Management of thoracolumbar spine injuries

Dr. Rishi Ram Poudel

Cause of injury.. Indian Scenario..!!

fall from height RTA Violence Gun shotinjuries

52.3

38.4

5 4.3

Upendra B, Khandwal P, Chowdhury B, Jayaswal A: Correlation of outcome measures with epidemiological factors in thoracolumbar spinal trauma. Indain J Orthop 2007 Oct;41(4):290-4.

Why dorsolumbar junction more succeptible??

Location between the stiff kyphotic dorsal spine and more mobile lordotic lumbar spine

Dennis three column concept..

Middle column providing greatest mechanical stability

Compression fractures..Denis

Failure under compression of anterior column. The middle column is intact and acts as a hinge.

Burst fractures.. Denis

Both end plates Superior end plate Inferior end plate

Burst rotation Burst lateral flexion

Failure under axial load of both the anterior and middle column originating at the level of one or both end plates of the same vertebrae

Burst fractures..Lateral film:

• Fracture of posterior wall cortex

• Loss of height of posterior vertebral body

• Retropulsion of fragment into canal

AP film

Increase in interpediculate distance

Unstable burst fractures..

• Loss of height >50%

• Kyphotic deformity >30 degrees

• Substantial posterior column injury

• Progessive deformity

• Progessive neurological deficit

Reason for Kyphotic deformity..biomechanics..!!

Seat-Belt type injuries..Denis

Failure of both posterior and middle columns under tension forces generated by flexion with its axis placed in the anterior column

Chance fracture

Fracture dislocations..

Flexion- rotation

Denis

Slice fracture

Fracture dislocations..

Shear type fracture dislocation

Denis

Postero-anterior shear injury with floating lamina

Anterio-posterior shear injury

Flexion-distraction

Fracture dislocations..Denis

Tear of anterior annulus fibrosus and stripping of ALL during subluxation

Fracture classification Denis

AXIAL-COMPRESSION MECHANISM

Morphologic Anatomic Neurologic Therapeutic

Compressionfracture

Anterior column compressed Intact Orthosis

Stable burst Retropulsed middle columnPosterior ligament intact

Intact

Compromised

Orthosis

Anterior decompression/stabilization

FLEXION-COMPRESSION MECHANISM

Morphologic Anatomic Neurologic Therapeutic

Wedge fracture Anterior column collapse(< 40% VB height)

Kyphosis >30º

Intact

Intact

Orthosis

Posterior instrumentation

Unstable burst Kyphosis 20-30º<50% canal compromise

Kyphosis > 30º>50% loss of anterior VB height>70% canal compromise Marked vertebral body comminution

Intact

Intact/Compromised

Orthosis vs posterior segmental instrumentation in distraction and extension

Anterior decompression/stabilization

Consider combined anteriorand posterior stabilization

FLEXION-DISTRACTION MECHANISM

Morphologic Anatomic Neurologic Therapeutic

TRUE CHANCE Tensile injury through bone Intact Orthosis if anatomically reduced

LIGAMENTOUSCHANCE

Tensile injury through ligament

Intact/Compromised Posterior reduction and compression instrumentation

EXTENSION MECHANISM

Morphologic Anatomic Neurologic Therapeutic

ANTERIOR OPENING OF DISC

Tensile failure of ALL and anterior annulus

Intact Orthosis

FRACTUREDISLOCATION

Laminar fracture

Anterior and middle column ligament disruption

Posterior vertebral body translation

Intact/Compromised

Posterior decompression, reduction andinstrumentation

ROTATION AND SHEAR MECHANISM

Morphologic Anatomic Neurologic Therapeutic

FRACTUREDISLOCATION

Facet fractures

Three column disruption

Vertebral translationIntact/Compromised

Posterior reduction and instrumentation

AO/Magrel classification..!!

