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

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

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

4. 3 Column Classification
Denis
Anterior - Ant 1/2 of disc /VB + ALL
Middle - Post 1/2 of disc/VB PLL
Posterior - Post Elements

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

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

7. Wedge compression fx

8. Wedge compression fx

9. 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

10. 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

11. Burst fx

12. Burst fx

13. Burst fx

14. 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)

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

16. Flex distraction injury

17. CT SCAN

18. MRI(flex-Distraction)

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

20. Traslational injury(fx dx injury)

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

22. Logrolling technique

23. 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

25. History and physical exam

27. 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

29. 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

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

31. PVB

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

34. Burst fx

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

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

37. 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 ?

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

39. 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

40. 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

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

42. Jewett brace (lateral bending is less of a concern)

43. TLSO

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

45. 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

46. 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.

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

48. POST APPROACH ligamentotaxis

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

50. Always long Osteoprosis Sever kyphosis Thoracolumbar junction
Sever comminution

51. Short costruct in Post app.
Low lumbar FX
360 fusion

52. 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

53. REVERSE CORTICAL SIGN

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

55. 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

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

59. Thank you for attention