Thoracic and lumbar region vertebral injuries

1. Presenter: Dr Yeshwanth Mohan
Moderator: Dr Joseph kartheek sir
Chairperson: Dr Srinivas Rao sir

23. Pars defect
(a) X-ray shows L5 pars defect;
(b) corticalization and 'rounding off of
the fracture on CT indicates
chronicity and non-union.
(c) Occasionally the pars defect is
visible on MRI scan, but MRI is better
served to evaluate disc degeneration
and other causes of pain such as
nerve root compression.

25. Any interruptions in the lines drawn
along the anterior or posterior aspects
of the vertebral bodies may be
suggestive of a break in the posterior
vertebral line

26. CT:

28. Due to disc or
Fracture Or
Epidural hematoma

30. DENNIS CLASSIFICATION
SYSTEM
A.COMPRESSION
A. Both end plates
B. Superior end plate
C. Inferior end plate
D. Both end plates intact

31. DENNIS CLASSIFICATION SYSTEM
B.BURST TYPE
A. Both end plates
B. Superior end plate
C. Inferior end plate
D. Rotational deformity
E. Lateral translation
C.Flexion distraction type
A. Bony involving one segment
B. Soft tissue involving one
segment
C. Bony involving both segments
D. Soft tissue involving both
segment

32. A0/MAGERL CLASSIFICATION
A. COMPRESSION
B. DISRUPION
C. ROTATION

33. A1: Impaction
A2: Split
A3: Burst
B1: posterior ligamentous
B2: posterior osseous
B3: anterior through disc
C1: Type A+ torsion
C2: Type B+ torsion
C3: Torsion shear
A0/MAGERL CLASSIFICATION
A. COMPRESSION
B. DISRUPION
C. ROTATION

34. LOADING BEARING FRACTURE
CLASSIFICATION

36. Middle column provides the greatest stability

37. Fracture classification

39. Wedge-compression fractures
(a) Central compression fracture of the
vertebral body and
(B) anterior wedge compression fracture
with less than 20% loss of vertebral body
height. If the fracture is stable without
injury to the posterior ligamentous
complex,
(C,D)it can be managed conservatively
with 8-12 weeks in a plaster jacket' or a
lightweight removable orthosis. .
(E,F)Unstable compression fractures may
need posterior internal fixation if there is
disruption of the PLC

42. UNSTABLE BURST FRACTURE:
Loss of height >50%
Kyphotic deformity >30 degrees
Substantial posterior column injury
Progressive deformity
Progressive neurological deficit

45. (a,b)L1 burst fracture in an
18-year-old female, CT
demonstrates a large
interspinous gap (PLC
staption) and fragments
retropulsed into the canal.
(c)Simple posterior fixation
with Shantz screws allows
kyphosis correction and
distraction with indirect canal
decompression and anterior
column restoration
(d,e) Persistent neurological
symptoms prompted repeat
CT showing remaining
significant fragment in the
canal.
(f) Anterior decompression
and reconstruction with an
expandable cage

46. DENNIS BROWN
C.Flexion distraction type
A. Bony involving one segment
B. Soft tissue involving one segment
C. Bony involving both segments
D. Soft tissue involving both segment

49. a. This innocuous-looking lamina fracture is a Chance fracture.
b. The injury forces run posteriorly, from the lamina through the disc
anteriorly, making it a mixed bony-ligamentous Chance injury.
C,d: Surgical stabili zat on to posteriorinstrumentation

53. Thoraco lumbar injury classification and severity score (TLICS)
ALGORITHM

66. DECOMPRESSION
• The role of surgical decompression is controversial.
• The spinal canal in the thoracic area is small, and the cord blood
supply is sparse; significant neurologic injury is common with severe
fractures and dislocations in the thoracic spine.
• Fractures or fracture-dislocations in the lumbar region may result in
marked displacement and still cause little or no neurologic deficit.
• Not only is the canal larger in this lumbar area, but also the spinal
cord ends at approximately the first lumbar vertebra, and the cauda
equina is less vulnerable than the cord to injury.

67. • After many studies, authors concluded that conservative
management of thoracolumbar burst fractures is followed by a
marked degree of spontaneous redevelopment of the deformed
spinal canal, which supports conservative management of
thoracolumbar burst fractures in selected patients.
• The treatment of thoracic and lumbar burst fractures must be
individualized, and canal compromise from retropulsed bone
fragments is not in itself an absolute indication for surgical
decompression.

