14 thoracolumbar fractures
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14 thoracolumbar fractures

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    14 thoracolumbar fractures 14 thoracolumbar fractures Presentation Transcript

    • Thoracolumbar Fractures Patient Evaluation and Management
    •  
    •  
    • Outline
      • Epidemiology
      • Clinical evaluation
        • ATLS
        • Neuro exam
        • Neurogenic / spinal shock
      • Classification of spinal cord injury
        • Grading system
        • Complete VS incomplete
        • Incomplete cord syndromes
      • Pharmacological treatment
    • Outline
      • Radiographic Evaluation
        • Plain Xray
        • CT
        • MRI
        • Mylography
      • Spinal Stability
      • Classification of Fractures
      • Treatment of Specific Injuries
    • Epidemiology
      • Prevalence / Incidence
      • Bimodal Distribution
      • Cause
      • Multiple injury
    • Clinical Evaluation
      • Trauma / ATLS
      • ABC / GCS / 2 survey
      • Spine exam
        • Red flags
        • Inspect and palpate entire spine
        • Be thorough
    • Clinical Evaluation
      • Complete Neuro Evaluation
        • Dermatomal Sensory Testing
        • Assessment of Lumbar and Sacral motor root function
        • Reflex Examination
    • Dermatomal Sensory Testing
    • Lumbar and Sacral Motor Root Function
    • Lumbar and Sacral Motor Root Function
    • Reflex Examination
    • Spinal Shock
      • Physiologic disruption of all spinal cord function
      • Present or not present
      • Bulbocavernosus Reflex
    • Bulbocavernosus Reflex
    • Spinal Shock
      • No BCR
      • Flaccid paralysis, hypotonia, areflexia
      • Hours to days
      • + BCR
      • Hyper reflexia, spasticity, clonus
    • Neurogenic shock
      • Disruption of descending sympathetic outflow
      • No sympathetic response and unopposed vagal tone
      • Cardiovascular instability
      • treatment
    • Classification of Spinal Cord injury
      • Many Grading Systems
        • Impairment Based
          • Frankel
          • ASIA
          • Yale
          • Motor Index
        • Function Based
          • Modified Barthel Index
    • Grading of Spinal Cord Injury
    • Grading of Spinal Cord Injury
    • 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
    • Incomplete cord lesion
      • Determined by anatomic location of tissue injury
      • Must understand cord anatomy
      • Predictably pattern based on involvement
    • Incomplete cord lesion
    • Incomplete cord lesion
    • Central Cord syndrome
    • Anterior Cord Syndrome
    • Posterior cord syndrome
    • Brown Sequard Syndrome
    • Cauda Equina Syndrome
      • Cord ends L1/2 disc space
      • Lower motor neuron axons
      • Perianal anesthesia, sphincter and bladder dysfunction
    • Pharmacological Treatment
      • Modify 2 injury cascade
      • Many drugs
        • Corticosteroids
        • Antioxidants
        • Gangliosides
        • Opiod antagonists
        • Ca Channel Blockers
        • etc
    • Pharmacological Treatment
      • NASCIS 3
        • Steroids
        • Controversial study design
        • Accepted Treatment Protocol
          • Benefits
          • Contraindications
    • Radiographic Evaluation
      • Trauma Series
      • Poor historians
      • Noncontiguous injury
      • AP / Lat entire spine
    • Radiographic Evaluation
      • CT
        • All cases of suspected injury to posterior elements or posterior vertebral body
    •  
    • Radiographic Evaluation
      • MRI
        • Indicated in all cases of neuro deficit?
        • Both intrinsic and extrinsic cord injuries
      • Mylogram
        • Replaced by MRI
    • Spinal Stability
      • Holdsworth 1963
      • 2 column theory
      • Post. ligaments
    • Spinal Stability
      • Denis 1983
      • CT Scan
      • 3 column theory
    • Spinal Stability
      • Categorized major spinal injury into 4 groups:
        • 1. Compression Fracture
        • 2. Burst Fractures
        • 3. Flexion Distraction Injuries
        • 4. Fracture Dislocations
    • Compression Fracture
      • Failure of anterior column
      • Stable:
        • Tlso, hyperextension bracing
      • Unstable (>50% height, >30% kyphosis, multi level)
        • Posterior instrumented fusion vs non OR
        • Progressive deformity
    • 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 Fracture
      • Neuro intact
        • <20-30 kyphosis, <45-50 canal compromise
        • >20-30 kyphosis, >45-50 canal compromise
      • Neuro compromised
    • Decompression???
      • Complete
        • Early stabilization
        • Neuro outcome not changed by decompression
      • Incomplete
        • Stabilization and decompression beneficial (no controversy)
        • How to do it (controversial)
    • Decompression
      • Posterior
        • Indirect (distraction and ligamentotaxis)
        • Direct (transpedicle or posterolateral)
      • Anterior
        • Large / midline / incomplete
        • > 2 weeks since injury
        • Following posterior decompression
        • Partial / complete corpectomy
    •  
    •  
    •  
    • Flexion Distraction Injury
      • Bone or soft tissue?
    • Fracture Dislocation
      • High energy
      • Most have neuro deficit
      • Goal:
        • Stabilization for early mobilization
      • Incomplete deficit??
    • Gun Shot Wounds
      • Where is the bullet?
      • Complete / incomplete?
      • Progressive deficit?
      • Bowel injury?
    • THE END!!!
    • Treatment Overview
    • Compression Fracture
    • Burst Fracture
    • Flexion Distraction Injury
    • Fracture Dislocation
    • Minor Injury