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CME Orthopedic.pptx
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  2. 2. OUTLINE ▪ Quick revision ofanatomy ▪ How to read Xray, CT Scan and MRI ▪ Types for spinefracture ▪ AO Classification ▪ Brief idea onmanagement
  3. 3. ANATOMY • 33 Vertebrae • 24 are movable - 7Cervical ❖ Atypical :1st, 2nd and 7th cervical vertebrae ❖ Typical :3rd, 4th,5th and 6th cervical vertebrae
  4. 4. VERTEBRAE CERVICAL TYPI CAL CERVICAL VERTEBR AE ❖ Body: small and broader from side to side than before backward ❖ Vertebral foramen:Larger than body, triangular in shape ❖ Bifid spinous process
  5. 5. ATYPICAL CERVICALVERTEBRAE C1- Atlas □ No body and no Spinous Process □ Consists of anterior and posterior arches and 2 lateralmasses □ SuperiorArticular Facets are kidney shaped
  6. 6. C2- Axis □ The strongest cervicalvertebra □ Odontoid process = Dens □ Has two large, flat surface superior articular facets □ Has a large Bifid spinous process that can be felt deep in the nuchal groove C7 □ Characterized by general structure of vertebra but has long spinous process and notbifid □ Large transverse process
  7. 7. CERVICAL X-RAY INTERPRETATION ❖ 3 standard views: Lateral, AP and Odontoid peg view (open mouth view)
  8. 8. Systemic Approach: 1.Coverage : All cervical vertebrae are visible from the skull base until T1 2. Alignment: 4 longitudinallines ❖ Anterior Vertebral Line: line of theanterior longitudinal ligament ❖ Posterior Vertebral Line: line ofthe posterior longitudinal ligament ❖ Spinolaminal Line: line formed by the anterior edge of the spinous processes ❖ Spinous Process Line 3. Bones: vertebral body height 4.Spacing: Discs and spinous process (should be approximately equal in height)
  9. 9. 1. Alignment: by tracing the anterior and posterior margins of the vertebraeand of the spinous process, normal lumbar lordosis 2. Bones: vertebral body height, outline of the bone/fracture / bony erosion (lytic or sclerotic) 3. Spacing: Disc should be equal in height 4. Pedicle:look for widening or displacement of the pedicle (which indicative of burst fracture), THORACOLUMBAR XRAY
  10. 10. Anterior Column: - Anterior half of vertebralbody - Anterior part ofintervertebral disk - Anterior longitudinal ligament Middle Column: - Posterior half of vertebralbody - Posterior part ofintervertebral disk - Posterior longitudinal ligament Posterior Column: - Pedicle - Facet joints - Posterior body arches - Interspinous ligament - Supraspinous ligament 🡪 Important to establish whetherthe injury is stable or unstable THREE COLUMN CONCEPT
  11. 11. 1. COMPRESSION FRACTURE ◼ Mechanism of injury: due to severe spinal flexion ◼ Traumatic /Non-traumatic ◼ Example: Fall from height on the heels or buttock ◼ Commonlyno neurological deficit
  12. 12. X-RAY FEATURES ✔ Reduce height of the anterior vertebral body ✔ Anterior superior endplate fracture of vertebral body ✔ Wedge shape appearance ✔ Posterior cortex intact
  13. 13. 2. BURST FRACTURE ❑ Mechanism due to severe axial compression may ‘explode’ the vertebral body, ❑ shattering the posterior part of vertebral body and extruding fragments of bone into the spinal canal ❑ Example: fall from height in erect position, landing on the feet ❑ Usually unstable ❑ In cervical spine: this fracture commonly cause neurological deficit ❑ In thoracolumbar spine: this force rarely neurological deficit (due to wide canal at this level)
  14. 14. X-RAY FEATURES - Both anterior and middle column are disrupted - A large vertebral body fragment is displaced anteriorly - Retropulsion of bone into
  15. 15. ❖ Widening of the interpedicular distance ❖ Seen in 80% of burst fracture
  16. 16. JEFFERSON FRACTURE ▪ burst fracture of the atlas C1 ▪ described as a four-part fracture with double fractures through the anterior and posterior arches ▪ Mechanism injury : Axial loading along the axis of the cervical spine (diving headfirst into shallow water) ▪ Radiographs will show asymmetry in the odontoid view ▪ treated conservatively (hard collar immobilization)
  17. 17. HANGMAN FRACTURE ▪ known as a hyperextension injury causing bilateral pedicular fracture of C2 ▪ most common symptom : neck pain following a fall or motor vehicle accident ▪ can be very unstable ▪ leading to increasing deformity that can result in serious damage to the spinal cord or progressive pain. ▪ Younger age group average ▪ Tx :immobilization and surgical intervention
  18. 18. CHANCE FRACTURE ❖ Also known as Flexion-Distraction ❖ Mechanism of injury: combined flexion and posterior distraction ( seen typically in severe seat belt injuries) ❖ It is an unstable injury because posterior and middle columns fail under tension and anterior column fails under compression ❖ Associated injury with GI injuries ❖ MRI to evaluate injury of posterior elements
  19. 19. HOWTO READASPINECT: ABCS - CT is often used to image fractures, ligament injuries and dislocations 1. Adequacy of image and alignment Assess spinal alignment on the scout and midsagittal images. The normal lumbar spine has a smooth lordosis. Relative lumbar kyphosis may be due to degenerative disc disease or anterior vertebral collapse
  20. 20. Kyphosis due to vertebral collapse of L3
  21. 21. 2. Bone -Review each vertebral body in the bone window, scrolling down the vertebral column - Look for changes in bone density. -midsagittal views, ensure the vertebral body is square and of similar height to the adjacent vertebrae 3. Cartilage -ensure that there is no loss of disc height, as compared with adjacent levels, and look for endplate fractures or abnormalities -Further MRI can be requested if there is any clinical suspicion.