68. • Canal compromise without ongoing residual neural tissue
compression, which does not correlate with neurologic deficit, must
be distinguished from ongoing neural compression, which does
correlate with neurologic deficit.
• Compression of the neural elements by retropulsed bone fragments
can be relieved indirectly by the application of distractive forces
through posterior instrumentation or directly by exploration of the
spinal canal through a posterolateral or anterior approach.

69. • Severely comminuted fractures with multiple pieces of bone pushed
into the spinal canal may not be completely reduced by distraction
instrumentation.
• If the reverse cortical sign is present, the posterior longitudinal
ligament is likely not intact and ligamentotaxis will not occur.

70. • The posterolateral technique for decompression of the spinal canal is
effective at the thoracolumbar junction and in the lumbar spine.
• This procedure involves hemilaminectomy and removal of a pedicle
with a high-speed burr to allow posterolateral decompression of the
dura along its anterior aspect.

71. • In the thoracic spine, where less room is available for the cord, this
technique involves increased risk to the neural elements.
• The anterior approach allows direct decompression of the thecal sac
but is a less familiar approach to many surgeons.
• Visceral and vascular structures may be injured, and this approach
carries the greatest risk of potential morbidity. In addition, anterior
decompression and placement of a strut graft or cage provides
modest immediate stability to the fracture if the anterior longitudinal
ligament is preserved.
• To have adequate stability, anterior fixation is needed if anterior
decompression is done.

72. • When anterior decompression and strut grafting or cage placement are
performed in the presence of posterior instability, posterior
instrumentation and fusion can be done to improve stability.
• This combined posterior and anterior fixation allows for shorter constructs.
• At this time, we favor early posterior instrumentation with indirect or
posterolateral direct decompression in most patients requiring operative
treatment.
• If significant residual neural compression (not mere canal compromise)
exists post- operatively in a patient with an incomplete spinal cord injury,
an anterior decompression and reconstruction are done if no significant
clinical improvement over a reasonable period of time is noted.

73. • Posterior decompression must be carefully considered in all patients
with posterior vertical laminar fractures because of the increased
frequency of dural tears with exposed nerve roots and the possibility
of severe post- traumatic arachnoiditis.
• For patients with severe but incomplete spinal cord injuries at the
T12 to L3 levels, anterior decompression and reconstruction is the
favored treatment. A minimally invasive approach is used when
possible.
• Patients treated with posterior surgery had a statistically significant
lower operative time and blood loss.

74. • Posterior surgery was found to be as effective as anterior or
anteroposterior surgery when treating unstable thoracolumbar burst
fractures. Of the three procedures, posterior surgery takes the least
time, causes the least blood loss, and is the least expensive.

75. THORACIC AND LUMBAR SEGMENTAL
FIXATION WITH PEDICLE SCREWS
• A fully radiolucent table is used. Position
the patient to allow for postural reduction
when placed prone using a four-post frame
or chest rolls placed transversely or
longitudinally.
• Obtain images of the spine to confirm the
degree of postural spinal reduction after
positioning and determine the limits of the
incision.
• Prepare and drape the thoracolumbar
spine.

76. • Make a score incision from one spinous process
above the area to be instrumented to one
spinous process below the area to be
instrumented.
• Infiltrate the incision, subcutaneous tissue, and
muscle with epinephrine solution (1 mg in 500
mL of injectable saline).
• complete the incision sharply.
• Dissection with electrocautery.
• Delineate the fascia for later closure.
• Continue the dissection through the fascia and
subperiosteally expose the necessary levels after
radiographically confirming the level.

77. • Use electrocautery to release the muscle from the bone.
• Watch for evidence of a cerebrospinal fluid leak or the presence of
free nerve roots.
• Continue to widen the dissection to the tips of the transverse
processes in the thoracic and lumbar spine.

78. THORACIC PEDICLE SCREW PLACEMENT
• Obtain a true anteroposterior view
of the vertebra.
• On this view the superior endplate
should appear as a sharply defined
line with the superior most portion
of the pedicle just rostral to the
endplate. The pedicles should be
symmetric with one another, and
the tip of the spinous process should
be superimposed in the midline of
the vertebra.

79. • Position a burr near the superior medial
base of the transverse process such
that it is superimposed at the 2 o’clock
position on the right pedicle or the 10
o’clock position on the left pedicle on
the AP view. Use the burr to penetrate
the cortex in this location.
• Advance the pedicle probe, such that it
crosses from the lateral cortex of the
pedicle to the medial cortex of the
pedicle.

