SlideShare a Scribd company logo
Thoracolumber Fractures
Farhad Hussain
8/06/2018
Three Column Model
• Denis’ 3 column model of the spine attempts to identify CT criteria
of instability of thoracolumbar spine fractures.
• This model has generally good predictive value.
Anterior column:
• Anterior half of disc and vertebral body (VB) (includes anterior anulus fibrosus
(AF))
• Plus the anterior longitudinal ligament (ALL)
Middle column:
• Posterior half of disc and vertebral body (includes posterior wall of vertebral
body and posterior AF),
• Posterior longitudinal ligament (PLL)
• Pedicles
Posterior column:
• Posterior bony complex (posterior arch) with interposed posterior
ligamentous complex (supraspinous and interspinous ligament, facet joints
and capsule, and ligamentum flavum (LF)).
• Injury to this column alone does not cause instability
Classification
Minor injuries:
• Involve only a part of a column and do not lead to acute instability
(when not accompanied by major injures). Includes:
1. fracture of transverse process: usually neurologically intact except in
two areas:
a) L4–5 →lumbosacral plexus injuries (there may be associated renal injuries,
check U/A for blood)
b) T1–2 →brachial plexus injuries
2. fracture of articular process or pars interarticularis
3. isolated fractures of the spinous process: in the TL spine: these are
usually due to direct trauma.
• Often difficult to detect on plain x-ray
4. isolated laminar fracture: rare. Should be stable
Major Fractures
• The McAfee classification describes 6 main types of
fractures.2 A simplified system with four categories
• Type 1: Compression fracture: compression failure of
anterior column. Middle column intact
• (unlike the 3 other major injuries below) acting as a
fulcrum,
1. 2 subtypes:
a) anterior: most common between T6-T8 and T12-L3
● lateral x-ray: wedging of the VB anteriorly, no loss of
height of posterior VB, no subluxation
● CT: spinal canal intact. Disruption of anterior end-plate
b) lateral (rare)
2. clinical: no neurologic deficit
Burst Fractures
• Pure axial load →compression of vertebral
body →compression
• Failure of anterior and middle columns.
• Occur mainly at TL junction, usually between
T10 and L2.
Radiology
a) Lateral x-ray:
– Cortical fracture of posterior VB wall
– Loss of posterior VB height
– Retropulsion of bone fragment from
end plate(s) into canal
Radiology
b) AP x-ray:
• Increase of interpediculate
distance (IPD)
• Vertical fracture of lamina
• Splaying of facet joints: ↑
IPD indicates failure of
middle column
Radiology
c) CT: demonstrates break in
posterior wall of VB with
retropulsed bone in spinal
canal (average: 50%
obstruct ion of canal area),
increase in IPD with splaying
of posterior arch (including
facets)
Radiology
• d) MRI: compromise of anterior canal
by bone fragment; possible cord
compression usually with fragments
occupying > 50% of the canal diameter
Clinical
• clinical: depends on level (thoracic cord more sensitive and less
room in canal than conus region), the impact at the time of
disruption, and the extent of canal obstruction
a) ≈ 50% intact at initial examination (half of these recalled leg
numbness, tingling, and/or weakness initially after trauma that
subsided)
b) of patients with deficits, only 5% had complete paraplegia
Seat belt Fractures
• flexion across a fulcrum anterior to the anterior column (e.g. seat belt)
→compression of anterior column & distraction failure of both middle
and posterior columns.
• May be bony or ligamentous
Fracture-dislocation
• failure of all 3 columns due to compression, tension, rotation or
shear →subluxation or dislocation
3 subtypes
• a) flexion rotation: posterior and middle columns totally
ruptured, anteriorly compressed → anterior wedging
● lateral x-ray: subluxation or dislocation. Preserved posterior
VB wall. Increased interspinous distance
● CT: rotation and offset of VBs with →canal diameter.
Jumped facets
● clinical: 25% neurologically intact. 50% of those with deficits
were complete paraplegics
b) shear: all 3 columns disrupted (including ALL)
• when trauma force directed posteriorly to anteriorly (more common) VB
above shears forward fracturing the posterior arch (→free floating lamina)
and the superior facet of the inferior vertebra
• clinical: all 7 cases were complete paraplegics
c) flexion distraction
• radiographically resemble seat-belt type with addition of subluxation, or
with compression of anterior column >10–20%
• clinical: neurologic deficit (incomplete in 3 cases, complete in 1)
Associated injuries
• vertebral end-plate avulsion, ligamentous injuries, and hip
and pelvic fractures.
• Thoracolumbar fractures may be associated with
hemodynamic instability as a result of hemothorax or aortic
injury.
• Fractures of the transverse processes may be associated with
abdominal trauma (e.g. renal injuries at L4–5).
Stability and treatment of thoracolumbar spine
fractures
Minor injuries
• Isolated thoracolumbar transverse process fractures (as
demonstrated on spinal CT) do not require intervention or
consultation of a spine service.
Major spine injuries
Denis categorized the instability as:
1st degree: mechanical instability
2nd degree: neurological instability
3rd degree: both mechanical & neurological instability
Anterior Column Injury
• Isolated anterior column injuries are usually stable
• Treat initially with analgesics and recumbency (bed-rest) for
comfort × 1–3 weeks
• Diminution of pain is a good indication to commence mobilization
with or without external immobilization (corset or TLSO× ≈ 12
weeks) depending on the degree of kyphosis
• Vertebroplasty (± kyphoplasty) may be an option
• Serial x-rays to rule-out progressive deformity
The following exceptions may be unstable (1st degree) and often require
surgery
Unstable compression fractures
1. a single compression fracture with:
a) loss of >50% of height with angulation (particularly if the anterior part
of the wedge comes to
a point)
b) excessive kyphotic angulation at one segment (various criteria are used,
none are absolute. Values quoted: > 30°, > 40°)
2. 3 or more contiguous compression fractures
3. neurologic deficit (generally does not occur with pure compression
fracture)
4. disrupted posterior column or more than minimal middle column failure
