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

Reflex Examination

Spinal Shock Physiologic disruption of all spinal cord function Present or not present Bulbocavernosus Reflex

Spinal Shock No BCR Flaccid paralysis, hypotonia, areflexia Hours to days + BCR Hyper 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

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

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 Series Poor historians Noncontiguous 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 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