Thoracolumbar Fractures

Patient Evaluation and Management

Outline

Epidemiology

Clinical evaluation ATLS Neuro exam Neurogenic / spinal shock

Classification of spinal cord injury Grading system Complete VS incomplete Incomplete cord syndromes

Pharmacological treatment

Outline

Radiographic Evaluation Plain Xray CT MRI Mylography

Spinal Stability

Classification of Fractures

Treatment of Specific Injuries

Epidemiology

Prevalence / Incidence

Bimodal Distribution

Cause

Multiple injury

Clinical Evaluation

Trauma / ATLS

ABC / GCS / 2 survey

Spine exam Red flags Inspect and palpate entire spine Be thorough

Clinical Evaluation

Complete Neuro Evaluation Dermatomal Sensory Testing

Assessment of Lumbar and Sacral motor root function

Reflex Examination

Dermatomal Sensory Testing

Lumbar and Sacral Motor Root Function

Lumbar and Sacral Motor Root Function

Reflex Examination

Spinal Shock

Physiologic disruption of all spinal cord function

Present or not present

Bulbocavernosus Reflex

Bulbocavernosus Reflex

Spinal Shock

No BCRFlaccid paralysis, hypotonia, areflexiaHours to days

+ BCRHyper reflexia, spasticity, clonus

Neurogenic shock

Disruption of descending sympathetic outflow

No sympathetic response and unopposed vagal tone

Cardiovascular instability

treatment

Classification of Spinal Cord injury

Many Grading Systems Impairment Based

Frankel ASIA Yale Motor Index

Function Based Modified Barthel Index

Grading of Spinal Cord Injury

Grading of Spinal Cord Injury

Complete VS Incomplete

Complete No function below level of injury Absence of sensation and voluntary

movement in S4/5 distribution

Incomplete Preservation of sensation in S4/5

distribution and voluntary control of anal sphincter

Incomplete cord lesion

Determined by anatomic location of tissue injury

Must understand cord anatomy

Predictably pattern based on involvement

Incomplete cord lesion

Incomplete cord lesion

Central Cord syndrome

Anterior Cord Syndrome

Posterior cord syndrome

Brown Sequard Syndrome

Cauda Equina Syndrome

Cord ends L1/2 disc space

Lower motor neuron axons

Perianal anesthesia, sphincter and bladder dysfunction

Pharmacological Treatment

Modify 2 injury cascade

Many drugs Corticosteroids Antioxidants Gangliosides Opiod antagonists Ca Channel Blockers etc

Pharmacological Treatment

NASCIS 3

Steroids

Controversial study design

Accepted Treatment Protocol Benefits Contraindications

Radiographic Evaluation

Trauma SeriesPoor historiansNoncontiguous injury

AP / Lat entire spine

Radiographic Evaluation

CT All cases of suspected injury to

posterior elements or posterior vertebral body

Radiographic Evaluation

MRI Indicated in all cases of neuro deficit? Both intrinsic and extrinsic cord

injuries

Mylogram Replaced by MRI

Spinal Stability

Holdsworth 1963

2 column theory

Post. ligaments

Spinal Stability

Denis 1983

CT Scan

3 column theory

Spinal Stability

Categorized major spinal injury into 4 groups:

1. Compression Fracture 2. Burst Fractures 3. Flexion Distraction Injuries 4. Fracture Dislocations

Compression Fracture

Failure of anterior column

Stable: Tlso, hyperextension bracing

Unstable (>50% height, >30% kyphosis, multi level)

Posterior instrumented fusion vs non OR Progressive deformity

Burst Fracture

Failure of anterior and middle column Axial compression

+/- failure of posterior column Compression or tensile force

Most common at T/L junction

Burst Fracture

Neuro intact <20-30 kyphosis, <45-50 canal

compromise >20-30 kyphosis, >45-50 canal

compromise

Neuro compromised

Decompression???

Complete Early stabilization Neuro outcome not changed by

decompression

Incomplete Stabilization and decompression beneficial

(no controversy) How to do it (controversial)

Decompression

Posterior Indirect (distraction and ligamentotaxis) Direct (transpedicle or posterolateral)

Anterior Large / midline / incomplete > 2 weeks since injury Following posterior decompression

Partial / complete corpectomy

Flexion Distraction Injury

Bone or soft tissue?

Fracture Dislocation

High energy

Most have neuro deficit

Goal: Stabilization for early mobilization

Incomplete deficit??

Gun Shot Wounds

Where is the bullet?Complete / incomplete?Progressive deficit?Bowel injury?

THE END!!!

Treatment Overview

Compression Fracture

Burst Fracture

Flexion Distraction Injury

Fracture Dislocation

Minor Injury