1. Thoracolumbar Fractures
Patient Evaluation and Management

4. 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

5. Outline Radiographic Evaluation Spinal Stability
Plain Xray CT
MRI
Mylography
Spinal Stability
Classification of Fractures
Treatment of Specific Injuries

6. Epidemiology Prevalence / Incidence Bimodal Distribution Cause
Multiple injury

7. Clinical Evaluation Trauma / ATLS ABC / GCS / 2 survey Spine exam
Red flags
Inspect and palpate entire spine
Be thorough

8. Clinical Evaluation Complete Neuro Evaluation
Dermatomal Sensory Testing
Assessment of Lumbar and Sacral motor root function
Reflex Examination

9. Dermatomal Sensory Testing

10. Lumbar and Sacral Motor Root Function

11. Lumbar and Sacral Motor Root Function

12. Reflex Examination

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

14. Bulbocavernosus Reflex

15. Spinal Shock No BCR Flaccid paralysis, hypotonia, areflexia
Hours to days
+ BCR
Hyper reflexia, spasticity, clonus

16. Neurogenic shock Disruption of descending sympathetic outflow
No sympathetic response and unopposed vagal tone
Cardiovascular instability
treatment

17. Classification of Spinal Cord injury
Many Grading Systems
Impairment Based
Frankel
ASIA
Yale
Motor Index
Function Based
Modified Barthel Index

18. Grading of Spinal Cord Injury

19. Grading of Spinal Cord Injury

20. Complete VS Incomplete
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

21. Incomplete cord lesion
Determined by anatomic location of tissue injury
Must understand cord anatomy
Predictably pattern based on involvement

22. Incomplete cord lesion

23. Incomplete cord lesion

24. Central Cord syndrome

25. Anterior Cord Syndrome

26. Posterior cord syndrome

27. Brown Sequard Syndrome

28. Cauda Equina Syndrome Cord ends L1/2 disc space
Lower motor neuron axons
Perianal anesthesia, sphincter and bladder dysfunction

29. Pharmacological Treatment
Modify 2 injury cascade
Many drugs
Corticosteroids
Antioxidants
Gangliosides
Opiod antagonists
Ca Channel Blockers
etc

30. Pharmacological Treatment
NASCIS 3
Steroids
Controversial study design
Accepted Treatment Protocol
Benefits
Contraindications

31. Radiographic Evaluation
Trauma Series
Poor historians
Noncontiguous injury
AP / Lat entire spine

32. Radiographic EvaluationCT
All cases of suspected injury to posterior elements or posterior vertebral body

34. Radiographic Evaluation
MRI
Indicated in all cases of neuro deficit?
Both intrinsic and extrinsic cord injuries
Mylogram
Replaced by MRI

35. Spinal Stability
Holdsworth 1963
2 column theory
Post. ligaments

36. Spinal Stability
Denis 1983
CT Scan
3 column theory

37. Spinal Stability Categorized major spinal injury into 4 groups:
1. Compression Fracture
2. Burst Fractures
3. Flexion Distraction Injuries
4. Fracture Dislocations

38. 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

39. Burst Fracture Failure of anterior and middle column
Axial compression
+/- failure of posterior column
Compression or tensile force
Most common at T/L junction

40. Burst Fracture Neuro intact Neuro compromised
<20-30 kyphosis, <45-50 canal compromise
>20-30 kyphosis, >45-50 canal compromise
Neuro compromised

41. Decompression??? Complete Incomplete Early stabilization
Neuro outcome not changed by decompression
Incomplete
Stabilization and decompression beneficial (no controversy)
How to do it (controversial)

42. Decompression Posterior Anterior
Indirect (distraction and ligamentotaxis)
Direct (transpedicle or posterolateral)
Anterior
Large / midline / incomplete
> 2 weeks since injury
Following posterior decompression
Partial / complete corpectomy

46. Flexion Distraction Injury
Bone or soft tissue?

47. Fracture Dislocation High energy Most have neuro deficit Goal:
Stabilization for early mobilization
Incomplete deficit??

48. Gun Shot Wounds Where is the bullet? Complete / incomplete?
Progressive deficit?
Bowel injury?

49. THE END!!!

50. Treatment Overview

51. Compression Fracture

52. Burst Fracture

53. Flexion Distraction Injury

54. Fracture Dislocation

55. Minor Injury