Spine Spine fracturefracture

Dakheel A. Al-Dakheel, MBBS, SSC(Ortho)Dakheel A. Al-Dakheel, MBBS, SSC(Ortho)Orthopaedic surgery departmentOrthopaedic surgery department

King Fahd Hospital of the UniversityKing Fahd Hospital of the UniversityKhobar, KSA Khobar, KSA

NOTE : THIS PRESENTATION NOTE : THIS PRESENTATION DOES NOT REPLACE DOES NOT REPLACE

ATTENDANCE OR ATTENDANCE OR INFORMATION GIVEN IN THE INFORMATION GIVEN IN THE LECTURE.IT IS INTENDED AS LECTURE.IT IS INTENDED AS A HIGHLIGHT FOR THE TOPICA HIGHLIGHT FOR THE TOPIC

Thoraco-lumbar fractureThoraco-lumbar fracture

Incidence:Incidence:

• Neurological deficit may occur in 10–25% of patients Neurological deficit may occur in 10–25% of patients with spinal trauma with spinal trauma

• Incidence of spinal injury in the US is between 4 and 5.3 Incidence of spinal injury in the US is between 4 and 5.3 per hundred thousand of population per hundred thousand of population

• The common causes of spinal trauma include The common causes of spinal trauma include Road traffic accidents - 45% Road traffic accidents - 45% Falls - 20% Falls - 20% Sports -15% Sports -15%

• The male to female ratio is 4:1. The male to female ratio is 4:1. • The overall survival rate for patients with spinal injuries The overall survival rate for patients with spinal injuries

is 86% at 10 years is 86% at 10 years • Incidence of noncontiguous, multilevel vertebral injuries Incidence of noncontiguous, multilevel vertebral injuries

is approximately 20%is approximately 20%

Mechanism of injuryMechanism of injury

• MVA 50%MVA 50%• Falls 25%Falls 25%• Gunshot 15%Gunshot 15%• Sport 10%Sport 10%

• Most of patient with spine injury have an Most of patient with spine injury have an associated injuriesassociated injuries

• 80% multiple injuries80% multiple injuries• 26% head & face injury26% head & face injury• 16% major chest injury16% major chest injury• 10% major abdominal injury10% major abdominal injury• 8% long bone/ pelvic fractures8% long bone/ pelvic fractures

Incidence of missed Incidence of missed spinal fracturespinal fracture

• The prevalence of The prevalence of delay in diagnosisdelay in diagnosis of trauma of trauma• cervical spine is cervical spine is 22-33%22-33%• thoracolumbar spine is thoracolumbar spine is 5%.5%.

• 22%22% in tertiary centre. in tertiary centre.

• The main causes areThe main causes are :- :-• a low level of suspiciona low level of suspicion• failure to take proper radiographsfailure to take proper radiographs• poly traumapoly trauma• failure to interpret the x rayfailure to interpret the x ray• intoxicationintoxication• decrease level of consciousness decrease level of consciousness

Multiple Spinal Multiple Spinal FractureFracture

• Calenoff, Chessare,& Calenoff, Chessare,& Rogers reported an Rogers reported an

incidence of incidence of 4.5%4.5%

DemographicsDemographics

• SCI is predominantly a disease of young men.SCI is predominantly a disease of young men.

• Average age at injury is 29.7 years.Average age at injury is 29.7 years.

• Median age is 25 yearsMedian age is 25 years

• 82% male.82% male.

• Occurrence increase with increase Occurrence increase with increase daylightdaylight..

Medical problems in SCIMedical problems in SCI

• The leading cause of death in acute phase is The leading cause of death in acute phase is respiratory failure & pneumonia.respiratory failure & pneumonia.

• Pulmonary problemsPulmonary problems also the leading cause of also the leading cause of readmission in the readmission in the 11stst year. year.

