THORACOLUMBAR FRACTURES

By Dr. Rishit J Soni2nd 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 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 .

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

Secondary survey : Complete Spine examinationThorough history Inspect and palpate entire spinePer 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 TestingReflex 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 atrophyDo 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 detrusorsSomatic(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

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

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 body.

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.

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 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.

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

Early stabilizationNeurological outcome not changed by

decompression

Incomplete injuryStabilization 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

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