  22. 22. 4. Soft tissue and spinal canal - Look in the spinal canal, particularly in the axial and sagittal views, to detect any abnormalities such as retropulsed bone fragments from burst fractures Burst fracture with retropulsion into the spinal canal. Spinal cord injury should be suspected and further imaging such as magnetic resonance imaging may be required.
  23. 23. HOW TO READ MRI SPINE There are two basic types of MRI images which differ by the timing of the radiofrequency pulses, named T1-weighted images and T2-weighted images. T1 images highlight FATty tissue.T2 images highlight FAT ANDWATER within tissues.
  24. 24. Left: MRI lumbarspine sagittal T1 image, Right:MRI lumbarspine sagittalT2
  25. 25. 1. The Central Canal in the MRILumbar Spine
  26. 26. 2. Vertebral body
  27. 27. 3. Alignment
  28. 28. 4. Intervertebral Discs
  29. 29. Axial views
  30. 30. AO Classification ◼Spine thoracolumbar classification system consists of only three classes of thoracolumbar injuries.
  31. 31. •A0: no or clinically insignificant fractures of the spinous or transverse processes •A1: also known as wedge compression injuries; they involve a single anterior or middle endplate of the vertebral body without the involvement of the posterior aspect Type A Compression Injury
  32. 32. •A2: also known as split or pincer type injuries; they involve both endplates without the involvement of the posterior wall •A3: also known as incomplete burst injuries; they involve a single end plate along with the posterior vertebral wall; a vertical laminar fracture is usually also present (insufficient to qualify as a tension band failure) •A4: also known as complete burst injuries; they involve both end plates along with the posterior vertebral wall and are also often associated with a laminar fracture (insufficient to qualify as a tension band failure)
  33. 33. B type : Distraction Injuries •B1: also known as Chance fractures or pure transosseous tension band disruption; they disrupt the pedicles and spinous process in a single vertebral level; a distracted horizontal fracture through the vertebral body is often but not necessarily present •B2: also known as osseoligamentous posterior tension band disruption; they involve an intervertebral body level with disruption to the posterior tension band ligaments with or without involving the posterior bones; a type A fracture is often present and should be specified separately
  34. 34. Type C injuries involve displacement in any direction. No subtypes are present as there are numerous possibilities of dislocating fractures.
  35. 35. Manageme nt
  36. 36. • The TLICS consists of three independent parameters: • The integrity of the posterior ligamentous complex plays an important role in the TLICS.
  37. 37. Management of spinal injuries • Objective: – Preserve neurological function – Relieve neural compression – Restore the spine alignment – Stabilize the spine – Rehabiitate the patient • Indication for urgent surgical stabilization – Unstable fracture with neuro deficit – Unstable fracture in patient with multiple injuries
  38. 38. Burst fracture Non operative - Ambulation as tolerated with or without thoracolumbosacral orthosis Indications •patients that are neurologically intact and mechanically stable •posterior ligament complex preserved •vertebral body has lost < 50% of body height •TLICS score = 3 or lower
  39. 39. Burst fracture Operative Surgical decompression & spinal stabilization Indications • neurologic deficits with radiographic evidence of cord/thecal sac compression • unstable fracture pattern as defined by – injury to the Posterior Ligament Complex (PLC) – progressive kyphosis • TLICS score = 5 or higher
  40. 40. Chance fracture • Non operative – Immobilization in cast or TLSO • Neurologically intact patient with – Stable injury patterns with intact posterior elements – Bony chance fracture • Operative – Surgical decompression and stabilization • Pt with neurologic deficit • Unstable spine with injury to the posterior ligament (soft tissue – Chance fracture)
  41. 41. Compression fracture • Non operative – Observation, bracing and medical management • PLL intact even if >30 degrees kyphosis or >50% loss of vertebral body height
  42. 42. Compression fracture • Operative – Vertebroplasty – Kyphoplasty • Patient continue to have severe pain symptoms after 6 weeks of non operative treatment – Surgical decompression and stabilization • Progressive neurologic deficit • PLL injury and unstable spine
  43. 43. Take Home Message -Dont forget regarding line on spine Xray -MRI T1 FATT2 FAT WATER -Column concept -TLICS score 4 and more surgical intervention
  44. 44. Referenc es ri /t1_and_t2_images and-t ools/ao-spine-classification-systems
  45. 45. Thank You