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 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

12. Reflex Examination

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

20. 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

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

22. 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 Evaluation CT 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 <20-30 kyphosis, <45-50 canal compromise >20-30 kyphosis, >45-50 canal compromise Neuro compromised

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

42. Decompression Posterior 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