McCormack load shearing classificationA. Comminution/Involvement of vertebral body

B. Displacement/ Apposition of fracture parts

C. Deformity correction[(A+B)/2-C]

Low scores (3-6) can be managed with short segment posterior stabilization only

High scores (7-9) require additional anterior stabilization to prevent failure of posterior implant

ASIA impairment scaleA COMPLETE: No motor or sensory function is preserved in the sacral

segments S4-S5

B INCOMPLETE: Sensory but not motor function is preserved below the neurologic level and includes sacral segments S4-S5

C INCOMPLETE: Motor function is preserved below the neurological level and more than half of key muscles below neurologic level have a muscle grade less than 3

D INCOMPLETE: Motor function is preserved below the neurological level and at least half of the key muscles below the neurologic level have a muscle grade more than 3

E NORMAL motor and sensory functions

Thoracolumbar Injury Classification and Severity Score(TLICS)

Evaluating PLC..!!

Clinical signs:

1. Palpable interspinousdefect

2. Posterior tenderness

X ray:

1. Kyphosis >30 degrees

2. > 50% compression of anterior vertebral body

3. interspinousspacing greater than 7 mm than adjacent vertebrae

CT scan:

1. Diastasis of facet joints

2. Spinous process avulsion

MRI:

1. Edema in region of PLC (T2)

2. Disruption of PLC components (T1)

(SSL,ISL,LF,Capsule)

Initial management…

ATLS protocol

• Injuries impairing respiratory and circulatory function treated with priority

• Log roll technique for manipulating the patient

• C-spine immobilization

Systematic Approach

1

2

3

4

5

Systematic Approach

Miss a Step and you are nowhere..!!

Examination

Trauma Bay

E.R.

• Information

• Mechanism

– energy, energy

• Direction of Impact

• Associated Injuries

Starts in the….

Does “unexaminable” mean no examination?

NO!• Inspect for bruising or ecchymosis

• Palpate for step-off or deformity

• Rectal Tone

• Reflex exam

– Bulbocavernosus

– Clonus/Babinski

Thoracolumbar spine..!!

Lateral view..:

• Vetebral Body heights

• Alignment of bodies/Angulation of spine

• Contour of bodies

• Presence of disc spaces

• Encroachment of body on canal

• Loss of vertebral body height

• Kyphosis measurement – COBB angle

AP view:

• Alignment

• Symmetry/ Shape of pedicles

• Interpedicular distance

• Position of spinousprocess

• Contour of bodies

Spinal shock..!!

Commonly used but poorly understood term

Loss of spinal reflexes caudal to a spinal cord injury.

First phase of response to spinal cord to injury associated with initial flaccid paralysis below the lesion

Spinal shock..!

The return of bulbocavernosus reflex marks the resolution of spinal shock

Reflex is not always initially lost and may take longer to recover making assessment confusing

Spinal shock: Pathophysiology..!!

EDEMA

VENOUS

CONGESTION

DAMAGE TO BLOOD

VESSELS

MICROHAEMMORRHAGE

SPINAL SHOCK

After resolution of shock ,variable preserved functions below the injury level

1.Residual axons with sprouting collaterals

2. Denervation hypersensitivity

If no motor or sensory function below the level of injury can be documented when spinal shock ends, a complete spinal cord injury is present, and the prognosis is poor for recovery of distal motor or sensory function

Neurogenic shock..!!

Loss of symphatetic outflow related to spinal shock

Vasodilation of the viscera and peripheries resulting in hypotension without TACHYCARDIA

Fluid administration Pulmonary edema

SCI: Complete Vs Incomplete

Complete• No function below level of injury

• Absence of sensation and voluntary movement in S4/5 distribution

IncompletePreservation of sensation in S4/5 distribution and voluntary control of anal sphincter

The difference between a complete and incomplete spinal cord injury is the PRESENCE OF SACRAL SPARING identified by the presence of ANAL SENSATION

Role of steroid..!!

High doses of methyl-prednisolone

Closed, blunt spinal cord trauma presenting within 8 hours• Loading dose of 30 mg/kg given as bolus i/v

• Continue infusion 5.4mg /kg x 24 hours if the patient presented within 3 hours of injury

• Continue infusion x 48 hours if the patient presented 3 to 8 hours after injury

NASCIS II & III

Polytraumatized spine patients..!Perioperative and post-opeartive mortality and morbidity were not increased by emergent stabilization

Neurologic improvement was increased and life threatening complications were reduced

Mc Lain RF, Benson DR:Urgent surgical stabilization of spine fractures in polytraumatized patients Spine 1999;24:1646

Managing Thoracolumbar Spine Fractures..!