5. progressive kyphosis: risk of progressive kyphosis is increased when loss of
height of anterior vertebral body is >75%. Risk is higher for lumbar
compression fractures than thoracic
Middle Column Failure
• These are unstable (often requiring surgery) with the
following exceptions which should be stable
Stable middle column fractures
• Above T8 if the ribs and sternum are intact (provides anterior
stabilization)
• Below L4 if the posterior elements are intact
• Chance fracture (anterior column compression , middle
column distraction)
• Anterior column disruption with minimal middle column
failure
Posterior Column Disruption
• Not acutely unstable unless accompanied by failure of the
middle column (posterior longitudinal ligament and posterior
anulus fibrosus). However, chronic instability with kyphotic
deformity may develop (especially in children).
Seat-belt type injuries without neurologic
deficit
• No immediate danger of neurologic injury. Treat most with external
immobilization in extension (e. g TLSO).
Fracture-dislocation
Unstable. Treatment options:
1. surgical decompression and stabilization: usually needed in
cases with
a) compression with >50% loss of height with angulation
b) or, kyphotic angulation >40° (or >25%)
c) or, neurologic deficit
d) or, desire to shorten length of time of bedrest
2. prolonged bedrest: an option if none of the above are present
When vertebral body resection (vertebral corpectomy) is
performed, options to access: transthoracic or
transabdominal approach (or combined), transpedicular (for
thoracic spine), lateral (retroperitoneal/ retropleural)
approach.
Fracture and compression usually occurs at the superior margin
of vertebral body, thus start resection at the inferior disc
interspace. Followed by strut graft (cage or bone: iliac crest or
fibula or tibia). Posterior instrumentation is usually required
Burst fractures
• Not all burst fractures are alike.
• Some burst fractures may eventually cause neurologic deficit (even
if no deficit initially).
Surgical indications for burst fractures: burst fracture with any of the
following:
• Anterior vertebral body height ≤50% of the posterior height
• Residual canal diameter ≤50% of normal
• Kyphotic angulation ≥ 20°
• When the increased interpediculate distance usually present on the
initial film widens further on AP x-ray when standing in brace/cast
• Neurologic deficit (incomplete)
• Progressive kyphosis
Common surgical options for burst or severe compression fractures:
1. If instrumentation alone is needed
A) can place pedicle screws in 2 levels above and 2 levels below the
fracture
B) if the index level can be included (i.E. If the pedicles are intact
enough to accept shorter screws), similar biomechanical stability
can be achieved by placing screws at the index level (the fractured
level) and then just 1 above and 1 below
2. If decompression of the spinal canal and/or anterior support is
needed, corpectomy and strut graft (e.g. with expandable cage)
with percutaneous pedicle screws may be used.
Approaches:
a) from posterior approach e.g. laminectomy with transpedicular
approach and impacting bone anteriorly out of canal with a mallet
and reverse angled curette, or
b) lateral corpectomy and removal of bone from canal
• For those not undergoing surgery (i.e. when surgery is not required
or is contraindicated), an option is to treat with recumbency from
1–6 weeks (the duration depending on pain and degree of
deformity).
• Avoid early ambulation →further axial loading (even in cast). When
appropriate, begin ambulation in an orthosis (e.g. molded
thoracolumbar sacral orthosis (TLSO) and follow patient for 3–5
months with serial x-rays to detect progressive collapse or
angulation which may need further intervention.
Thoracolumbar injury classification and
severity score (TLICS)
• The TLICS system has been proposed to simplify classification an d
discussion of thoracolumbar fractures.
• Points are assigned, the scores are summed, and management
guidelines are given.
• Neurologic deficit, especially when partial, favors surgery.
Surgical Treatment
Burst Fractures
Choice of Approach:
• Surgical considerations: a posterior approach is preferred if there is
a dural tear, whereas a burst fracture with partial deficit and canal
compromise may be treated more effectively from an anterior
approach.
• A small progression in angular deformity may occur when posterior
stabilization is performed alone (since the injury to the anterior
column is not corrected), but by itself usually does not require
intervention.
For a posterior approach
• In ideal situation (good bone quality, pedicle screw placement goes
well (i.e. no fracture, no breach), and non-smoking patient) then
one can fuse/rod one above and one below the fracture (using
pedicle screws; longer constructs are needed with laminar hooks).
• With a short segment fusion like this, approximately 10° of lordosis
be lost with time, therefore, one should try to overcorrect a little to
accommodate the anticipated settling.
• If the patient does not meet the above criteria (e.g. poor bone quality),
an option is to “rod long, fuse short” (e.g. rod 2 levels above and
below the fracture but fuse only 1 level above and below)
• Remove the hardware when the fusion is solid (e.g. at 8–12 months) –
this avoids fusing a nonpathologic segment just to get a better anchor.
• Fusing across critical levels (i.e. thoracolumbar junction with T11 or L1
compression fractures) requires that the fusion incorporate 2–3 levels
on each side of the junction (the forces of the long segment of the
relatively immobile thoracic spine with the lumbar spine at the T-L
junction increase the risk of nonunion)
Wound infections
• Postoperative wound infect ions with spinal instrumentation are
usually due to Staph. aureus.
• With titanium hardware it may respond to debridement of
devitalized tissue and thorough washout (typically with 3 L of
antibiotic irrigation flushed into the wound using a pulse lavage
device – avoiding direct irrigation of any exposed dura) without
removal of instrumentation, followed by antibiotics.
• Persistent infection may respond to. If this is inadequate, removal
of instrumentation may occasionally be required
Thank You

