Spinal Cord Injuries; Thoracolumbar Fractures Donald S. Corenman, M.D., D.C.
Anatomy of the Cord and Cauda <ul><li>Spinal cord from foramen magnum to L1 </li></ul><ul><li>Conus at L1 for bowel and bl...
Physiological Anatomy of the Thoracic Spine <ul><li>Facets lie in the frontal plane- allowing rotation </li></ul><ul><li>R...
Physiological Anatomy of the Lumbar Spine <ul><li>Large discs allow more ROM </li></ul><ul><li>Facets prevent rotation </l...
Thoracolumbar Junction <ul><li>Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress riser) </li></ul><ul><li...
Mechanisms of Injury <ul><li>How much energy was imparted into the individual  (fall from height vs fall from level skiing...
Patient History <ul><li>Loss of consciousness </li></ul><ul><li>Loss of motor strength (temp or present) </li></ul><ul><li...
Patient Examination <ul><li>ABCs first, then trauma examination </li></ul><ul><li>Motor strength L1-S1(for suspected thora...
Neurologic Injury <ul><li>Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours </li></ul><ul><li...
Concordant Spinal Injuries <ul><li>3 patterns </li></ul><ul><li>Watch out for distracting injuries </li></ul><ul><li>10% o...
Classification System <ul><li>Holdsworth 2 column theory </li></ul><ul><li>Denis 3 column theory </li></ul>
Classification of Injuries <ul><li>Simple Compression (1-2 column injury) </li></ul><ul><li>Stable burst (2-3 column injur...
Compression Fractures <ul><li>Only anterior column injury </li></ul><ul><li>Middle? and post. OK </li></ul><ul><li>Ant. co...
Flexion distraction <ul><li>Easy to miss- may look benign </li></ul><ul><li>Anterior column > 50% crushed </li></ul><ul><l...
Stable Burst <ul><li>Both ant and middle column involvement </li></ul><ul><li>Minimal kyphosis </li></ul><ul><li>No neuro ...
Unstable Burst <ul><li>3 column involvement </li></ul><ul><li>Possible neuro involvement </li></ul><ul><li>Severe communit...
Chance Fractures <ul><li>Old “Seatbelt injuries” </li></ul><ul><li>Center of rotation is anterior to ALL </li></ul><ul><li...
Fracture Dislocations <ul><li>Translation in lower lumbar spine may be developmental (nly L3-S1 spondylolysthesis) </li></...
Pathological Fractures  <ul><li>Normally in patient with history of CA </li></ul><ul><li>May be hard to distinguish from i...
Insufficiency Fractures <ul><li>Normally in elderly females </li></ul><ul><li>Osteopenia/malacia </li></ul><ul><li>Bones h...
So how do you read the films? <ul><li>Look at alignment of vertebra </li></ul><ul><li>On AP- measure pedicle distance and ...
Look at alignment <ul><li>Look at how the anterior and posterior aspects of the body line up </li></ul>
Spinous Process Splaying <ul><li>Indicative of either chance (stable) or flexion distraction (unstable) injury </li></ul>
Laminar Split <ul><li>Associated with burst or flex-distraction fractures </li></ul><ul><li>Look on exam for root injuries...
Measure Kyphosis <ul><li>Measure from closest intact endplates </li></ul>
Measure Ant. and Middle Column Heights <ul><li>Compare with vertebra above and below </li></ul>
Measure pedicle distances <ul><li>Compare to vertebra adjacent to injured one </li></ul>
Anterior Column Fx Treatment <ul><li>Simple compressions can be placed in a Jewett or TLSO off the shelf brace and dischar...
Stable Bursts and Lateral Compression Fractures <ul><li>Admit- pain mgmt and neuro checks </li></ul><ul><li>Brace manageme...
Complications from Fracture <ul><li>Pneumothorax (thoracic Fxs with asso rib Fxs)/ </li></ul><ul><li>Ileus (30-60%) </li><...
Stress Testing <ul><li>Fracture that may be unstable in custom TLSO </li></ul><ul><li>Bed rest until TLSO arrives </li></u...
