traumatic conditions of dorso-lumbar spine
TRANSCRIPT
Traumatic conditions Traumatic conditions of Dorso-Lumbar of Dorso-Lumbar
spinespine
Anatomy of Thoracic SpineAnatomy of Thoracic Spine
Kyphosis Kyphosis is is natural alignmentnatural alignment
Narrow spinal Narrow spinal canalcanal
Facet orientationFacet orientation Rib factor on Rib factor on
stabilitystability Conus at T12-L1Conus at T12-L1
Anatomy of Lumbar SpineAnatomy of Lumbar Spine
LordosisLordosis is natural is natural alignmentalignment
Larger vertebral Larger vertebral bodiesbodies
Facet orientationFacet orientation Cauda equinaCauda equina
Thoracolumbar JunctionThoracolumbar Junction
Transition ZoneTransition Zone
Kyphosis Kyphosis LordosisLordosis
Mechanical Difference:Mechanical Difference:
Lumbar spine less stiff in Lumbar spine less stiff in flexionflexion
Transition Zone:Transition Zone:Predisposed to FailurePredisposed to Failure
Little opportunity for force Little opportunity for force dispersiondispersion
Central loadingCentral loading
of T-L junctionof T-L junction
Not anatomically Not anatomically disposed to transfer forcedisposed to transfer force
Patient EvaluationPatient Evaluation
Pre-hospital carePre-hospital care
EMT personnelEMT personnel Initial assessmentInitial assessment Transport and immobilizationTransport and immobilization
Patient EvaluationPatient Evaluation
ABC’s of TraumaABC’s of Trauma HistoryHistory Physical ExaminationPhysical Examination Neurological ClassificationNeurological Classification
Clinical AssessmentClinical Assessment
InspectionInspection PalpationPalpation Neurological EvaluationNeurological Evaluation
ASIA Impairment ScaleASIA Impairment Scale Sensory EvaluationSensory Evaluation Motor EvaluationMotor Evaluation Reflex EvaluationReflex Evaluation
Bulbocavernosus, BabinskiBulbocavernosus, Babinski
Clinical AssessmentClinical Assessment
Associated InjuriesAssociated Injuries Meyer, 1984 – 28% have other major Meyer, 1984 – 28% have other major
organ system injuriesorgan system injuries Noncontiguous spine fractures 3-56%Noncontiguous spine fractures 3-56% Always monitor HematocritAlways monitor Hematocrit GU: Foley recommended, check post-void GU: Foley recommended, check post-void
residuals, if abnormal get cystometrogramresiduals, if abnormal get cystometrogram GI: prepare for ileus.GI: prepare for ileus.
Radiographic EvaluationRadiographic Evaluation
Trauma series includes: lateral cervical, chest, Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P lateral thoracic, A/P and lateral lumbar and A/P pelvispelvis
Obtunded patients require further skeletal surveyObtunded patients require further skeletal survey
CT scan – bony injuriesCT scan – bony injuries
MRI – images spinal cord, intervertebral discs, MRI – images spinal cord, intervertebral discs, ligamentous structuresligamentous structures
Thoracolumbar Fractures Thoracolumbar Fractures ControversiesControversies
CLASSIFICATION!!!!!CLASSIFICATION!!!!!Indications for surgeryIndications for surgery
Optimal time for surgeryOptimal time for surgery
Best approach for surgeryBest approach for surgery
CLASSIFICATION CLASSIFICATION SYSTEMSSYSTEMS
Convey informationConvey information
Produce treatment planProduce treatment plan
Monitor patient progressMonitor patient progress
Research toolResearch tool
BBööhler 1930hler 1930
Importance of injury mechanismImportance of injury mechanism
6 types of spinal fractures included in 6 types of spinal fractures included in systemsystem• CompressionCompression• Flexion Flexion • Extension Extension • Lateral flexionLateral flexion• ShearShear• TorsionalTorsional
DENIS 3 Column ClassificationDENIS 3 Column Classification
