thoracolumbar fractures patient evaluation and management
TRANSCRIPT
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Thoracolumbar Fractures
Patient Evaluation and Management
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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
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Outline
Radiographic Evaluation Plain Xray CT MRI Mylography
Spinal Stability
Classification of Fractures
Treatment of Specific Injuries
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Epidemiology
Prevalence / Incidence
Bimodal Distribution
Cause
Multiple injury
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Clinical Evaluation
Trauma / ATLS
ABC / GCS / 2 survey
Spine exam Red flags Inspect and palpate entire spine Be thorough
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Clinical Evaluation
Complete Neuro Evaluation Dermatomal Sensory Testing
Assessment of Lumbar and Sacral motor root function
Reflex Examination
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Dermatomal Sensory Testing
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Lumbar and Sacral Motor Root Function
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Lumbar and Sacral Motor Root Function
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Reflex Examination
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Spinal Shock
Physiologic disruption of all spinal cord function
Present or not present
Bulbocavernosus Reflex
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Bulbocavernosus Reflex
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Spinal Shock
No BCRFlaccid paralysis, hypotonia, areflexiaHours to days
+ BCRHyper reflexia, spasticity, clonus
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Neurogenic shock
Disruption of descending sympathetic outflow
No sympathetic response and unopposed vagal tone
Cardiovascular instability
treatment
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Classification of Spinal Cord injury
Many Grading Systems Impairment Based
Frankel ASIA Yale Motor Index
Function Based Modified Barthel Index
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Grading of Spinal Cord Injury
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Grading of Spinal Cord Injury
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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
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Incomplete cord lesion
Determined by anatomic location of tissue injury
Must understand cord anatomy
Predictably pattern based on involvement
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Incomplete cord lesion
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Incomplete cord lesion
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Central Cord syndrome
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Anterior Cord Syndrome
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Posterior cord syndrome
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Brown Sequard Syndrome
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Cauda Equina Syndrome
Cord ends L1/2 disc space
Lower motor neuron axons
Perianal anesthesia, sphincter and bladder dysfunction
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Pharmacological Treatment
Modify 2 injury cascade
Many drugs Corticosteroids Antioxidants Gangliosides Opiod antagonists Ca Channel Blockers etc
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Pharmacological Treatment
NASCIS 3
Steroids
Controversial study design
Accepted Treatment Protocol Benefits Contraindications
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Radiographic Evaluation
Trauma SeriesPoor historiansNoncontiguous injury
AP / Lat entire spine
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Radiographic Evaluation
CT All cases of suspected injury to
posterior elements or posterior vertebral body
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Radiographic Evaluation
MRI Indicated in all cases of neuro deficit? Both intrinsic and extrinsic cord
injuries
Mylogram Replaced by MRI
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Spinal Stability
Holdsworth 1963
2 column theory
Post. ligaments
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Spinal Stability
Denis 1983
CT Scan
3 column theory
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Spinal Stability
Categorized major spinal injury into 4 groups:
1. Compression Fracture 2. Burst Fractures 3. Flexion Distraction Injuries 4. Fracture Dislocations
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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
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Burst Fracture
Failure of anterior and middle column Axial compression
+/- failure of posterior column Compression or tensile force
Most common at T/L junction
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Burst Fracture
Neuro intact <20-30 kyphosis, <45-50 canal
compromise >20-30 kyphosis, >45-50 canal
compromise
Neuro compromised
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Decompression???
Complete Early stabilization Neuro outcome not changed by
decompression
Incomplete Stabilization and decompression beneficial
(no controversy) How to do it (controversial)
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Decompression
Posterior Indirect (distraction and ligamentotaxis) Direct (transpedicle or posterolateral)
Anterior Large / midline / incomplete > 2 weeks since injury Following posterior decompression
Partial / complete corpectomy
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Flexion Distraction Injury
Bone or soft tissue?
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Fracture Dislocation
High energy
Most have neuro deficit
Goal: Stabilization for early mobilization
Incomplete deficit??
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Gun Shot Wounds
Where is the bullet?Complete / incomplete?Progressive deficit?Bowel injury?
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THE END!!!
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Treatment Overview
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Compression Fracture
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Burst Fracture
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Flexion Distraction Injury
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Fracture Dislocation
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Minor Injury