7. Compression fractures.. Denis
Failure under compression of anterior column. The middle column is intact
and acts as a hinge.
8. Burst fractures.. Denis
Both end plates Superior end plate Inferior end plate
Burst rotation Burst lateral flexion
Failure under axial load of both the anterior and middle column originating at the
level of one or both end plates of the same vertebrae
9. Burst fractures..
Lateral film:
• Fracture of posterior wall cortex
• Loss of height of posterior vertebral body
• Retropulsion of fragment into canal
AP film
Increase in interpediculate distance
12. Seat-Belt type injuries..
Denis
Chance fracture
Failure of both posterior and middle columns under tension forces
generated by flexion with its axis placed in the anterior column
23. McCormack load shearing classification
A. Comminution/Involvement of vertebral body
Low scores (3-6) can be managed with
short segment posterior stabilization only
B. Displacement/ Apposition of fracture parts
High scores (7-9) require additional anterior
stabilization to prevent failure of posterior
implant
C. Deformity correction[(A+B)/2-C]
24. ASIA impairment scale
A COMPLETE: No motor or sensory function is preserved in the sacral
segments S4-S5
B INCOMPLETE: Sensory but not motor function is preserved below the
neurologic level and includes sacral segments S4-S5
C INCOMPLETE: Motor function is preserved below the neurological
level and more than half of key muscles below neurologic level have a
muscle grade less than 3
D INCOMPLETE: Motor function is preserved below the neurological
level and at least half of the key muscles below the neurologic level
have a muscle grade more than 3
E NORMAL motor and sensory functions
26. Evaluating PLC..!!
Clinical signs:
1. Palpable
interspinous
defect
2. Posterior
tenderness
X ray:
1. Kyphosis >30
degrees
2. > 50%
compression of
anterior
vertebral body
3. interspinous
spacing greater
than 7 mm than
adjacent
vertebrae
CT scan:
1. Diastasis of facet
joints
2. Spinous process
avulsion
MRI:
1. Edema in region of
PLC (T2)
2. Disruption of PLC
components (T1)
(SSL,ISL,LF,Capsule)
27. Initial management…
ATLS protocol
• Injuries impairing respiratory and circulatory
function treated with priority
• Log roll technique for manipulating the
patient
• C-spine immobilization
30. Examination
Trauma Bay
E.R.
• Information
• Mechanism
– energy, energy
• Direction of Impact
• Associated Injuries
Starts in the….
31. Does “unexaminable” mean no
examination?
NO!
• Inspect for bruising or ecchymosis
• Palpate for step-off or deformity
• Rectal Tone
• Reflex exam
– Bulbocavernosus
– Clonus/Babinski
32. Thoracolumbar spine..!!
Lateral view..:
• Vetebral Body heights
• Alignment of bodies/Angulation of spine
• Contour of bodies
• Presence of disc spaces
• Encroachment of body on canal
• Loss of vertebral body height
• Kyphosis measurement – COBB angle
33. AP view:
• Alignment
• Symmetry/ Shape of
pedicles
• Interpedicular distance
• Position of spinous
process
• Contour of bodies
34. Spinal shock..!!
Commonly used but poorly understood
term
Loss of spinal reflexes caudal to a spinal cord
injury.
