1. Traumatic conditions of Dorso-Lumbar spine

5. Anatomy of Thoracic Spine Kyphosis is natural alignment Kyphosis is natural alignment Narrow spinal canal Narrow spinal canal Facet orientation Facet orientation Rib factor on stability Rib factor on stability Conus at T12-L1 Conus at T12-L1

6. Anatomy of Lumbar Spine Lordosis is natural alignment Lordosis is natural alignment Larger vertebral bodies Larger vertebral bodies Facet orientation Facet orientation Cauda equina Cauda equina

7. Thoracolumbar Junction Transition Zone Transition Zone Kyphosis Lordosis Mechanical Difference: Mechanical Difference: Lumbar spine less stiff in flexion Lumbar spine less stiff in flexion

8. Transition Zone: Predisposed to Failure Little opportunity for force dispersion Central loading of T-L junction Not anatomically disposed to transfer force Not anatomically disposed to transfer force

9. Patient Evaluation Pre-hospital care Pre-hospital care EMT personnel EMT personnel Initial assessment Initial assessment Transport and immobilization Transport and immobilization

10. Patient Evaluation ABC’s of Trauma ABC’s of Trauma History History Physical Examination Physical Examination Neurological Classification Neurological Classification

11. Clinical Assessment Inspection Inspection Palpation Palpation Neurological Evaluation Neurological Evaluation ASIA Impairment Scale ASIA Impairment Scale Sensory Evaluation Sensory Evaluation Motor Evaluation Motor Evaluation Reflex Evaluation Reflex Evaluation Bulbocavernosus, Babinski Bulbocavernosus, Babinski

12. Clinical Assessment Associated Injuries Associated Injuries Meyer, 1984 – 28% have other major organ system injuries Meyer, 1984 – 28% have other major organ system injuries Noncontiguous spine fractures 3-56% Noncontiguous spine fractures 3-56% Always monitor Hematocrit Always monitor Hematocrit GU: Foley recommended, check post-void residuals, if abnormal get cystometrogram GU: Foley recommended, check post-void residuals, if abnormal get cystometrogram GI: prepare for ileus. GI: prepare for ileus.

13. Radiographic Evaluation Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P pelvis Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P pelvis Obtunded patients require further skeletal survey Obtunded patients require further skeletal survey CT scan – bony injuries CT scan – bony injuries MRI – images spinal cord, intervertebral discs, ligamentous structures MRI – images spinal cord, intervertebral discs, ligamentous structures

14. Thoracolumbar Fractures Controversies CLASSIFICATION!!!!! Indications for surgery Optimal time for surgery Best approach for surgery

15. CLASSIFICATION SYSTEMS Convey information Produce treatment plan Monitor patient progress Research tool

16. Böhler 1930 Importance of injury mechanism Importance of injury mechanism 6 types of spinal fractures included in system 6 types of spinal fractures included in system Compression Compression Flexion Flexion Extension Extension Lateral flexion Lateral flexion Shear Shear Torsional Torsional

17. DENIS 3 Column Classification Anterior - Ant 1/3 of disc /VB + ALL Middle - Post 1/3 of disc/VB + PLL Posterior - Post Elements

18. McAfee Classification Six types CT based-100 patients Middle column most important

19. AO Mechanistic Classification Complex subdivisions to include most fractures

20. Spinal Cord Injury Accurately Document Neurological Status Remember SPINAL SHOCK Prognosis of deficit at 48hours

21. Spinal Cord Injury FRANKEL ANo motorNo sensation BNo motorMin. sensation CMotor(2-3)Sensation DMotor(4-5)Sensation ENormalNormal

22. Spinal Cord Injury A.S.I.A. AComplete - no motor or sensation BIncomplete - sensation, no motor CIncomplete - sensation, motor<3 DIncomplete - sensation, motor  3 ENormal

23. Spinal Cord Injury- Power MRC Grade 012345 none visible contraction contracts, not against gravity contracts against gravity not resistance contracts against resistance normal

24. Treatment Spine Trauma Severity Score Determined by: Injury Morphology Injury Morphology Neurology Neurology Ligamentous Integrity Ligamentous Integrity

25. Next Step - Direct TX Assign Points ConservativeSurgery

26. Treatment Injuries with 3 points or less = non operative Injuries with 3 points or less = non operative Injuries with 4 points=Nonop vs Op Injuries with 4 points=Nonop vs Op Injuries with 5 points or more = surgery Injuries with 5 points or more = surgery

27. Non – Operative Treatment Options No treatment advice / restrict activity Spinal ‘immobilisation’ Bed rest Lumbar pillow / Log rolling Casting / Bracing Combination treatment

28. THE AIMS OF TREATMENT Prevent neurological deterioration Minimise spinal deformity Fracture healing Minimise complications Acceptable function

29. Complications Bed rest sequelae Respiratory compromise Worsening of deformity Neurological deterioration

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