NEUROLOGICAL DEFICIT

YES

COMPLETE INCOMPLETE

POSTERIOR

FUSION ANTERIOR

DECOMPRESSION & FUSION

POSTERIOR

TRANSPEDICULAR

DECOMPRESSION AND

FUSION

CIRCUMFERENTIAL

PROCEDURES

NO

STABLEUNSTABLECONSERVATIVE

PLC intactPLC disrupted

Posterior fusion

±

Minimally

invasive(VBA)

Circumferential

fusion

Anterior fusion

Posterior fusion

with indirect

reduction ±

Minimally

invasive(VBA)

Stable fracture

Involving less than 2 columns

Kyphosis < 25 degrees

Compression < 50% of anterior column

Canal compromise < 50%

TLICS guidelines..!!

Non-operative management• Fractures with <10% vertebral height loss do not need external

support.

• Fractures with < 40% height loss and < 25 degrees kyphosis can be treated with a Jewett brace for 6 to 8 weeks.

• In fractures below T5, a plaster jacket or TLSO can be used.

• In higher fractures (above T5), a cervical component should be added to the brace.

Burst fractures in brace should regularly be assessed in standing radiographs with orthosis

Bony chance fracture if anatomically reduced can be treated with bracing

Burst fracture: non-operative vs operative treatment

Operative management is related with better kyphosis correction but with similar pain and functional outcomes 4 years post-operatively

Laminectomy: posterior direct decompression

Indications:

• Comminuted posterior elements causing direct neural compression

• Epidural hematoma requiring evacuation

• Repair of dural tear associated with burst and laminar fractures during posterior instrumentation and fusion

Posterior instrumentation:distraction and ligamentotaxis

Requires intact PLC

Contraindications:

• Canal compromise >67%

• Delay in operative treatment for > 4 days

• Where pedicle screw insertion is not feasible (atypical morphology, small dimension or traumatic fracture)

Greater neurologic improvement as compared to posterior or posterolateral decompression

• Return of normal bowel and bladder control achieved more frequently

• Even in cases of long-standing compression after fracture modest recovery

Patients with incomplete deficits (spinal cord or cauda equina) are ideal candidates because they have greater chances for neural recovery

ANTERIOR DECOMPRESSION AND FUSION

Indications:

• Retropulsed fragments occupying >67% canal area

• Extensive vertebral body comminution with significant kyphotic deformity

• Delay in operative treatment for 4 days

• Traumatic disc herniations causing symptomatic cord or root compression

Combined anterior and posterior methods

• When canal is compromised circumferentially

• Severe coronal or sagittal plane deformity (>40 degrees)

• Structural augmentation is deemed necessary(multiple contiguous levels of injury, poor bone quality or osteoporosis)

Burst fracture in thoracolumbar region (T11-L2) with neurological deficit from a retropulsed fragment should undergo anterior decompression and fusion as a solitary procedure or in combination with a posterior approach

However, relative indications and contraindications depending upon (LMNOPS)

Location

Mechanism

Neurology

Open vs closed

Stability

Kyphosis even in absence of neurological deficit likely to progress.

>30 degrees : late neurological deficit

Isolated anterior procedures L2 and below to be avoided: Pseudo-arthosis and vascular concern

Posterior element disruption and osteoporotic bone: additional posterior intrumentation

Vertebroplasty and Kyphoplasty..!!

Indications: • Osteoporotic VCF not responding to conservative management

• Spinal metastatic lesions & fractures

• Hemangiomas

Goal of vertebroplasty is to improve strength and stability

Goal of Kyphoplasty is to restore vertebral body height and stability. The use of baloon creates a void for cement placement under lower pressure and thus results in lower incidence of cement extravasation

Can be safely done in patients with refractory pain to conservative treatments.

Vertebroplasty technique..!!

Dangers..Needle injury..!

Canal breach Lateral passage and aortic damage

Complications ..!!

Transient increase in pain in the injected level

Cement leakage

Pulmonary embolism(marrow,cement,air)

Infection

Vertebroplasty vs kyphoplasty: Debate continues….

Kyphoplasty : more controlled procedure with height restoration and less chances of cement extravasation

Vertebroplasty: faster, more straightforward, cheaper that has not shown to give inferior results.