80. • The trajectory of the probe should be
chosen such that the tip of the probe
rests at the medial border of the pedicle
image after advancing to a depth of 18
mm.
• This can be confirmed on lateral image
intensifier views.

81. • It is not necessary to advance into the anterior third of the body.
• Use a small ball-tipped probe to sound the pedicle for cortical
breaches in all four quadrants and to confirm the vertebral body was
not penetrated anteriorly.
• Place the largest diameter screw that the pedicle will accept. This can
be determined from the AP view of the pedicle. The most narrow
pedicles are typically at the T4 to T6 levels.

82. • If the pedicle is too narrow to accept even
the smallest diameter screw, an “in-out-in”
path of the pedicle probe is safe.
• It will enter the bone and then exit the
bone into the costovertebral joint and
reenter through the lateral pedicle wall to
enter the vertebral body.
• This allows for safe screw placement,
although screw purchase is less than with
an intact pedicle.

83. LUMBAR PEDICLE SCREW PLACEMENT
• In the upper lumbar segments, the same
technique is used especially at L1 and L2. For
the lower levels with larger pedicles, we
usually prefer to place the lumbar screws
using a lateral image
• Obtain a true lateral view of the vertebra.
• Place the burr just posterior to the junction
of the transverse process and the superior
articular mass in line with the bisector of the
pedicle.

84. • Penetrate the cortex at this location, near
the junction of the pars interarticularis and
the superior articular mass. Decorticating
the transverse process before screw
insertion improves the effectiveness of
decortication and enhances the fusion bed.
• Use the cortical opening as the starting
point and advance a pedicle probe into the
pedicle.
• Direct the probe more medially at the lower
lumbar levels (usually 20 to 30 degrees at L5
and 0 to 10 degrees at the L1 level).
• Advance the probe to the anterior third of
the body.

85. • Use a small ball-tipped probe to sound the
pedicle in all four quadrants and to palpate the
vertebral body laterally and anteriorly to make
sure there are no cortical breaches.
• The largest diameter screw the pedicle will
accept (up to a 6.5-mm screw) is typically
placed. Larger screws can be placed but little is
usually gained, and the larger screws are more
likely to cause pedicle fracture and loss of screw
purchase.
• Place the screw after placing the bone graft onto
the de- corticated surface.
• Adjust the image intensifier to obtain an “end
on” view of the screw to verify radiographically
that the screw is within the pedicle.

86. ROD PLACEMENT
• Direct decompression, if needed, is completed
before rod placement.
• Cut the rod, allowing some excess length if
distraction will be applied.
• Contour the rod to assist in achieving reduction.
This usually means undercontouring the
kyphosis to help reduce the kyphotic deformity
as the rod is reduced into the screw “tulip.”
• Reduce the rod to the screws, using multiple
reduction instruments if needed to avoid
excessive pull on any individual screw, and insert
the blockers into the screw “tulip” loosely at
each level.

87. • Apply distraction or compression as
the injury dictates and complete in
situ rod contouring if necessary to
reduce the fracture.
• Confirm adequacy of the reduction
on anteroposterior and lateral
views.

88. • Decorticate the posterior elements and
transverse processes at each
instrumented level and place the bone
graft onto the decorticated surface.
• Close the fascia over a drain with
suture passed through the spinous
processes.
• Close remaining layers using a
subcuticular skin closure.

89. Post operative care
• Postoperatively a CT scan can be obtained to verify screw position
and to determine if there is any residual neural compression in a
patient with a neurologic deficit.
• The patient is mobilized on the first postoperative day with an
orthosis unless other injuries preclude this. The orthosis is continued
8 to 12 weeks, depending on resolution of pain and radiographic
follow- up for evidence of healing and maintenance of spinal
alignment.

90. ANTERIOR STABILIZATION
• Approach for anterior reconstruction varies considerably by level of
injury (T4 to L3)
• The primary advantages of an anterior approach are direct
decompression and restoration of the axial load-bearing portion of
the spine with a strut device.
• With restoration of some load bearing through the anterior spine,
shorter constructs are possible that can allow preservation of more
normal motion segments in some clinical settings.

91. • Correction of kyphosis also is enhanced with a direct anterior
approach.
• The anterior construct can consist of bone graft or a metallic cage
that may be adjustable with respect to length in conjunction with a
plate or rod device with screw fixation.
• Additionally, with a direct anterior decompression of the spinal canal,
it is possible to completely remove retropulsed fragments of bone or
disc material.