More Related Content

What's hot

Carpal instability - Orthopedic
Carpal instability - OrthopedicCarpal instability - Orthopedic
Carpal instability - Orthopedic
Fahad AlHulaibi
 
Posttraumatic spinal cord injury without radiographic abnormality
Posttraumatic spinal cord injury without radiographic abnormalityPosttraumatic spinal cord injury without radiographic abnormality
Posttraumatic spinal cord injury without radiographic abnormality
Ponnilavan Ponz
 
Calcaneal fractures
Calcaneal fracturesCalcaneal fractures
Calcaneal fractures
Rohit Vikas
 
Ankle arthrodesis
Ankle arthrodesisAnkle arthrodesis
Ankle arthrodesis
Dr venkatesh v
 
Posterior malleolus fracture
Posterior malleolus fracturePosterior malleolus fracture
Posterior malleolus fracture
AnuragSai7
 
Management of Shoulder dislocations and shoulder instability in sports
Management of Shoulder dislocations and shoulder instability in sports Management of Shoulder dislocations and shoulder instability in sports
Management of Shoulder dislocations and shoulder instability in sports
BhaskarBorgohain4
 
Talus anatomy, blood supply & fractures
Talus anatomy, blood supply & fracturesTalus anatomy, blood supply & fractures
Talus anatomy, blood supply & fractures
Hiren Divecha
 
Thoracolumbar fracture for mbbs
Thoracolumbar fracture for mbbsThoracolumbar fracture for mbbs
Thoracolumbar fracture for mbbs
Dr Mizan
 
Basics of knee arthroscopy for the beginners
Basics of knee arthroscopy for the beginnersBasics of knee arthroscopy for the beginners
Basics of knee arthroscopy for the beginners
BhaskarBorgohain4
 
Principles of locking compression plates
Principles of locking compression platesPrinciples of locking compression plates
Principles of locking compression plates
Dr Souvik Paul
 
Fractures of the olecranon
Fractures of the olecranonFractures of the olecranon
Fractures of the olecranon
Muhammad Abdelghani
 
TENS
TENSTENS
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
Dr. Donald Corenman, M.D., D.C.
 
Elbow fracture dislocations adam watts
Elbow fracture dislocations adam wattsElbow fracture dislocations adam watts
Elbow fracture dislocations adam watts
Adam Watts
 
Bearing surfaces THR
Bearing surfaces THRBearing surfaces THR
Bearing surfaces THR
orthoprince
 
Thoraco lumbar fractures of spine
Thoraco lumbar fractures of spine Thoraco lumbar fractures of spine
Thoraco lumbar fractures of spine
Sunil Santhosh
 
High tibial osteotomy
High tibial osteotomyHigh tibial osteotomy
High tibial osteotomy
orthoprince
 
Current Concepts in Treatment of Proximal Humerus Fractures
Current Concepts in Treatment of Proximal Humerus Fractures Current Concepts in Treatment of Proximal Humerus Fractures
Current Concepts in Treatment of Proximal Humerus Fractures
washingtonortho
 
syndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject reviewsyndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject review
Sunil Poonia
 
