14 thoracolumbar fractures


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14 thoracolumbar fractures

  1. 1. Thoracolumbar Fractures Patient Evaluation and Management
  2. 4. Outline <ul><li>Epidemiology </li></ul><ul><li>Clinical evaluation </li></ul><ul><ul><li>ATLS </li></ul></ul><ul><ul><li>Neuro exam </li></ul></ul><ul><ul><li>Neurogenic / spinal shock </li></ul></ul><ul><li>Classification of spinal cord injury </li></ul><ul><ul><li>Grading system </li></ul></ul><ul><ul><li>Complete VS incomplete </li></ul></ul><ul><ul><li>Incomplete cord syndromes </li></ul></ul><ul><li>Pharmacological treatment </li></ul>
  3. 5. Outline <ul><li>Radiographic Evaluation </li></ul><ul><ul><li>Plain Xray </li></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>Mylography </li></ul></ul><ul><li>Spinal Stability </li></ul><ul><li>Classification of Fractures </li></ul><ul><li>Treatment of Specific Injuries </li></ul>
  4. 6. Epidemiology <ul><li>Prevalence / Incidence </li></ul><ul><li>Bimodal Distribution </li></ul><ul><li>Cause </li></ul><ul><li>Multiple injury </li></ul>
  5. 7. Clinical Evaluation <ul><li>Trauma / ATLS </li></ul><ul><li>ABC / GCS / 2 survey </li></ul><ul><li>Spine exam </li></ul><ul><ul><li>Red flags </li></ul></ul><ul><ul><li>Inspect and palpate entire spine </li></ul></ul><ul><ul><li>Be thorough </li></ul></ul>
  6. 8. Clinical Evaluation <ul><li>Complete Neuro Evaluation </li></ul><ul><ul><li>Dermatomal Sensory Testing </li></ul></ul><ul><ul><li>Assessment of Lumbar and Sacral motor root function </li></ul></ul><ul><ul><li>Reflex Examination </li></ul></ul>
  7. 9. Dermatomal Sensory Testing
  8. 10. Lumbar and Sacral Motor Root Function
  9. 11. Lumbar and Sacral Motor Root Function
  10. 12. Reflex Examination
  11. 13. Spinal Shock <ul><li>Physiologic disruption of all spinal cord function </li></ul><ul><li>Present or not present </li></ul><ul><li>Bulbocavernosus Reflex </li></ul>
  12. 14. Bulbocavernosus Reflex
  13. 15. Spinal Shock <ul><li>No BCR </li></ul><ul><li>Flaccid paralysis, hypotonia, areflexia </li></ul><ul><li>Hours to days </li></ul><ul><li>+ BCR </li></ul><ul><li>Hyper reflexia, spasticity, clonus </li></ul>
  14. 16. Neurogenic shock <ul><li>Disruption of descending sympathetic outflow </li></ul><ul><li>No sympathetic response and unopposed vagal tone </li></ul><ul><li>Cardiovascular instability </li></ul><ul><li>treatment </li></ul>
  15. 17. Classification of Spinal Cord injury <ul><li>Many Grading Systems </li></ul><ul><ul><li>Impairment Based </li></ul></ul><ul><ul><ul><li>Frankel </li></ul></ul></ul><ul><ul><ul><li>ASIA </li></ul></ul></ul><ul><ul><ul><li>Yale </li></ul></ul></ul><ul><ul><ul><li>Motor Index </li></ul></ul></ul><ul><ul><li>Function Based </li></ul></ul><ul><ul><ul><li>Modified Barthel Index </li></ul></ul></ul>
  16. 18. Grading of Spinal Cord Injury
  17. 19. Grading of Spinal Cord Injury
  18. 20. Complete VS Incomplete <ul><li>Complete </li></ul><ul><ul><li>No function below level of injury </li></ul></ul><ul><ul><li>Absence of sensation and voluntary movement in S4/5 distribution </li></ul></ul><ul><li>Incomplete </li></ul><ul><ul><li>Preservation of sensation in S4/5 distribution and voluntary control of anal sphincter </li></ul></ul>
  19. 21. Incomplete cord lesion <ul><li>Determined by anatomic location of tissue injury </li></ul><ul><li>Must understand cord anatomy </li></ul><ul><li>Predictably pattern based on involvement </li></ul>
  20. 22. Incomplete cord lesion
  21. 23. Incomplete cord lesion
  22. 24. Central Cord syndrome
  23. 25. Anterior Cord Syndrome
  24. 26. Posterior cord syndrome
  25. 27. Brown Sequard Syndrome
  26. 28. Cauda Equina Syndrome <ul><li>Cord ends L1/2 disc space </li></ul><ul><li>Lower motor neuron axons </li></ul><ul><li>Perianal anesthesia, sphincter and bladder dysfunction </li></ul>
