Lumbar spine fracture and dislocation ANDALIB,ALI.MD Fellowship of spine surgery Medical university of Isfahan Kashani hospital

Age : male under 30 yrs old MCA Fall from height Sport Geriatric population Falling from standing position

Anatomic Classification 2 or 3 Columns Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Holdsworth’62 Kelley & Whitesides ’68

3 Column Classification Denis Anterior - Ant 1/2 of disc /VB + ALL Middle - Post 1/2 of disc/VB + PLL Posterior - Post Elements

Mc Afee classification Compression FX 2.Burst Fx 3.Flex-Distraction 4.FX-Dx

Mechanism of injury and classification Wedge compression fx Isolated failure of ant column Forward flex Neurologic injury rare except multiple adjucent vertebra

Wedge compression fx

Wedge compression fx

BURST FX key features : posterior vertebral body cortex fracture with retropulsion of bone into the canal widening of the interpedicular distance relative to the adjacent levels

Stable burst fx Ant and mid column fail in compression Unstable burst fx Ant and mid column fail in compression and post column fail in compression,lat flex or rotation and not fail in distraction

Burst fx

Burst fx

Burst fx

FLEX-DISTRACTION Flex distraction injury(bony or soft tissue) Flex axis post to ALL Ant column fail in compression Mid and post column fail in tension Unstable pattern( PLC failed)

PLC POSTERIOR LIG. COMPLEX(PLC): SUPRASPINOUS LIG INTERSPINOUS LIG LIGAMENTUM FLAVUM FACET JOINT CAPSULE

Flex distraction injury

CT SCAN

MRI(flex-Distraction)

Traslational injury(fx -dx injury) Malalignment neural canal Three column fail in shear Displacment in transverse plane

Traslational injury(fx dx injury)

Primary care ABC and ATLS hypovolemic shock vs neurogenic shock Log rolling technique and back board

Logrolling technique

Associated injury 45% seat belt fx intra abdominal injury(spleen,liver) 20% noncontiguous spinal fx(total spine x ray) Head injury and fx of extremities

History and physical exam

Cauda Equina Syndrome Cord ends L1/2 disc space Lower motor neuron axons(nerve roots from L1-5 and S1-5) Perianal anesthesia(saddle anesthesia), sphincter and bladder dysfunction,severe LBP,motror defecit

Imaging AP x ray:interpedcular widening(burst fx), Increased interspinous process distance(damage of PLC) Lat x ray:kyphotic deformity(cobb angle),vertebral collapse, PVB

% Anterior Height Loss=A1[(a'+a")/2] x 100 % Posterior Height Loss=P/[(p'+p")/2] x 100

PVB

CT scan Comminution of vertebral body Retropulsed fragment(size,location) Post element fx Helical CT scan choice in polytrauma pt

Burst fx

MRI Disc herniation Epidural hematoma Lig injury(PLC) -fat suppressed T2-weighted image(STIR) Intrasubstans alteration of spina cord(myelomalacia) SCIWORA Gun shot(contraversial)

Treatment goals: Maintain or restore spinal stability Correct deformity(coronal,sagital) Maximum neurologic recovery Improve pain Prompt rehabilitation

T.L fx treatment is controversial operation vs nonoperation? 2. optimal approach for patients who will be treated operation?(Ant vs Post) 3. direct decompression vs indirect decompression ?

no definitive literature most spine surgeons would not recommend allowing persistent neural compression in the presence of a neurological deficit.

the treatment of thoracic and lumbar fractures Neurological status of a patient(spinal cord, conus medullaris, or cauda equina injuries) Global imbalance in the sagittal or coronal plane ( No regional deformity) injury to the PLC

Non operative Indication Close observe Height loss>50% Focal kyphosis>25deg PLC disruption Obvious instability Intact PLC stable burst fx, normal neurologic exam stable burst and complete spinal cord injury

Nonoperative treatment Jewett brace or TLSO(caudal to T7) L5-S1 segment not sufficiently stabilized

Jewett brace (lateral bending is less of a concern)

TLSO

Compression fx treatment TLSO 12 weeks Pain improve 3 to 6 week Upright radiograph after brace

OPERATIVE TREATMENT (Ant vs post) Short segment posterior instrumentation the most common construct used, but specific construct design is dictated by the injury pattern and the neurology of the patient

SURGICAL APPROACH posterior approach is often favored with disruption of the PLC anterior approach in an incomplete neurologic injury with obvious anterior thecal sac compression.

POST APPROACH ONLY With PLC disruption Rotational and shear injury Canal compromise <50% with neurologic deficit

POST APPROACH ligamentotaxis

Short or long costruct? Disadvantage Advantage of short costruct Less fused segment Short surgical time Low cost Disadvantage High failure rate and psudoarthrosis

Always long Osteoprosis Sever kyphosis Thoracolumbar junction Sever comminution

Short costruct in Post app. Low lumbar FX 360 fusion

ANT APPROACH Canal compromise>67% and neurologic deficit Sever comminutted fx More than 5 days and neurologic deficit Kyphosis>30 and neurologic deficit Reverse cortical sign

REVERSE CORTICAL SIGN

Post app in severe neurologic deficit In pt with poor prognosis(Fx-DX) Fx in proximal of thoracic vertebra decompresion with laminectomy

Contraindication of Ant. Post instability 1.kyphosis>30 2.v.body collapse>50% 3.Translation>2.5mm 4.PLC disruption Sever osteoprosis Chest &abdomen injury Sever obesity &pulmonary disease L4-L5 fx

Take home message Anatomical fracture reduction, although desirable, has not been the primary treatment objective.

Thank you for attention