AnteriorAnterior - Ant 1/3 of disc - Ant 1/3 of disc /VB + ALL/VB + ALL
MiddleMiddle - Post 1/3 of - Post 1/3 of disc/VB + PLLdisc/VB + PLL
PosteriorPosterior - Post Elements - Post Elements
McAfee ClassificationMcAfee Classification
• Six types
• CT based-100 patients
• Middle column most important
AO Mechanistic ClassificationAO Mechanistic ClassificationComplex subdivisions to include most Complex subdivisions to include most
fracturesfracturesTypes Groups Subgroups Specificastions
A1.1A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3
A1.3A2.1
A compression A2 split A2.2A2.3A3.1 A3.1.1, A3.1.2, A3.1.3
A3 burst A3.2 A3.2.1, A3.2.2, A3.2.3A3.3 A3.3.1, A3.3.2, A3.3.3
B1.1 B1.1.1, B1.1.2, B1.1.3B1 post ligamentous B1.2 B1.2.1, B1.2.2, B1.2.3
B2.1B distraction B2 post osseous B2.2 B2.2.1, B2.2.2
B2.3 B2.3.1, B2.3.2B3.1 B3.1.1, B3.1.2
B3 anterior B3.2B3.3
C1.1C1 A with rotation C1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4
C2.1 C2.1.1, C2.1.2, C2.1.3, C2.1.4B rotation C2 B with rotation C2.2 C2.2.1, C2.2.2, C2.2.3
C2.3 C2.3.1, C2.3.2, C2.3.3C3 shear C3.1
C3.2
Spinal Cord InjurySpinal Cord Injury
Accurately Document Neurological StatusAccurately Document Neurological Status
Remember SPINAL SHOCKRemember SPINAL SHOCK
Prognosis of deficit at 48hoursPrognosis of deficit at 48hours
Spinal Cord InjurySpinal Cord Injury
FRANKELFRANKEL
AA No motorNo motor No sensationNo sensation
BB No motorNo motor Min. sensationMin. sensation
CC Motor(2-3)Motor(2-3) SensationSensation
DD Motor(4-5)Motor(4-5) SensationSensation
EE NormalNormal NormalNormal
Spinal Cord InjurySpinal Cord Injury
A.S.I.A.A.S.I.A.
AA Complete - no motor or sensationComplete - no motor or sensation
BB Incomplete - sensation, no motorIncomplete - sensation, no motor
CC Incomplete - sensation, motor<3Incomplete - sensation, motor<3
DD Incomplete - sensation, motorIncomplete - sensation, motor33
EE NormalNormal
Spinal Cord Injury- PowerSpinal Cord Injury- PowerMRC MRC
GradeGrade
00
11
22
33
44
55
nonenone
visible contractionvisible contraction
contracts, not against gravitycontracts, not against gravity
contracts against gravity not contracts against gravity not resistanceresistance
contracts against resistancecontracts against resistance
normalnormal
TreatmentTreatmentSpine Trauma Severity Spine Trauma Severity
ScoreScoreDetermined by:Determined by:
Injury MorphologyInjury MorphologyNeurologyNeurologyLigamentous IntegrityLigamentous Integrity
Next Step - Direct TXNext Step - Direct TX
Assign Points
Conservative
Surgery
TreatmentTreatment
Injuries with Injuries with 3 points3 points or less or less = = non operativenon operative
Injuries with 4 points=Nonop Injuries with 4 points=Nonop vs Opvs Op
Injuries with Injuries with 5 points5 points or or more = more = surgerysurgery
Non – Operative Treatment Non – Operative Treatment OptionsOptions
No treatmentNo treatment
advice / restrict activityadvice / restrict activity
Spinal ‘immobilisation’Spinal ‘immobilisation’
Bed restBed rest
Lumbar pillow / Log rollingLumbar pillow / Log rolling
Casting / BracingCasting / Bracing
Combination treatmentCombination treatment
THE AIMS OF TREATMENTTHE AIMS OF TREATMENT
Prevent neurological deteriorationPrevent neurological deterioration
Minimise spinal deformityMinimise spinal deformity
Fracture healingFracture healing
Minimise complicationsMinimise complications
Acceptable functionAcceptable function
ComplicationsComplications
Bed rest sequelaeBed rest sequelae
Respiratory compromiseRespiratory compromise
Worsening of deformityWorsening of deformity
Neurological deteriorationNeurological deterioration
THANK YOUTHANK YOU