Leading cause of death Leading cause of death in SCIin SCI

• Respiratory disease Respiratory disease 20.5%20.5%• Accident, poisoning, violence Accident, poisoning, violence 9.7%9.7%• Circulatory disease Circulatory disease 8.8%8.8%• Infections Infections 8.8%8.8%• Genitourinary disease Genitourinary disease 4.0%4.0%• Neoplasm Neoplasm 3.9%3.9%

Approach to Approach to Spine Trauma Spine Trauma

• Pre Hospital CarePre Hospital Care• The aim is to retrieve the patient from the The aim is to retrieve the patient from the

site of injury safely and rapidlysite of injury safely and rapidly• Transfer to a suitable facility.Transfer to a suitable facility.• spinal trauma should be suspected inspinal trauma should be suspected in

1.1. all unconscious patientsall unconscious patients

2.2. High energy traumaHigh energy trauma

3.3. Evidence of neurological deficitEvidence of neurological deficit

4.4. Multiple injuries Multiple injuries

• Proper extractionProper extraction• Intubation Intubation • ImmobilizationImmobilization• Cervical collar, sand bag, tape,Cervical collar, sand bag, tape,• ? Neck position ? Neck position

• ?pediatrics?pediatrics

Emergency AssessmentEmergency Assessment

•ATLSATLS

• Evaluating spinal injury begins in the Evaluating spinal injury begins in the secondary survey secondary survey

• History is taken & head to toe History is taken & head to toe examination examination

• Obtain history from Obtain history from • PatientPatient• Family membersFamily members• Paramedical personnel Paramedical personnel

HistoryHistory

• Mechanism of injuryMechanism of injury • Position of the patient when found Position of the patient when found • Transient motor or sensory loss Transient motor or sensory loss • Paradoxical breathing Paradoxical breathing • Seat belt Seat belt

InspectionInspection

• All clothing should be carefully removed • Any bleeding , abrasion or lacerations• Limb asymmetry • Voluntary limb movement • Chest expansion

PalpationPalpation

• Cervical collar removed carefullyCervical collar removed carefully

1.1. Tenderness Tenderness

2.2. Interspinous widening Interspinous widening

3.3. Malialignement of spinouse process Malialignement of spinouse process

4.4. Step off Step off

Neurological EvaluationNeurological Evaluation

• Neurological examination1. Sensory evaluation 2. Motor evaluation 3. Reflexes

Spinal reflexes Spinal reflexes

Cresmatic reflexCresmatic reflex

• Stocking inner thigh & observing the scrotum Stocking inner thigh & observing the scrotum movement movement

• Absence means UMNLAbsence means UMNL• Unilateral absence suggest LMNLUnilateral absence suggest LMNL

Sacral SparingSacral Sparing

1.1. Perianal/perineal sensationPerianal/perineal sensation2.2. Rectal toneRectal tone3.3. Big toe flexionBig toe flexion• Implies partial structural continuity Implies partial structural continuity

of white matter long tractsof white matter long tracts• May be only evidence of incomplete May be only evidence of incomplete

injuryinjuryhigher chance of recoveryhigher chance of recovery• Essential to check and documentEssential to check and document

Bulbocavernosus reflexBulbocavernosus reflex

• Pull glans or press Pull glans or press clitoris clitoris anal anal contraction (int. contraction (int. sphincter) around sphincter) around gloved fingergloved finger

• Absence is Absence is indicator of spinal indicator of spinal shockshock

Skeletal Trauma

RADIOLOGICAL RADIOLOGICAL ASSESMENTASSESMENT

• PLAIN FILM PLAIN FILM • AP & LATERALAP & LATERAL

CTCT

• Injury suspected on plain films• Better visualize fracture (specificity and

sensitivity)• Unable to adequately assess on plain films• Fracture or soft tissue injury in the plane of the

CT can be missed

MRIMRI

• Invaluable for assessing cord and soft tissuesInvaluable for assessing cord and soft tissues• R/O associated disc herniation ( facet R/O associated disc herniation ( facet

dislocations)dislocations)• Hemorrhage Hemorrhage vsvs edema in soft tissues ???? edema in soft tissues ????• Ligamentous tears and facet capsule Ligamentous tears and facet capsule

disruptions visualized with fat suppressiondisruptions visualized with fat suppression• May allow prognostic assessment of final May allow prognostic assessment of final

motor functionmotor function• Intrasubstance hematomaIntrasubstance hematoma

T1 T2 GRE

MRIMRI

Classification of Classification of ThoracoLumbar spine ThoracoLumbar spine

Fracture Fracture

Compression FractureCompression Fracture

Burst FractureBurst Fracture

Fracture DislocationFracture Dislocation

Flexion DistractionFlexion Distraction

ImagingImaging

Non-Operative Non-Operative ManagementManagement

Surgical interventionSurgical intervention

Complications of spine Complications of spine fracturefracture

• Neurological injuryNeurological injury• Instability ( pain & deformity)Instability ( pain & deformity)• Complication of surgery Complication of surgery

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