First phase of response to spinal cord to injury
associated with initial flaccid paralysis below
the lesion
35. Spinal shock..!
The return of bulbocavernosus reflex marks
the resolution of spinal shock
Reflex is not always initially lost and may take
longer to recover making assessment
confusing
36. Spinal shock: Pathophysiology..!!
After resolution of shock ,variable preserved
EDEMA
functions below the injury level
1.Residual axons with sprouting collaterals
2. Denervation hypersensitivity
VENOUS
CONGESTION
DAMAGE TO BLOOD
VESSELS
MICROHAEMMORRHAGE
SPINAL SHOCK
If no motor or sensory function below the level of injury can
be documented when spinal shock ends, a complete spinal
cord injury is present, and the prognosis is poor for recovery
of distal motor or sensory function
37. Neurogenic shock..!!
Loss of symphatetic outflow related to spinal
shock
Vasodilation of the viscera and peripheries
resulting in hypotension without
TACHYCARDIA
Fluid administration Pulmonary edema
38. SCI: Complete Vs Incomplete
Complete
• No function below level of injury
• Absence of sensation and voluntary movement
in S4/5 distribution
The difference between a complete and
incomplete spinal cord injury is the PRESENCE
OF SACRAL SPARING identified by the
presence Incomplete
of ANAL SENSATION
Preservation of sensation in S4/5 distribution and
voluntary control of anal sphincter
39. Role of steroid..!!
NASCIS II & III
High doses of methyl-prednisolone
Closed, blunt spinal cord trauma presenting
within 8 hours
• Loading dose of 30 mg/kg given as bolus i/v
• Continue infusion 5.4mg /kg x 24 hours if the
patient presented within 3 hours of injury
• Continue infusion x 48 hours if the patient
presented 3 to 8 hours after injury
40. Polytraumatized spine patients..!
Perioperative and post-opeartive mortality and
morbidity were not increased by emergent stabilization
Neurologic improvement was increased and life
threatening complications were reduced
Mc Lain RF, Benson DR:Urgent surgical stabilization of spine
fractures in polytraumatized patients Spine 1999;24:1646
43. Non-operative management
• Fractures with <10% vertebral height loss do not need external
support.
• Fractures with < 40% height loss and < 25 degrees kyphosis can be
treated with a Jewett brace for 6 to 8 weeks.
• In fractures below T5, a plaster jacket or TLSO can be used.
• In higher fractures (above T5), a cervical component should be
added to the brace.
Burst fractures in brace should regularly be assessed in standing radiographs
with orthosis
Bony chance fracture if anatomically reduced can be treated with bracing
44. Burst fracture: non-operative vs operative treatment
Operative management is related with better kyphosis
correction but with similar pain and functional outcomes 4
years post-operatively
45. Laminectomy: posterior direct
decompression
Indications:
• Comminuted posterior elements causing direct neural
compression
• Epidural hematoma requiring evacuation
• Repair of dural tear associated with burst and laminar
fractures during posterior instrumentation and fusion
46. Posterior instrumentation:distraction and ligamentotaxis
Contraindications:
• Canal compromise >67%
• Delay in operative treatment for > 4 days
• Where pedicle screw insertion is not feasible
(atypical morphology, small dimension or traumatic
fracture)
Requires intact PLC
47. Indications:
• Retropulsed fragments occupying >67% canal area
ANTERIOR DECOMPRESSION AND FUSION
• Extensive vertebral body comminution with
significant kyphotic deformity
Greater neurologic improvement as compared to
posterior or posterolateral decompression
• Delay in operative treatment for 4 days
• Return of normal bowel and bladder control achieved
more frequently
• Traumatic disc herniations causing symptomatic
cord or root compression
• Even in cases of long-standing compression after fracture
modest recovery
Patients with incomplete deficits (spinal cord or cauda equina) are
ideal candidates because they have greater chances for neural
recovery
48. Combined anterior and posterior
methods
• When canal is compromised circumferentially
• Severe coronal or sagittal plane deformity
(>40 degrees)
• Structural augmentation is deemed
necessary(multiple contiguous levels of
injury, poor bone quality or osteoporosis)
49. Kyphosis even in absence of neurological
deficit likely to progress.
>30 degrees : late neurological deficit
Burst fracture in thoracolumbar region (T11-L2) with
neurological deficit from a retropulsed fragment should
undergo anterior decompression and fusion as a solitary
procedure or in combination with a posterior approach
However, relative indications and contraindications depending
Isolated upon (LMNOPS)
anterior procedures L2 and below to
be Location
avoided: Pseudo-arthosis and vascular
concern
Mechanism
Neurology
Open vs closed
Stability
Posterior element disruption and osteoporotic
bone: additional posterior intrumentation
50. Vertebroplasty and Kyphoplasty..!!
Indications:
• Osteoporotic VCF not responding to conservative management
• Spinal metastatic lesions & fractures
• Hemangiomas
Goal of vertebroplasty is to improve strength and stability
Goal of Kyphoplasty is to restore vertebral body height and stability. The
use of baloon creates a void for cement placement under lower pressure
and thus results in lower incidence of cement extravasation
51. Can be safely done in patients with refractory pain to
conservative treatments.