45 degrees vs upright
Surgical Indications <ul><li>Neurological Involvement </li></ul><ul><li>Flexion distraction injury </li></ul><ul><li>Great...
Time to healing <ul><li>Most non-surgical fractures heal within 12 weeks </li></ul><ul><li>Jewett/ TLSO on whenever uprigh...
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Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spine surgeon

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Colorado spine surgeon, Dr. Donald Corenman, M.D., D.C. (http://neckandback.com), is an expert in treating spinal cord injuries associated with a traumatic fall, sports related injury or accident. Many spine fractures include a thoracolumbar fracture, which is a break in one or more of the thoracic and lumbar vertebrae. Spine fractures can be very serious but are also treatable in many cases. This presentation on spinal cord injuries, spine fractures and thoracolumbar fractures details events that can lead to this injury, symptoms and treatment options.

Dr. Corenman is a renowned Colorado spine surgeon and also is an expert at all spine conditions and disorders including scoliosis, degenerative disc disease, spinal stenosis, sciatica, herniated disc, slipped disc and spondylolythesis. He is also a sports medicine specialist and treats athletes with traumatic sports related injuries. He recently launched his own website (http://neckandback.com) to educate patients on spine disorders and to offer second opinions to physicians and colleagues who are seeking additional information on specific spine injuries and treatment options.

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Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spine surgeon

  1. 1. Spinal Cord Injuries; Thoracolumbar Fractures Donald S. Corenman, M.D., D.C.
  2. 2. Anatomy of the Cord and Cauda <ul><li>Spinal cord from foramen magnum to L1 </li></ul><ul><li>Conus at L1 for bowel and bladder (nervi eriganties S1-S5) </li></ul><ul><li>Peripheral nerves for lower extremities start from T9-T12 </li></ul><ul><li>L1 roots start innervation of lower extremities </li></ul><ul><li>Thoracic blood supply to the cord tenuous at T10-T12 (artery of Adamkowitz) </li></ul><ul><li>Lumbar blood supply abundant </li></ul>
  3. 3. Physiological Anatomy of the Thoracic Spine <ul><li>Facets lie in the frontal plane- allowing rotation </li></ul><ul><li>Ribs resist rotation and add 3x the normal stiffness in lateral rotation </li></ul><ul><li>Kyphosis of the T spine loads the anterior column </li></ul><ul><li>Lower 2 vertebra have floating ribs and no costotransverse articulations </li></ul><ul><li>Canal size in thoracic spine relatively small </li></ul>
  4. 4. Physiological Anatomy of the Lumbar Spine <ul><li>Large discs allow more ROM </li></ul><ul><li>Facets prevent rotation </li></ul><ul><li>Spinal canal wider </li></ul><ul><li>Lordosis loads the facets </li></ul>
  5. 5. Thoracolumbar Junction <ul><li>Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress riser) </li></ul><ul><li>Lowest 2 thoracic vertebra have less extrinsic stability secondary to changes in facet orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to stabilize, therefore less rotational resistance) </li></ul><ul><li>In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into lordosis leaving the transition vertebra exposed to pure compression </li></ul><ul><li>Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2 vertebra at the thoracolumbar junction </li></ul>
  6. 6. Mechanisms of Injury <ul><li>How much energy was imparted into the individual (fall from height vs fall from level skiing vs ejection from car) </li></ul><ul><li>What was the loading force (impact onto buttocks vs impact onto flexed neck vs impact from object) </li></ul><ul><li>What was the force trajectory (beam impact vs restrained MVA vs collision with tree) </li></ul><ul><li>What was the quality of the tissue of the recipient to resist force (young adult vs senior/ preexisting pathology) </li></ul>