Complex elbow injury 2013
Complex elbow injury 2013Complex elbow injury 2013
Complex elbow injury 2013
Sumroeng Neti
 

What's hot (20)

Carpal instability - Orthopedic
Carpal instability - OrthopedicCarpal instability - Orthopedic
Carpal instability - Orthopedic
 
Posttraumatic spinal cord injury without radiographic abnormality
Posttraumatic spinal cord injury without radiographic abnormalityPosttraumatic spinal cord injury without radiographic abnormality
Posttraumatic spinal cord injury without radiographic abnormality
 
Calcaneal fractures
Calcaneal fracturesCalcaneal fractures
Calcaneal fractures
 
Ankle arthrodesis
Ankle arthrodesisAnkle arthrodesis
Ankle arthrodesis
 
Posterior malleolus fracture
Posterior malleolus fracturePosterior malleolus fracture
Posterior malleolus fracture
 
Management of Shoulder dislocations and shoulder instability in sports
Management of Shoulder dislocations and shoulder instability in sports Management of Shoulder dislocations and shoulder instability in sports
Management of Shoulder dislocations and shoulder instability in sports
 
Talus anatomy, blood supply & fractures
Talus anatomy, blood supply & fracturesTalus anatomy, blood supply & fractures
Talus anatomy, blood supply & fractures
 
Thoracolumbar fracture for mbbs
Thoracolumbar fracture for mbbsThoracolumbar fracture for mbbs
Thoracolumbar fracture for mbbs
 
Basics of knee arthroscopy for the beginners
Basics of knee arthroscopy for the beginnersBasics of knee arthroscopy for the beginners
Basics of knee arthroscopy for the beginners
 
Principles of locking compression plates
Principles of locking compression platesPrinciples of locking compression plates
Principles of locking compression plates
 
Fractures of the olecranon
Fractures of the olecranonFractures of the olecranon
Fractures of the olecranon
 
TENS
TENSTENS
TENS
 
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
Spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spi...
 
Elbow fracture dislocations adam watts
Elbow fracture dislocations adam wattsElbow fracture dislocations adam watts
Elbow fracture dislocations adam watts
 
Bearing surfaces THR
Bearing surfaces THRBearing surfaces THR
Bearing surfaces THR
 
Thoraco lumbar fractures of spine
Thoraco lumbar fractures of spine Thoraco lumbar fractures of spine
Thoraco lumbar fractures of spine
 
High tibial osteotomy
High tibial osteotomyHigh tibial osteotomy
High tibial osteotomy
 
Current Concepts in Treatment of Proximal Humerus Fractures
Current Concepts in Treatment of Proximal Humerus Fractures Current Concepts in Treatment of Proximal Humerus Fractures
Current Concepts in Treatment of Proximal Humerus Fractures
 
syndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject reviewsyndesmotic injury mechanism and treatment subject review
syndesmotic injury mechanism and treatment subject review
 
Complex elbow injury 2013
Complex elbow injury 2013Complex elbow injury 2013
Complex elbow injury 2013
 

Similar to Thoracolumber fractures

THORACOLUMBAR SPINE INJURIES
THORACOLUMBAR SPINE INJURIESTHORACOLUMBAR SPINE INJURIES
THORACOLUMBAR SPINE INJURIES
Suman Subedi
 
Cervical spine trauma
Cervical spine traumaCervical spine trauma
Cervical spine trauma
Dr. Soe Moe Htoo
 
319 thoracolumbar trauma
319 thoracolumbar trauma319 thoracolumbar trauma
319 thoracolumbar trauma
Neurosurgery Vajira
 
Thoracolumbar fracture cme
Thoracolumbar fracture cmeThoracolumbar fracture cme
Thoracolumbar fracture cme
Siti Aishah Mohd Zameri
 
Cervical trauma
Cervical traumaCervical trauma
Cervical trauma
Ali Jiwani
 
Spinal cord injuries spinalfractures thoracolumbar fracture
Spinal cord injuries spinalfractures thoracolumbar fractureSpinal cord injuries spinalfractures thoracolumbar fracture
Spinal cord injuries spinalfractures thoracolumbar fracture
Nabil Khalil
 
Fracture and dislocation of the shoulder girdle
Fracture and dislocation of the shoulder girdleFracture and dislocation of the shoulder girdle
Fracture and dislocation of the shoulder girdle
omar ababneh
 
Spinal injury
Spinal injurySpinal injury
Spinal injury
Mahmoud Zidan
 
Ct spine fractures ppt
Ct spine fractures pptCt spine fractures ppt
Ct spine fractures ppt
BipulBorthakur
 
2017.01.25, Howard, LS-Spine
2017.01.25, Howard, LS-Spine2017.01.25, Howard, LS-Spine
2017.01.25, Howard, LS-Spine
Robert Lieberson, MD, FAANS, FACS
 