92. • Even with the advances, injuries with posterior ligamentous complex
disruption should be considered very carefully before recommending
anterior-only stabilization.
• Anterior fixation devices consist of a plate or paired rods secured to
the spine with bone screws or bolts that have a threaded portion
extending through the plate and accepting a nut to capture the plate.
• Most systems have two fixation points at each vertebral level to
better resist flexion.

93. ANTERIOR PLATING
• After induction of anesthesia, place
the patient in a right lateral decubitus
position, with appropriate padding to
allow for a left-sided thoracic or
retroperitoneal approach.
• It is important that the patient remain
in a true lateral position so screw
trajectory can be correctly
determined.
• Complete routine skin preparation
including the iliac crest if this will be
used as a graft.

94. • Use the image intensifier to locate the intended incision directly
lateral to the injured segment.
• In the thoracic spine this is typically through the rib that is two levels
above the injured level.
• For lumbar injuries a retroperitoneal approach through the 10th or
11th rib usually is used.

95. • Make an incision overlying the rib and dissect down to the rib
periosteum with electrocautery.
• Elevate the periosteum circumferentially around the rib and elevate
the neurovascular bundle from the inferior rib margin.
• Resect the portion of the rib necessary for access to the spine.
• Make sure to remove enough rib posteriorly.
• The rib can be used along with the resected vertebral body for bone
graft and should be maintained.

96. • For a transthoracic approach (T4 to T10),
enter the pleural space and retract the
lung with a wet laparotomy sponge.
Shape a malleable retractor to maintain
the operative field.
• Identify the aorta by palpation and ligate
the segmental vessels 1 cm from the
aorta. Divide between ligatures at the
injured level. Vascular clips can be used to
supplement the ligatures.
• Ligating the artery of Adamkiewicz, which
has a variable location, is an inherent risk
of this procedure.

97. • For a retroperitoneal approach (T11 to L3),
maintain the pleura intact if possible and
enter the retroperitoneal space, dissecting
bluntly down to the iliopsoas.
• Use a wet laparotomy sponge and a
malleable retractor to maintain the
operative field. Ligate the segmental
arteries at the injured level and the level
above and below 1 cm from the aorta.
• The artery of Adamkiewicz can be as low as
L2.
• Elevate the iliopsoas from the spine from
the anterior margin, taking care to avoid the
genitofemoral nerve and ureter.

98. • Incise the discs above and below the injured segment and remove
most of the disc, leaving the anteriormost disc and anterior
longitudinal ligament intact.
• Using the space created by removing the discs, remove the vertebral
body in its midportion with a rongeur.
• An osteotome is useful to remove the posterior bone, which is
preserved for graft.
• After creating a cavity in the midportion of the body, remove the
posterior bone by progressively thinning the remaining bone and
pulling it into the created defect across the canal to the level of the
far pedicle medial wall to achieve a satisfactory decompression.

99. • Clean the two endplates of all cartilage and
soft tissue. A surgical assistant should apply
firm, anteriorly directed pressure over the
spine to correct kyphosis.
• Obtain a bone graft or cage device of the
desired length. Fill allograft humeral shaft or a
metallic cage with the available bone from the
operative field.
• With kyphosis correction maintained, impact
the strut into place. The strut should be
secure once it is in position, but avoid
excessive length because it increases the risk
of mechanical failure through subsidence.

100. • Determine the appropriate plate length and
position the plate.
• Determine the transverse dimension of the
intact vertebra so appropriate-length screws
or bolts can be used for bi- cortical fixation,
depending on the device used.
• Identify the entry points of screws.
• Place the first screw or bolt in the posterior
position of the caudal vertebra.
• Take care when determining placement of
this screw to drill and place the screw parallel
to the end plate and directed away from the
spinal canal.

101. • Place the adjacent screw again parallel to
the end plate and angled slightly
posteriorly.
• Place the screws at the cephalad level
similarly.
• Once all screws are secured, obtain
hemostasis and close the wound in a
routine manner over suction drains or
chest tube as appropriate.

103. Post operative care
• The patient is kept at bed rest until the chest tube is removed. The
patient is then mobilized in a TLSO that is worn at all times when the
spine is more vertical than 30 degrees from the horizontal plane. The
TLSO is used for 12 to 16 weeks, depending on the clinical course.

107. THANK YOU