  7. 7. Patient History <ul><li>Loss of consciousness </li></ul><ul><li>Loss of motor strength (temp or present) </li></ul><ul><li>Sensory changes (temp or present) </li></ul><ul><li>Incontinence (at scene vs current) </li></ul><ul><li>Localized pain to other areas </li></ul><ul><li>Dyspnea (pneumothorax) </li></ul><ul><li>Past medical history </li></ul>
  8. 8. Patient Examination <ul><li>ABCs first, then trauma examination </li></ul><ul><li>Motor strength L1-S1(for suspected thoracolumbar injury) </li></ul><ul><li>Sensory C4-S3 </li></ul><ul><li>Reflexes (hyperreflexia asso. with preexisting myelopathy) </li></ul><ul><li>Rectal exam (sensory, tone and contraction) (missed conus injury) </li></ul><ul><li>Bulbocavernosis (if necessary) </li></ul>
  9. 9. Neurologic Injury <ul><li>Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours </li></ul><ul><li>Only for central injuries- not peripheral nerve injuries (conus is central injury) </li></ul>
  10. 10. Concordant Spinal Injuries <ul><li>3 patterns </li></ul><ul><li>Watch out for distracting injuries </li></ul><ul><li>10% of patients can have other spinal injuries </li></ul><ul><li>Severity of trauma- splenic/ liver and vessel injury </li></ul>
  11. 11. Classification System <ul><li>Holdsworth 2 column theory </li></ul><ul><li>Denis 3 column theory </li></ul>
  12. 12. Classification of Injuries <ul><li>Simple Compression (1-2 column injury) </li></ul><ul><li>Stable burst (2-3 column injury) </li></ul><ul><li>Unstable burst (3 column injury) </li></ul><ul><li>Flexion distraction (2 nonconjoined columns) </li></ul><ul><li>Chance (3 column failure all in tension) </li></ul><ul><li>Fracture dislocation (3 column injury) </li></ul><ul><li>Pure Dislocation (rare) (3 column injury) </li></ul><ul><li>Pathological (any and all) </li></ul><ul><li>Insufficiency (any and all) </li></ul><ul><li>Multiple contiguous fractures (nly 1-2 columns) </li></ul>
  13. 13. Compression Fractures <ul><li>Only anterior column injury </li></ul><ul><li>Middle? and post. OK </li></ul><ul><li>Ant. column less than 30% </li></ul><ul><li>No more than 10 deg kyphosis </li></ul><ul><li>No neuro injury </li></ul>
  14. 14. Flexion distraction <ul><li>Easy to miss- may look benign </li></ul><ul><li>Anterior column > 50% crushed </li></ul><ul><li>Middle column mainly intact </li></ul><ul><li>Significant spinous process widening </li></ul><ul><li>Unstable </li></ul>
  15. 15. Stable Burst <ul><li>Both ant and middle column involvement </li></ul><ul><li>Minimal kyphosis </li></ul><ul><li>No neuro involvement </li></ul><ul><li>No laminar fracture </li></ul>
  16. 16. Unstable Burst <ul><li>3 column involvement </li></ul><ul><li>Possible neuro involvement </li></ul><ul><li>Severe communition </li></ul><ul><li>Significant pedicle widening </li></ul><ul><li>Look for laminar fracture (asso. with root entrapment) </li></ul>
  17. 17. Chance Fractures <ul><li>Old “Seatbelt injuries” </li></ul><ul><li>Center of rotation is anterior to ALL </li></ul><ul><li>May be “bony” chance or purely ligamentous </li></ul><ul><li>Normally neuro intact </li></ul><ul><li>“ Bony” stable, ligamentous unstable even though all are 3 column injuries </li></ul>
  18. 18. Fracture Dislocations <ul><li>Translation in lower lumbar spine may be developmental (nly L3-S1 spondylolysthesis) </li></ul><ul><li>Always abnormal in thoracic spine (ribs) </li></ul><ul><li>Unstable </li></ul><ul><li>Normally- neuro deficit </li></ul><ul><li>Can be hidden at mid thoracic spine </li></ul><ul><li>3 column injury </li></ul>
  19. 19. Pathological Fractures <ul><li>Normally in patient with history of CA </li></ul><ul><li>May be hard to distinguish from insufficiency fracture </li></ul><ul><li>May be multiple levels </li></ul><ul><li>Fracture out of proportion to force of trauma </li></ul><ul><li>Suspicion calls for MRI and ?Bx </li></ul>