ACETABULUM And HIP DISLOCATION Report.pptx
ACETABULUM And HIP DISLOCATION Report.pptxACETABULUM And HIP DISLOCATION Report.pptx
ACETABULUM And HIP DISLOCATION Report.pptx
CarlosAcua91
 
L01_Hip-dislocatinos-femoral-head.ppt
L01_Hip-dislocatinos-femoral-head.pptL01_Hip-dislocatinos-femoral-head.ppt
L01_Hip-dislocatinos-femoral-head.ppt
toto798365
 
Acetabular fractures
Acetabular fracturesAcetabular fractures
Acetabular fractures
chetan narra
 
neck x ray.pptx
neck x ray.pptxneck x ray.pptx
neck x ray.pptx
FatimaAmirlou
 
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
Abdellah Nazeer
 
dorsolumbar injuries.pptx
dorsolumbar injuries.pptxdorsolumbar injuries.pptx
dorsolumbar injuries.pptx
KareemElsharkawy6
 
Spine trauma basics
Spine trauma basicsSpine trauma basics
Spine trauma basics
DR. D. P. SWAMI
 
CME Orthopedic.pptx
CME Orthopedic.pptxCME Orthopedic.pptx
CME Orthopedic.pptx
Parveen739769
 
CME SPINAL INJURY.pptx
CME SPINAL INJURY.pptxCME SPINAL INJURY.pptx
CME SPINAL INJURY.pptx
mieyoi
 
A summary of fractures of acetabulum
A summary of fractures of acetabulumA summary of fractures of acetabulum
A summary of fractures of acetabulum
Libin Thomas
 

Similar to Thoracolumber fractures (20)

THORACOLUMBAR SPINE INJURIES
THORACOLUMBAR SPINE INJURIESTHORACOLUMBAR SPINE INJURIES
THORACOLUMBAR SPINE INJURIES
 
Cervical spine trauma
Cervical spine traumaCervical spine trauma
Cervical spine trauma
 
319 thoracolumbar trauma
319 thoracolumbar trauma319 thoracolumbar trauma
319 thoracolumbar trauma
 
Thoracolumbar fracture cme
Thoracolumbar fracture cmeThoracolumbar fracture cme
Thoracolumbar fracture cme
 
Cervical trauma
Cervical traumaCervical trauma
Cervical trauma
 
Spinal cord injuries spinalfractures thoracolumbar fracture
Spinal cord injuries spinalfractures thoracolumbar fractureSpinal cord injuries spinalfractures thoracolumbar fracture
Spinal cord injuries spinalfractures thoracolumbar fracture
 
Fracture and dislocation of the shoulder girdle
Fracture and dislocation of the shoulder girdleFracture and dislocation of the shoulder girdle
Fracture and dislocation of the shoulder girdle
 
Spinal injury
Spinal injurySpinal injury
Spinal injury
 
Ct spine fractures ppt
Ct spine fractures pptCt spine fractures ppt
Ct spine fractures ppt
 
2017.01.25, Howard, LS-Spine
2017.01.25, Howard, LS-Spine2017.01.25, Howard, LS-Spine
2017.01.25, Howard, LS-Spine
 
ACETABULUM And HIP DISLOCATION Report.pptx
ACETABULUM And HIP DISLOCATION Report.pptxACETABULUM And HIP DISLOCATION Report.pptx
ACETABULUM And HIP DISLOCATION Report.pptx
 
L01_Hip-dislocatinos-femoral-head.ppt
L01_Hip-dislocatinos-femoral-head.pptL01_Hip-dislocatinos-femoral-head.ppt
L01_Hip-dislocatinos-femoral-head.ppt
 
Acetabular fractures
Acetabular fracturesAcetabular fractures
Acetabular fractures
 
neck x ray.pptx
neck x ray.pptxneck x ray.pptx
neck x ray.pptx
 
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...
 
dorsolumbar injuries.pptx
dorsolumbar injuries.pptxdorsolumbar injuries.pptx
dorsolumbar injuries.pptx
 
Spine trauma basics
Spine trauma basicsSpine trauma basics
Spine trauma basics
 
CME Orthopedic.pptx
CME Orthopedic.pptxCME Orthopedic.pptx
CME Orthopedic.pptx
 
CME SPINAL INJURY.pptx
CME SPINAL INJURY.pptxCME SPINAL INJURY.pptx
CME SPINAL INJURY.pptx
 
A summary of fractures of acetabulum
A summary of fractures of acetabulumA summary of fractures of acetabulum
A summary of fractures of acetabulum
 

Recently uploaded

Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
MuhammadMuneer49
 
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfTest bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
rightmanforbloodline
 
