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![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]](https://image.slidesharecdn.com/finalpresentation-141121124416-conversion-gate02/85/thoracolumbar-spinal-trauma-23-320.jpg)
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Similar to thoracolumbar spinal trauma
thoracolumbar spinal trauma
- 1. Management of thoracolumbar spine injuries Dr. Rishi Ram Poudel
- 3. Cause of injury..Indian Scenario..!! fall from height RTA Violence Gun shot injuries 52.3 38.4 5 4.3 Upendra B, Khandwal P, Chowdhury B, Jayaswal A: Correlation of outcome measures with epidemiological factors in thoracolumbar spinal trauma. Indain J Orthop 2007 Oct;41(4):290-4.
- 4. Why dorsolumbar junctionmore succeptible?? Location between the stiff kyphotic dorsal spine and more mobile lordotic lumbar spine
- 5. Dennis three columnconcept..
- 6. Middle column providing greatest mechanical stability
- 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.. Lateralfilm: • Fracture of posterior wall cortex • Loss of height of posterior vertebral body • Retropulsion of fragment into canal AP film Increase in interpediculate distance
- 10. Unstable burst fractures.. • Loss of height >50% • Kyphotic deformity >30 degrees • Substantial posterior column injury • Progessive deformity • Progessive neurological deficit
- 11. Reason for Kyphoticdeformity..biomechanics..!!
- 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
- 13. Fracture dislocations.. Flexion-rotation Denis Slice fracture
- 14. Fracture dislocations.. Sheartype fracture dislocation Denis Postero-anterior shear injury with floating lamina Anterio-posterior shear injury
- 15. Fracture dislocations.. Flexion-distraction Denis Tear of anterior annulus fibrosus and stripping of ALL during subluxation
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- 17. AXIAL-COMPRESSION MECHANISM MorphologicAnatomic Neurologic Therapeutic Compression Anterior column compressed Intact Orthosis fracture Stable burst Retropulsed middle column Posterior ligament intact Intact Compromised Orthosis Anterior decompression/stabilization
- 18. FLEXION-COMPRESSION MECHANISM MorphologicAnatomic Neurologic Therapeutic Wedge fracture Anterior column collapse (< 40% VB height) Kyphosis >30º Intact Intact Orthosis Posterior instrumentation Unstable burst Kyphosis 20-30º <50% canal compromise Kyphosis > 30º >50% loss of anterior VB height >70%canal compromise Marked vertebral body comminution Intact Intact/Compromised Orthosis vs posterior segmental instrumentation in distraction and extension Anterior decompression/stabilization Consider combined anterior and posterior stabilization
- 19. FLEXION-DISTRACTION MECHANISM MorphologicAnatomic Neurologic Therapeutic TRUE CHANCE Tensile injury through bone Intact Orthosis if anatomically reduced LIGAMENTOUS CHANCE Tensile injury through ligament Intact/Compromised Posterior reduction and compression instrumentation
- 20. EXTENSION MECHANISM MorphologicAnatomic Neurologic Therapeutic ANTERIOR OPENING OF DISC Tensile failure of ALL and anterior annulus Intact Orthosis FRACTURE DISLOCATION Laminar fracture Anterior and middle column ligament disruption Posterior vertebral body translation Intact/Compromised Posterior decompression, reduction and instrumentation
- 21. ROTATION AND SHEARMECHANISM Morphologic Anatomic Neurologic Therapeutic FRACTURE DISLOCATION Facet fractures Three column disruption Vertebral translation Intact/Compromised Posterior reduction and instrumentation
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- 23. McCormack load shearingclassification 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
- 25. Thoracolumbar Injury Classificationand Severity Score(TLICS)
- 26. Evaluating PLC..!! Clinicalsigns: 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… ATLSprotocol • Injuries impairing respiratory and circulatory function treated with priority • Log roll technique for manipulating the patient • C-spine immobilization
- 28. Systematic Approach 1 2 3 4 5
- 29. Systematic Approach Missa Step and you are nowhere..!!
- 30. Examination Trauma Bay E.R. • Information • Mechanism – energy, energy • Direction of Impact • Associated Injuries Starts in the….
- 31. Does “unexaminable” meanno examination? NO! • Inspect for bruising or ecchymosis • Palpate for step-off or deformity • Rectal Tone • Reflex exam – Bulbocavernosus – Clonus/Babinski
- 32. Thoracolumbar spine..!! Lateralview..: • 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..!! Commonlyused 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..! Thereturn 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..!! Lossof symphatetic outflow related to spinal shock Vasodilation of the viscera and peripheries resulting in hypotension without TACHYCARDIA Fluid administration Pulmonary edema
- 38. SCI: Complete VsIncomplete 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
- 41. Managing Thoracolumbar SpineFractures..! NEUROLOGICAL DEFICIT YES COMPLETE INCOMPLETE POSTERIOR FUSION ANTERIOR DECOMPRESSION & FUSION POSTERIOR TRANSPEDICULAR DECOMPRESSION AND FUSION CIRCUMFERENTIAL PROCEDURES NO UNSTABLE STABLE CONSERVATIVE PLC disrupted PLC intact Posterior fusion ± Minimally invasive(VBA) Circumferential fusion Anterior fusion Posterior fusion with indirect reduction ± Minimally invasive(VBA) Stable fracture Involving less than 2 columns Kyphosis < 25 degrees Compression < 50% of anterior column Canal compromise < 50%
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- 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-operativevs 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 andligamentotaxis 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: • Retropulsedfragments 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 andposterior 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 inabsence 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 safelydone in patients with refractory pain to conservative treatments.
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- 55. Dangers..Needle injury..! Canalbreach Lateral passage and aortic damage
- 56. Complications ..!! Transientincrease 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 stabilizationof 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 toprovide 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..!! Properlyaligned 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…!! 1cm 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
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- 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
- 66. Short segment fixationplus transpedicular augmentation..!!
- 67. Transpedicular augmentation:better final restoration of vertebral height Allen li et al: Indian J Orthop. 2007 Oct-Dec; 41(4): 362–367.
- 68. Rehabilitation..!! Bladder dysfunction: • Intermittent catheterization • Supra-pubic catheterization in penile ulceration • Valsalva, Crede method Bowel dysfunction: • Regular intake of high fluids and dietary fibers • Pulse water irrigation of rectum • Electrical stimulation of abdominal musculature • Prokinetic agents: cisapride • Suppositories
- 69. Rehabilitation..!! Spasticity •Physical therapy: rhythmic passive movements, muscular stretching exercises • Direct muscle electrical stimulation • Oral baclofen Pain • Non-pharmacologic massage and heat, TENS • Pharmacologic: Gabapentin DVT prevention • Compression stockings • LMWH
- 70. Rehabilitation..!! Bed soreprevention • 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
- 71. Rehabilitation..!! Postural hypotension • Clonidine • Elastic stockings, abdominal binders Prevention of respiratory infections Chest physiotherapy, steam inhalation, incentive spirometry Manual assisted coughing
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