  20. 20. Insufficiency Fractures <ul><li>Normally in elderly females </li></ul><ul><li>Osteopenia/malacia </li></ul><ul><li>Bones have “washed out” appearance </li></ul><ul><li>Minimal force vectors </li></ul><ul><li>Multiple levels (normally) </li></ul><ul><li>Kyphosis greater than 70 degrees may need surgery </li></ul><ul><li>?Vertebroplasty </li></ul>
  21. 21. So how do you read the films? <ul><li>Look at alignment of vertebra </li></ul><ul><li>On AP- measure pedicle distance and look for both SP splaying and laminar fractures </li></ul><ul><li>Measure kyphosis from intact endplates </li></ul><ul><li>Measure anterior and middle column height </li></ul><ul><li>Look for retropulsion </li></ul><ul><li>High index of suspicion for other fractures </li></ul>
  22. 22. Look at alignment <ul><li>Look at how the anterior and posterior aspects of the body line up </li></ul>
  23. 23. Spinous Process Splaying <ul><li>Indicative of either chance (stable) or flexion distraction (unstable) injury </li></ul>
  24. 24. Laminar Split <ul><li>Associated with burst or flex-distraction fractures </li></ul><ul><li>Look on exam for root injuries (they become entrapped in lamina) </li></ul><ul><li>Possible association with dural tear </li></ul>
  25. 25. Measure Kyphosis <ul><li>Measure from closest intact endplates </li></ul>
  26. 26. Measure Ant. and Middle Column Heights <ul><li>Compare with vertebra above and below </li></ul>
  27. 27. Measure pedicle distances <ul><li>Compare to vertebra adjacent to injured one </li></ul>
  28. 28. Anterior Column Fx Treatment <ul><li>Simple compressions can be placed in a Jewett or TLSO off the shelf brace and discharged from the ED or office as long as pain is controlled, fracture is stable with new standing x-rays in brace and they don’t have an ileus. Cannot treat fractures above T6 without cervical extension </li></ul>
  29. 29. Stable Bursts and Lateral Compression Fractures <ul><li>Admit- pain mgmt and neuro checks </li></ul><ul><li>Brace management -Off the shelf TLSO for simple compressions greater than 30% and lateral compressions, Custom TLSO for unusual body habitis, severe bursts and pts that need stability testing. CASH for insufficiency Fxs </li></ul>
  30. 30. Complications from Fracture <ul><li>Pneumothorax (thoracic Fxs with asso rib Fxs)/ </li></ul><ul><li>Ileus (30-60%) </li></ul><ul><li>Splenic, liver and vessel injury (mechanism of injury) </li></ul><ul><li>DVT/PE </li></ul><ul><li>Decubitis </li></ul><ul><li>UTI </li></ul><ul><li>Pneumonia </li></ul><ul><li>Renal failure (hydronephrosis from cauda equina involvement) </li></ul>
  31. 31. Stress Testing <ul><li>Fracture that may be unstable in custom TLSO </li></ul><ul><li>Bed rest until TLSO arrives </li></ul><ul><li>X Rays supine/ 45deg/ 90 deg/ upright </li></ul><ul><li>Stop if neuro involvement, sig. Pain increase or sig. Increased kyphosis </li></ul>
  32. 32. 45 degrees vs upright
  33. 33. Surgical Indications <ul><li>Neurological Involvement </li></ul><ul><li>Flexion distraction injury </li></ul><ul><li>Greater than 50% canal compromise with >15 degrees kyphosis </li></ul><ul><li>>25 degrees kyphosis </li></ul><ul><li>Failure of stress testing (severe pain, angulation above 25 degrees, neuro symptoms) </li></ul><ul><li>Fracture dislocations </li></ul><ul><li>Soft tissue “chance” fractures </li></ul>
  34. 34. Time to healing <ul><li>Most non-surgical fractures heal within 12 weeks </li></ul><ul><li>Jewett/ TLSO on whenever upright </li></ul><ul><li>When healed- 4 weeks of PT for deconditioning </li></ul><ul><li>Residuals of barometric sensitive discomfort and occasionally problems with lifting </li></ul><ul><li>10 % may need to go on to surgery from instability pain </li></ul>
  35. 35. Thank You
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