Skin Diseases That Happen During Summer.
 Skin Diseases That Happen During Summer. Skin Diseases That Happen During Summer.
Skin Diseases That Happen During Summer.
Gokuldas Hospital
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
KerlynIgnacio
 
Histololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptxHistololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptx
AyeshaZaid1
 
How to Control Your Asthma Tips by gokuldas hospital.
How to Control Your Asthma Tips by gokuldas hospital.How to Control Your Asthma Tips by gokuldas hospital.
How to Control Your Asthma Tips by gokuldas hospital.
Gokuldas Hospital
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
NX Healthcare
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
rishi2789
 
Travel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International TravelersTravel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International Travelers
NX Healthcare
 
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfNAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
Rahul Sen
 
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIESLOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
ShraddhaTamshettiwar
 
Pharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and AntagonistPharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and Antagonist
Dr. Nikhilkumar Sakle
 
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
rishi2789
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
SIVAVINAYAKPK
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
rishi2789
 
Acute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdfAcute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdf
Jim Jacob Roy
 
June 2024 Oncology Cartoons By Dr Kanhu Charan Patro
June 2024 Oncology Cartoons By Dr Kanhu Charan PatroJune 2024 Oncology Cartoons By Dr Kanhu Charan Patro
June 2024 Oncology Cartoons By Dr Kanhu Charan Patro
Kanhu Charan
 
Pollen and Fungal allergy: aeroallergy.pdf
Pollen and Fungal allergy: aeroallergy.pdfPollen and Fungal allergy: aeroallergy.pdf
Pollen and Fungal allergy: aeroallergy.pdf
Chulalongkorn Allergy and Clinical Immunology Research Group
 
How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.
Gokuldas Hospital
 
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
Holistified Wellness
 

Recently uploaded (20)

Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
 
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfTest bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
 
Skin Diseases That Happen During Summer.
 Skin Diseases That Happen During Summer. Skin Diseases That Happen During Summer.
Skin Diseases That Happen During Summer.
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
 
Histololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptxHistololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptx
 
How to Control Your Asthma Tips by gokuldas hospital.
How to Control Your Asthma Tips by gokuldas hospital.How to Control Your Asthma Tips by gokuldas hospital.
How to Control Your Asthma Tips by gokuldas hospital.
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
 
Travel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International TravelersTravel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International Travelers
 
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfNAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
 
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIESLOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
LOW BIRTH WEIGHT. PRETERM BABIES OR SMALL FOR DATES BABIES
 
Pharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and AntagonistPharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and Antagonist
 
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 4_ANTI VIRAL DRUGS.pdf
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
 
Acute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdfAcute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdf
 
June 2024 Oncology Cartoons By Dr Kanhu Charan Patro
June 2024 Oncology Cartoons By Dr Kanhu Charan PatroJune 2024 Oncology Cartoons By Dr Kanhu Charan Patro
June 2024 Oncology Cartoons By Dr Kanhu Charan Patro
 
Pollen and Fungal allergy: aeroallergy.pdf
Pollen and Fungal allergy: aeroallergy.pdfPollen and Fungal allergy: aeroallergy.pdf
Pollen and Fungal allergy: aeroallergy.pdf
 
How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.
 