Increased rates of cement migration doesn’t significantly results in increased morbidity

DAMAGE CONTROL SURGERY : 3 PHASE APPROACH

Establish rapid

control of

hemorrhage

Identify major

injuries

1

Stabilize major

fractures

Reduce

dislocated joints

Decontaminate

open wounds

2

Once normal

physiology is

restored ,

definitive surgical

repairs

3

Posterior internal stabilization of thoracic or lumbar trauma

Anterior decompression or complex stabilization procedures as allowed by patient’s physiologic condition

Definitive surgery electively scheduled for experienced spine surgeon

General care: ventilatory care, pressure care , bowel bladder management, thromboembolic prophylaxis, control of infections . Minimize systemic insult to the patient

Window of opportunity

The ability to provide good internal fixation with minimal soft

tissue disruption is the key point of the AO principles of

treatment of extremity fractures. SPINAL FRACTURES ARE NO

DIFFERENT.

Concept of MIS procedures:

• Avoid need for large surgical dissection resulting in less

denervation and muscle atrophy as well as less damage to stabilizing

structures such as facet joints.

• Reduce the morbidity associated with standard open procedures

Primary role: restore or augment posterior tension band

APPLICATIONS:

1.Axial compression injuries (compression/burst #)

Supplemenatal posterior fixation of anterior corpecectomy when required for decompression or anterior column support.

As a primary procedure : MIS decompression and radiculopathy

2.Flexion-distraction injuries

Pure bony Chance Fractures allowing direct osteosynthesis rather than spinal fusion

3.Damage control Orthopaedics

Temporary stabilization in patients with multiple traumatic injuries who might not be physiologically able to tolerate definitive open procedure early in their hospitalization

4.When bracing of stable fractures is difficult or contraindicated

As an internal splint for patients associated with chest trauma, significant respiratory compromise , morbid obesity.

Surgical technique..!!

Properly aligned AP and Lateral images

Flat supeior end plate (only one end plate shadow)

Pedicles just below superior end plate and spinous processes centered between the pedicles

Superior end plate flat

Single posterior vertebral body shadow

Superimposed pedicles

Surgical technique…!!1 cm vertical incision lateral to pedicle

Insertion of Jamshidi needle:

Starting point: supero-lateral quadrant of pedicle , advanced down untill it appears to be at posterior border of vertebral body on lateral image.

Tip of needle within medial half of pedicle on AP image

Guide wire

Dilators: Largest dilator as a working tube

Cannulated pedicle screw over guide wire

Surgical technique..!!

VIDEO-ASSISTED THORACIC SURGERY(VATS)

Despite a long learning curve and technical demands it has several advantages

• Better cosmesis

• Adequate exposure from T2-L1

• Less morbidity

• Better illumination, magnification

Contraindications:

• Inability to tolerate single lung ventilation

• Emphysema, acute respiratory insufficiency

• Previous thoracotomy

Short segment fixation plus transpedicular augmentation..!!

Transpedicular augmentation:better final

restoration of vertebral height

Allen li et al: Indian J Orthop. 2007 Oct-Dec; 41(4): 362–367.

Rehabilitation..!!

Bladder dysfunction:• Intermittent catheterization

• Supra-pubic catheterization in penile ulceration

• Valsalva, Crede method

Bowel dysfunction:• Regular intake of high fluids and dietary fibers

• Pulse water irrigation of rectum

• Electrical stimulation of abdominal musculature

• Prokinetic agents: cisapride

• Suppositories

Spasticity

• Physical therapy: rhythmic passive movements, muscular stretching exercises

• Direct muscle electrical stimulation

• Oral baclofen

Pain

• Non-pharmacologic massage and heat, TENS

• Pharmacologic: Gabapentin

DVT prevention

• Compression stockings

• LMWH

Rehabilitation..!!

Bed sore prevention

• Posture change every 2 hourly

• Air mattress

• Use of pillows and foam wedges at bony prominences

High protein diet

Debridement of established sore to fasten healing

Rehabilitation..!!

Rehabilitation..!!Postural hypotension

• Clonidine

• Elastic stockings, abdominal binders

Prevention of respiratory infections

Chest physiotherapy, steam inhalation, incentive spirometry

Manual assisted coughing

Rehabilitation..!!Community re-intregation is must.

Thank You..!!!!!