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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
Thoracic and lumbar fractures account for 50% of all spinal traumatic fractures.
• Incidence. 4-5 per 100,000. 18 - 35 years. Male\ Female = 4:1 Neurologic injury 25% of cases.
• 65% of TL#s occurs between the T9&L2 vertebrae. (thoracolumbar Junction)
• Cervical - 7 vertebrae• Thoracic - 12 vertebrae• Lumbar - 5 vertebrae• Sacral - 5 fused vertebrae• Coccyx - 4 fused vertebrae
4
5
Functional spinal unit
Composed of: • 2 adjacent vertebrae • Facet joint• Inter vertebral disc • Intervening ligaments
7
This unit is responsible for Movement of spine
Thoracic Spine• Kyphotic Curve. • Ribs more stiffness, resist rotation.• T11,T12 have floating ribs;
No costotransverse articulations.
No sternal attachement.
•Facet orientation limited flexion/extension.•Canal is relatively small.
Lumbar Spine
• Lordotic Curve.• Large discs More mobility• Spinal canal wider.• Spinal cord ended at L1.• Facet orientation more flexion/extension.
ETIOLOGY• High energy trauma (RTA 50%)• Falls.• Sports accident.• Gunshot injury.• Osteoporosis• Tumors • Weak bone(malnutrition,renal,RA,DM,endocrine).
– 16% major chest injury– 10% major abdominal injury– 8% long bone/ pelvic fractures
Spinal fracture should be suspected in;1. Comatosed patient.2. High energy trauma.3. Evidence of neurological deficit.4. Multiple injuries:
Missed TL#s reach 5%, And reach 22% in cervical fractures.
The main causes are,• Poly trauma.• low level of suspicion.• Intoxication \ unconsciousness• Failure to take proper radiographs.• Failure to interpret the x ray.
CLASSIFICATION
Three column theory
ANTERIOR COLUMN
MIDDLE COLUMN
POSTERIOR COLUMN
Spinal Stability
• Categorized major spinal injury into 4 groups:
– 1. Compression Fracture– 2. Burst Fractures– 3. Flexion Distraction Injuries– 4. Fracture Dislocations
• 45% of TL#s.
• Anterior column failure
(Anterior or lateral flexion)
• Middle, Post. Column intact.
• Usually no Neurological deficits.
COMPRESSION (WEDGE) FRACTURE
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.
Compression Fracture
Compression Fractures
• Only anterior column injury• Middle? and post. OK• Ant. column less than 30%• No more than 10 deg kyphosis• No neuro injury
Burst fractures
• 15 % of TL#s• Anterior& middle column failure. (Axial compression)
• Most common at T/L junction• Neurological deficit.
Burst Fracture
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.
Stable Burst
• Both ant and middle column involvement
• Minimal kyphosis• No neuro involvement• No laminar fracture
Unstable Burst• 3 column involvement• Possible neuro
involvement• Severe communition• Significant pedicle
widening• Look for laminar
fracture (asso. with root entrapment)
FLEXION-DISTRACTION = SEAT-BELT-TYPE = CHANCE #
• Posterior &middle columns failure. (hyperflexion then tension forces)
• Anterior column - partial damage. - functions like a hinge.
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.
Flexion Distraction Injury
Fracture-Dislocation
• Failure of all columns (compression, tension,
rotation, or shear). • anterior hinge is disrupted.• Dislocation.• Severe neurological deficit.
Flexion distraction• Easy to miss- may look
benign• Anterior column >
50% crushed• Middle column mainly
intact• Significant spinous
process widening• Unstable
Fracture Dislocations• Translation in lower
lumbar spine may be developmental (nly L3-S1 spondylolysthesis)
• Always abnormal in thoracic spine (ribs)
• Unstable• Normally- neuro deficit• Can be hidden at mid
thoracic spine• 3 column injury
Fracture Dislocation
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.
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
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
RADIOLOGICAL ASSESMENT
X-RAYS Lateral View
• Alignment.
• Contour of bodies.
• Disc spaces.
• Angulation.
• Encroachment on canal.
• Loss of vertebral body height.
X-RAYS Lateral View
• Measurement of degree of vertebral body compression.
• Look at how the ant.& post. aspects of the body line up.
X-RAYS Lateral View
X-RAYS Lateral View
• Measure Kyphosis.
• Measure from closest intact endplates.
• Alignment• Symmetry/ Shape of
pedicles• Interpedicular distance• Position of spinous process• Contour of bodies
X-RAYS A-P view
X-RAYS A-P view• Lateral vertebral body height.
• Interpedicular distance. • Distance between the spinous
processes.
Treatment
Goals
1. Maximise neurological recovery .
2. Maintain or restore spinal alignment.
3. Obtain a healed and stable spinal column.
4. Prevent future deformity.
Spinal Cord Injury
Methylprednisolone
• 30mg/kg iv bolus over 15min. • 5.4 mg/kg/h infusion over 23 hrs (first 3 hours).
• 5.4 mg/kg/h for 47hrs (if > 3 – 8 hrs passed).
Proton pump inhibitor & LMW Heparin
Non-operative treatment
Bed Rest• Strict bed rest for 3- 4 weeks.• Avoid flexion, sit-ups, & spinal rotation.• Avoid weight bearing. • Bed rolling encouraged.
Bracing
• Treated with brace for 6-8 weeks.
• Wear on whenever upright.
• Ambulation & Transfers.
• Solid healing 8-12 weeks.
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
Operative treatmentIndications:• Ant. vertebral height loss > 40%.• Canal compromise > 40%. • Kyphosis > 25 degrees.• Neural compression.
Aim• Neural Decompression.• Stabilization.• Solid fusion.
Surgical options
Anterior FixationPosterior Fixation
Vertebroplasty
Kyphoplasty
Anterior decompression and stabilisation