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
 

Thoracolumber fractures

  • 2. Three Column Model • Denis’ 3 column model of the spine attempts to identify CT criteria of instability of thoracolumbar spine fractures. • This model has generally good predictive value.
  • 3. Anterior column: • Anterior half of disc and vertebral body (VB) (includes anterior anulus fibrosus (AF)) • Plus the anterior longitudinal ligament (ALL) Middle column: • Posterior half of disc and vertebral body (includes posterior wall of vertebral body and posterior AF), • Posterior longitudinal ligament (PLL) • Pedicles Posterior column: • Posterior bony complex (posterior arch) with interposed posterior ligamentous complex (supraspinous and interspinous ligament, facet joints and capsule, and ligamentum flavum (LF)). • Injury to this column alone does not cause instability
  • 4. Classification Minor injuries: • Involve only a part of a column and do not lead to acute instability (when not accompanied by major injures). Includes: 1. fracture of transverse process: usually neurologically intact except in two areas: a) L4–5 →lumbosacral plexus injuries (there may be associated renal injuries, check U/A for blood) b) T1–2 →brachial plexus injuries 2. fracture of articular process or pars interarticularis 3. isolated fractures of the spinous process: in the TL spine: these are usually due to direct trauma. • Often difficult to detect on plain x-ray 4. isolated laminar fracture: rare. Should be stable
  • 5. Major Fractures • The McAfee classification describes 6 main types of fractures.2 A simplified system with four categories • Type 1: Compression fracture: compression failure of anterior column. Middle column intact • (unlike the 3 other major injuries below) acting as a fulcrum, 1. 2 subtypes: a) anterior: most common between T6-T8 and T12-L3 ● lateral x-ray: wedging of the VB anteriorly, no loss of height of posterior VB, no subluxation ● CT: spinal canal intact. Disruption of anterior end-plate b) lateral (rare) 2. clinical: no neurologic deficit
  • 6. Burst Fractures • Pure axial load →compression of vertebral body →compression • Failure of anterior and middle columns. • Occur mainly at TL junction, usually between T10 and L2.
  • 7.
  • 8.
  • 9. Radiology a) Lateral x-ray: – Cortical fracture of posterior VB wall – Loss of posterior VB height – Retropulsion of bone fragment from end plate(s) into canal
  • 10. Radiology b) AP x-ray: • Increase of interpediculate distance (IPD) • Vertical fracture of lamina • Splaying of facet joints: ↑ IPD indicates failure of middle column
  • 11. Radiology c) CT: demonstrates break in posterior wall of VB with retropulsed bone in spinal canal (average: 50% obstruct ion of canal area), increase in IPD with splaying of posterior arch (including facets)
  • 12.
  • 13. Radiology • d) MRI: compromise of anterior canal by bone fragment; possible cord compression usually with fragments occupying > 50% of the canal diameter
  • 14.
  • 15. Clinical • clinical: depends on level (thoracic cord more sensitive and less room in canal than conus region), the impact at the time of disruption, and the extent of canal obstruction a) ≈ 50% intact at initial examination (half of these recalled leg numbness, tingling, and/or weakness initially after trauma that subsided) b) of patients with deficits, only 5% had complete paraplegia
  • 16. Seat belt Fractures • flexion across a fulcrum anterior to the anterior column (e.g. seat belt) →compression of anterior column & distraction failure of both middle and posterior columns. • May be bony or ligamentous
  • 17.
  • 18. Fracture-dislocation • failure of all 3 columns due to compression, tension, rotation or shear →subluxation or dislocation 3 subtypes • a) flexion rotation: posterior and middle columns totally ruptured, anteriorly compressed → anterior wedging ● lateral x-ray: subluxation or dislocation. Preserved posterior VB wall. Increased interspinous distance ● CT: rotation and offset of VBs with →canal diameter. Jumped facets ● clinical: 25% neurologically intact. 50% of those with deficits were complete paraplegics
  • 19. b) shear: all 3 columns disrupted (including ALL) • when trauma force directed posteriorly to anteriorly (more common) VB above shears forward fracturing the posterior arch (→free floating lamina) and the superior facet of the inferior vertebra • clinical: all 7 cases were complete paraplegics c) flexion distraction • radiographically resemble seat-belt type with addition of subluxation, or with compression of anterior column >10–20% • clinical: neurologic deficit (incomplete in 3 cases, complete in 1)
  • 20.
  • 21. Associated injuries • vertebral end-plate avulsion, ligamentous injuries, and hip and pelvic fractures. • Thoracolumbar fractures may be associated with hemodynamic instability as a result of hemothorax or aortic injury. • Fractures of the transverse processes may be associated with abdominal trauma (e.g. renal injuries at L4–5).
  • 22. Stability and treatment of thoracolumbar spine fractures Minor injuries • Isolated thoracolumbar transverse process fractures (as demonstrated on spinal CT) do not require intervention or consultation of a spine service. Major spine injuries Denis categorized the instability as: 1st degree: mechanical instability 2nd degree: neurological instability 3rd degree: both mechanical & neurological instability
  • 23. Anterior Column Injury • Isolated anterior column injuries are usually stable • Treat initially with analgesics and recumbency (bed-rest) for comfort × 1–3 weeks • Diminution of pain is a good indication to commence mobilization with or without external immobilization (corset or TLSO× ≈ 12 weeks) depending on the degree of kyphosis • Vertebroplasty (± kyphoplasty) may be an option • Serial x-rays to rule-out progressive deformity
  • 24. The following exceptions may be unstable (1st degree) and often require surgery Unstable compression fractures 1. a single compression fracture with: a) loss of >50% of height with angulation (particularly if the anterior part of the wedge comes to a point) b) excessive kyphotic angulation at one segment (various criteria are used, none are absolute. Values quoted: > 30°, > 40°) 2. 3 or more contiguous compression fractures 3. neurologic deficit (generally does not occur with pure compression fracture) 4. disrupted posterior column or more than minimal middle column failure 5. progressive kyphosis: risk of progressive kyphosis is increased when loss of height of anterior vertebral body is >75%. Risk is higher for lumbar compression fractures than thoracic