  27. 29. Pharmacological Treatment <ul><li>Modify 2 injury cascade </li></ul><ul><li>Many drugs </li></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><li>Antioxidants </li></ul></ul><ul><ul><li>Gangliosides </li></ul></ul><ul><ul><li>Opiod antagonists </li></ul></ul><ul><ul><li>Ca Channel Blockers </li></ul></ul><ul><ul><li>etc </li></ul></ul>
  28. 30. Pharmacological Treatment <ul><li>NASCIS 3 </li></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Controversial study design </li></ul></ul><ul><ul><li>Accepted Treatment Protocol </li></ul></ul><ul><ul><ul><li>Benefits </li></ul></ul></ul><ul><ul><ul><li>Contraindications </li></ul></ul></ul>
  29. 31. Radiographic Evaluation <ul><li>Trauma Series </li></ul><ul><li>Poor historians </li></ul><ul><li>Noncontiguous injury </li></ul><ul><li>AP / Lat entire spine </li></ul>
  30. 32. Radiographic Evaluation <ul><li>CT </li></ul><ul><ul><li>All cases of suspected injury to posterior elements or posterior vertebral body </li></ul></ul>
  31. 34. Radiographic Evaluation <ul><li>MRI </li></ul><ul><ul><li>Indicated in all cases of neuro deficit? </li></ul></ul><ul><ul><li>Both intrinsic and extrinsic cord injuries </li></ul></ul><ul><li>Mylogram </li></ul><ul><ul><li>Replaced by MRI </li></ul></ul>
  32. 35. Spinal Stability <ul><li>Holdsworth 1963 </li></ul><ul><li>2 column theory </li></ul><ul><li>Post. ligaments </li></ul>
  33. 36. Spinal Stability <ul><li>Denis 1983 </li></ul><ul><li>CT Scan </li></ul><ul><li>3 column theory </li></ul>
  34. 37. Spinal Stability <ul><li>Categorized major spinal injury into 4 groups: </li></ul><ul><ul><li>1. Compression Fracture </li></ul></ul><ul><ul><li>2. Burst Fractures </li></ul></ul><ul><ul><li>3. Flexion Distraction Injuries </li></ul></ul><ul><ul><li>4. Fracture Dislocations </li></ul></ul>
  35. 38. Compression Fracture <ul><li>Failure of anterior column </li></ul><ul><li>Stable: </li></ul><ul><ul><li>Tlso, hyperextension bracing </li></ul></ul><ul><li>Unstable (>50% height, >30% kyphosis, multi level) </li></ul><ul><ul><li>Posterior instrumented fusion vs non OR </li></ul></ul><ul><ul><li>Progressive deformity </li></ul></ul>
  36. 39. Burst Fracture <ul><li>Failure of anterior and middle column </li></ul><ul><ul><li>Axial compression </li></ul></ul><ul><li>+/- failure of posterior column </li></ul><ul><ul><li>Compression or tensile force </li></ul></ul><ul><li>Most common at T/L junction </li></ul>
  37. 40. Burst Fracture <ul><li>Neuro intact </li></ul><ul><ul><li><20-30 kyphosis, <45-50 canal compromise </li></ul></ul><ul><ul><li>>20-30 kyphosis, >45-50 canal compromise </li></ul></ul><ul><li>Neuro compromised </li></ul>
  38. 41. Decompression??? <ul><li>Complete </li></ul><ul><ul><li>Early stabilization </li></ul></ul><ul><ul><li>Neuro outcome not changed by decompression </li></ul></ul><ul><li>Incomplete </li></ul><ul><ul><li>Stabilization and decompression beneficial (no controversy) </li></ul></ul><ul><ul><li>How to do it (controversial) </li></ul></ul>
  39. 42. Decompression <ul><li>Posterior </li></ul><ul><ul><li>Indirect (distraction and ligamentotaxis) </li></ul></ul><ul><ul><li>Direct (transpedicle or posterolateral) </li></ul></ul><ul><li>Anterior </li></ul><ul><ul><li>Large / midline / incomplete </li></ul></ul><ul><ul><li>> 2 weeks since injury </li></ul></ul><ul><ul><li>Following posterior decompression </li></ul></ul><ul><ul><li>Partial / complete corpectomy </li></ul></ul>
  40. 46. Flexion Distraction Injury <ul><li>Bone or soft tissue? </li></ul>
  41. 47. Fracture Dislocation <ul><li>High energy </li></ul><ul><li>Most have neuro deficit </li></ul><ul><li>Goal: </li></ul><ul><ul><li>Stabilization for early mobilization </li></ul></ul><ul><li>Incomplete deficit?? </li></ul>
  42. 48. Gun Shot Wounds <ul><li>Where is the bullet? </li></ul><ul><li>Complete / incomplete? </li></ul><ul><li>Progressive deficit? </li></ul><ul><li>Bowel injury? </li></ul>
  43. 49. THE END!!!
  44. 50. Treatment Overview
  45. 51. Compression Fracture
  46. 52. Burst Fracture
  47. 53. Flexion Distraction Injury
  48. 54. Fracture Dislocation
  49. 55. Minor Injury