56. Complications ..!!
Transient increase in pain in the injected level
Cement leakage
Pulmonary embolism(marrow,cement,air)
Infection
57. Vertebroplasty vs kyphoplasty: Debate
continues….
Kyphoplasty : more controlled procedure with
height restoration and less chances of cement
extravasation
Vertebroplasty: faster, more straightforward,
cheaper that has not shown to give inferior results.
Increased rates of cement migration doesn’t
significantly results in increased morbidity
58. DAMAGE CONTROL SURGERY : 3 PHASE APPROACH
Establish rapid
control of
hemorrhage
Identify major
injuries
1
Stabilize major
fractures
Reduce
dislocated joints
Decontaminate
open wounds
2
Once normal
physiology is
restored ,
definitive surgical
repairs
3
59. Posterior internal
stabilization of
thoracic or lumbar
trauma
Anterior decompression or
complex stabilization
procedures as allowed by
patient’s physiologic
condition
Window of opportunity
Definitive surgery electively scheduled for
experienced spine surgeon
General care: ventilatory care, pressure care , bowel
bladder management, thromboembolic prophylaxis,
control of infections . Minimize systemic insult
to the patient
60. The ability to provide good internal fixation with minimal soft
tissue disruption is the key point of the AO principles of
treatment of extremity fractures. SPINAL FRACTURES ARE NO
DIFFERENT.
Primary role: restore or augment posterior tension band
APPLICATIONS:
1.Axial compression injuries (compression/burst #)
Supplemenatal posterior fixation of anterior corpecectomy when required for decompression or
anterior column support.
As a primary procedure : MIS decompression and radiculopathy
2.Flexion-distraction injuries
Pure bony Chance Fractures allowing direct osteosynthesis rather than spinal fusion
3.Damage control Orthopaedics
Temporary stabilization in patients with multiple traumatic injuries who might not be
physiologically able to tolerate definitive open procedure early in their hospitalization
4.When bracing of stable fractures is difficult or contraindicated
As an internal splint for patients associated with chest trauma, significant respiratory
compromise , morbid obesity.
Concept of MIS procedures:
• Avoid need for large surgical dissection resulting in less
denervation and muscle atrophy as well as less damage to stabilizing
structures such as facet joints.
• Reduce the morbidity associated with standard open procedures
61. Surgical technique..!!
Properly aligned AP and Lateral images
Flat supeior end plate (only one end
plate shadow)
Pedicles just below superior end plate
and spinous processes centered
between the pedicles
Superior end plate flat
Single posterior vertebral body shadow
Superimposed pedicles
62. Surgical technique…!!
1 cm vertical incision lateral to pedicle
Insertion of Jamshidi needle:
Starting point: supero-lateral quadrant of pedicle , advanced
down untill it appears to be at posterior border of vertebral
body on lateral image.
Tip of needle within medial half of pedicle on AP image
Guide wire
Dilators: Largest dilator as a working tube
Cannulated pedicle screw over guide wire
64. VIDEO-ASSISTED THORACIC SURGERY(VATS)
Despite a long learning curve and technical
demands it has several advantages
• Better cosmesis
• Adequate exposure from T2-L1
• Less morbidity
• Better illumination, magnification
Contraindications:
• Inability to tolerate single lung ventilation
• Emphysema, acute respiratory insufficiency
• Previous thoracotomy
70. Rehabilitation..!!
Bed sore prevention
• Posture change every 2 hourly
• Air mattress
• Use of pillows and foam wedges at bony
prominences
High protein diet
Debridement of established sore to fasten
healing