  • 25. Middle Column Failure • These are unstable (often requiring surgery) with the following exceptions which should be stable Stable middle column fractures • Above T8 if the ribs and sternum are intact (provides anterior stabilization) • Below L4 if the posterior elements are intact • Chance fracture (anterior column compression , middle column distraction) • Anterior column disruption with minimal middle column failure
  • 26. Posterior Column Disruption • Not acutely unstable unless accompanied by failure of the middle column (posterior longitudinal ligament and posterior anulus fibrosus). However, chronic instability with kyphotic deformity may develop (especially in children).
  • 27. Seat-belt type injuries without neurologic deficit • No immediate danger of neurologic injury. Treat most with external immobilization in extension (e. g TLSO).
  • 28. Fracture-dislocation Unstable. Treatment options: 1. surgical decompression and stabilization: usually needed in cases with a) compression with >50% loss of height with angulation b) or, kyphotic angulation >40° (or >25%) c) or, neurologic deficit d) or, desire to shorten length of time of bedrest 2. prolonged bedrest: an option if none of the above are present
  • 29. When vertebral body resection (vertebral corpectomy) is performed, options to access: transthoracic or transabdominal approach (or combined), transpedicular (for thoracic spine), lateral (retroperitoneal/ retropleural) approach. Fracture and compression usually occurs at the superior margin of vertebral body, thus start resection at the inferior disc interspace. Followed by strut graft (cage or bone: iliac crest or fibula or tibia). Posterior instrumentation is usually required
  • 30. Burst fractures • Not all burst fractures are alike. • Some burst fractures may eventually cause neurologic deficit (even if no deficit initially). Surgical indications for burst fractures: burst fracture with any of the following: • Anterior vertebral body height ≤50% of the posterior height • Residual canal diameter ≤50% of normal • Kyphotic angulation ≥ 20° • When the increased interpediculate distance usually present on the initial film widens further on AP x-ray when standing in brace/cast • Neurologic deficit (incomplete) • Progressive kyphosis
  • 31. Common surgical options for burst or severe compression fractures: 1. If instrumentation alone is needed A) can place pedicle screws in 2 levels above and 2 levels below the fracture B) if the index level can be included (i.E. If the pedicles are intact enough to accept shorter screws), similar biomechanical stability can be achieved by placing screws at the index level (the fractured level) and then just 1 above and 1 below
  • 32. 2. If decompression of the spinal canal and/or anterior support is needed, corpectomy and strut graft (e.g. with expandable cage) with percutaneous pedicle screws may be used. Approaches: a) from posterior approach e.g. laminectomy with transpedicular approach and impacting bone anteriorly out of canal with a mallet and reverse angled curette, or b) lateral corpectomy and removal of bone from canal
  • 33. • For those not undergoing surgery (i.e. when surgery is not required or is contraindicated), an option is to treat with recumbency from 1–6 weeks (the duration depending on pain and degree of deformity). • Avoid early ambulation →further axial loading (even in cast). When appropriate, begin ambulation in an orthosis (e.g. molded thoracolumbar sacral orthosis (TLSO) and follow patient for 3–5 months with serial x-rays to detect progressive collapse or angulation which may need further intervention.
  • 34. Thoracolumbar injury classification and severity score (TLICS) • The TLICS system has been proposed to simplify classification an d discussion of thoracolumbar fractures. • Points are assigned, the scores are summed, and management guidelines are given. • Neurologic deficit, especially when partial, favors surgery.
  • 35.
  • 36.
  • 37. Surgical Treatment Burst Fractures Choice of Approach: • Surgical considerations: a posterior approach is preferred if there is a dural tear, whereas a burst fracture with partial deficit and canal compromise may be treated more effectively from an anterior approach. • A small progression in angular deformity may occur when posterior stabilization is performed alone (since the injury to the anterior column is not corrected), but by itself usually does not require intervention.
  • 38. For a posterior approach • In ideal situation (good bone quality, pedicle screw placement goes well (i.e. no fracture, no breach), and non-smoking patient) then one can fuse/rod one above and one below the fracture (using pedicle screws; longer constructs are needed with laminar hooks). • With a short segment fusion like this, approximately 10° of lordosis be lost with time, therefore, one should try to overcorrect a little to accommodate the anticipated settling.
  • 39. • If the patient does not meet the above criteria (e.g. poor bone quality), an option is to “rod long, fuse short” (e.g. rod 2 levels above and below the fracture but fuse only 1 level above and below) • Remove the hardware when the fusion is solid (e.g. at 8–12 months) – this avoids fusing a nonpathologic segment just to get a better anchor. • Fusing across critical levels (i.e. thoracolumbar junction with T11 or L1 compression fractures) requires that the fusion incorporate 2–3 levels on each side of the junction (the forces of the long segment of the relatively immobile thoracic spine with the lumbar spine at the T-L junction increase the risk of nonunion)
  • 40. Wound infections • Postoperative wound infect ions with spinal instrumentation are usually due to Staph. aureus. • With titanium hardware it may respond to debridement of devitalized tissue and thorough washout (typically with 3 L of antibiotic irrigation flushed into the wound using a pulse lavage device – avoiding direct irrigation of any exposed dura) without removal of instrumentation, followed by antibiotics. • Persistent infection may respond to. If this is inadequate, removal of instrumentation may occasionally be required