cervical spine


Paediatric injuries

• sudden deceleration injury

• no bony injury

• ligs. more elastic than cord

upper C-spine injuries

<8years


Paediatric injuries

• sudden deceleration injury/ seatbelt


PECARN High risk factors

• High risk MVA – >55mph

– ejection

– rollover

– death

• Diving / axial load

• Predisposing condition • Klippel Feil

• Downs Syndrome

• Altered mental status

• Substantial torso injury

• Focal Neurological deficit

• Torticollis

• c/o Neck pain

8 criteria


Paediatric injuries

Cervical spine case

10 year old fall off trampoline

no spinal tenderness

full range of motion

normal neurology

exam

neck pain

stiffness

no neurolog. symptoms

no imaging needed


Paediatric injuries

Cervical spine case

10 year old fall off trampoline

plain Xrays

CT only the area in ?

MRI preferrable

Refer on

investigation

2 PECARN points

neck pain

loss of range

neurology - normal Hx/exam


Paediatric injuries

painful rye neck

Min. or no trauma

often assoc. with URTI

usually settles with analgesia/soft collar

plain Xrays suffice with AP open mouth

CT always shows rotatory subluxation

so DON’T CT

torticollis


Paediatric injuries

no other PECARN parameters

torticollis

soft collar

review 1 week

if still symptomatic – refer on

other PECARN parameters

refer on


Paediatric injuries

high velocity

flexion/distraction (seat-belt)

30% intra abdominal injuries

often paralysed

Thoracolumbar spine


• sudden deceleration injury/ seatbelt

•SCIWORA

Paediatric injuries

Thoracolumbar spine


• ligs. don’t heal • frequently require fixation/fusion • neuro. outcome better than adults • often develop scoliosis

Paediatric injuries

Thoracolumbar spine


Adult injuries

young / healthy

elderly/infirmed

Cervical spine

normal bone

often pathological bone


Adult injuries

• high energy

• often paralysed

diving injuries

(normal bone)


Operative stabilisation

• Unstable spine

• Improved rehab potential with stable spine

• Easier to manage chest injuries on ICU

• Unlikely to recover neurological function as ASIA A


Rugby in Australia

• 0.5 / 10000 player years • 115 admissions NSW 1984-1996 • 49 permanent quadriplegics


Adult injuries

• low energy

• require urgent reduction

football injuries


rugby injuries

• 32 patients were completely paralysed at the time of reduction (ASIA A)

– 8 were reduced within four hours of injury and 5 of them made a full recovery

– Of the remaining 24 who were reduced AFTER four hours of injury, none made a full recovery and only 1 patient made a partial recovery that was meaningful


Rugby injuries

• Low-velocity trauma causing SCI presents an opportunity for secondary prevention of permanent injury (rugby, diving, other sports)

• Appears to result from secondary insult, rather than primary mechanical spinal cord damage

• Time from injury to reduction, and hence reperfusion is critical


Adult injuries

hidden flexion injury

well documented injury

neck pain / tenderness

neuropathic pain

normal xray

refer for MRI ? ligament damage

flex/extension lat. Xray

repeat xray 2 weeks / 4 weeks


Adult injuries

peg #’s

hyperextension injuries/central cord syndrome

elderly/infirmed

why did they fall?

Cervical spine


Adult injuries

elderly/infirmed

non union rate high

myelopathy rate low

surgical complications high

supervised neglect

Cervical spine

peg #’s


Adult injuries

elderly/infirmed

low energy fall

min. bone injury

pre-existing canal stenosis

vascular component

preserved LL function

loss upper limb function

non-op. treatment

Cervical spine

hyperextension injuries


Adult cervical injuries

•unstable

collars?

surgery / halo brace

•stable soft collar / no splint


Conclusions

• HARD COLLARS DO NOT IMMOBILISE THE UNSTABLE SPINE

• In-line stabilisation/soft collar/sandbags is just as effective as hard collar


Adult injuries

falls

bone/ligament. disruption

10% neurological injury

management contraversial

Thoraco-lumbar spine

flexion/compression injuries burst #s


Adult Thoracolumbar injuries

• 62 Year old male

• Window cleaner

• Fell from 10 feet – T12 vertebral #

• No significant co-morbidities

• Neurological injury - T12 ASIA E (normal)


Burst # neurologically normal

natural history •will kyphosis cause pain? •will retropulsed bone cause neuro. loss?


Clinical Series

Mumford et al Spine • 2 year follow up burst fractures treated

conservatively • 66% good / very good clinical results • 90% return to their previous jobs

Weinstein et al (1998) • Burst fractures treated conservatively • 88% return to their previous jobs • Average kyphosis 26.4 degrees at end of follow-up


Wood JBJS (A) 2003

• Prospective, randomised

• All burst fractures, stable and unstable with normal neurology

• Based on functional and radiographic scores

• Some operated anteriorly some posteriorly

• Hooks, screws, fibular struts, range of levels

• No benefit from surgery


• Shen, Spine (2001) – 80 patients

– Prospective, almost randomised (singer paraplegic)

– Closed, burst fractures

– Normal neurology

– Initial improvement with surgery (3-6 months) • Pain

• Kyphosis

– No significant functional difference at 2 years

– Operative treatment – Cost x4


Siebenga Spine 2006

• Prospective randomised

• A type fractures with normal neurology

• All operated posteriorly – short segment

• Functional and radiographic parameters

• Better outcome with surgery for A3 subtype

• Pain, kyphosis, return to work


If you asked 100 spine surgeons if a burst fracture needed surgery how

many answers would you get?

200


stabilise

• decompression will not influence neurol. outcome

• stabilization allows early mobilisation

neurologically complete burst #’s


burst #’s

classification

neurologically incomplete


anterior reconstruction

• complete decompression

• recon. anterior column

neurologically incomplete burst #’s

? influences neurol. outcome


Adult injuries

osteoporotic crush #’s


mechanical pain

progressive deformity

rarely neurological compromise


Adult injuries

osteoporotic crush #’s

pain management

exclude malignancy

?bracing

osteoporosis management

vertebroplasty/kyphoplasty



Thank you

spinal trauma helpful hints - briz brain & spine · •low-velocity trauma causing sci presents...

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