traumatic conditions of dorso-lumbar spine

Traumatic conditions Traumatic conditions of Dorso-Lumbar of Dorso-Lumbar

spinespine

Anatomy of Thoracic SpineAnatomy of Thoracic Spine

Kyphosis Kyphosis is is natural alignmentnatural alignment

Narrow spinal Narrow spinal canalcanal

Facet orientationFacet orientation Rib factor on Rib factor on

stabilitystability Conus at T12-L1Conus at T12-L1

Anatomy of Lumbar SpineAnatomy of Lumbar Spine

LordosisLordosis is natural is natural alignmentalignment

Larger vertebral Larger vertebral bodiesbodies

Facet orientationFacet orientation Cauda equinaCauda equina

Thoracolumbar JunctionThoracolumbar Junction

Transition ZoneTransition Zone

Kyphosis Kyphosis LordosisLordosis

Mechanical Difference:Mechanical Difference:

Lumbar spine less stiff in Lumbar spine less stiff in flexionflexion

Transition Zone:Transition Zone:Predisposed to FailurePredisposed to Failure

Little opportunity for force Little opportunity for force dispersiondispersion

Central loadingCentral loading

of T-L junctionof T-L junction

Not anatomically Not anatomically disposed to transfer forcedisposed to transfer force

Patient EvaluationPatient Evaluation

Pre-hospital carePre-hospital care

EMT personnelEMT personnel Initial assessmentInitial assessment Transport and immobilizationTransport and immobilization

Patient EvaluationPatient Evaluation

ABC’s of TraumaABC’s of Trauma HistoryHistory Physical ExaminationPhysical Examination Neurological ClassificationNeurological Classification

Clinical AssessmentClinical Assessment

InspectionInspection PalpationPalpation Neurological EvaluationNeurological Evaluation

ASIA Impairment ScaleASIA Impairment Scale Sensory EvaluationSensory Evaluation Motor EvaluationMotor Evaluation Reflex EvaluationReflex Evaluation

Bulbocavernosus, BabinskiBulbocavernosus, Babinski

Clinical AssessmentClinical Assessment

Associated InjuriesAssociated Injuries Meyer, 1984 – 28% have other major Meyer, 1984 – 28% have other major

organ system injuriesorgan system injuries Noncontiguous spine fractures 3-56%Noncontiguous spine fractures 3-56% Always monitor HematocritAlways monitor Hematocrit GU: Foley recommended, check post-void GU: Foley recommended, check post-void

residuals, if abnormal get cystometrogramresiduals, if abnormal get cystometrogram GI: prepare for ileus.GI: prepare for ileus.

Radiographic EvaluationRadiographic Evaluation

Trauma series includes: lateral cervical, chest, Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P lateral thoracic, A/P and lateral lumbar and A/P pelvispelvis

Obtunded patients require further skeletal surveyObtunded patients require further skeletal survey

CT scan – bony injuriesCT scan – bony injuries

MRI – images spinal cord, intervertebral discs, MRI – images spinal cord, intervertebral discs, ligamentous structuresligamentous structures

Thoracolumbar Fractures Thoracolumbar Fractures ControversiesControversies

CLASSIFICATION!!!!!CLASSIFICATION!!!!!Indications for surgeryIndications for surgery

Optimal time for surgeryOptimal time for surgery

Best approach for surgeryBest approach for surgery

CLASSIFICATION CLASSIFICATION SYSTEMSSYSTEMS

Convey informationConvey information

Produce treatment planProduce treatment plan

Monitor patient progressMonitor patient progress

Research toolResearch tool

BBööhler 1930hler 1930

Importance of injury mechanismImportance of injury mechanism

6 types of spinal fractures included in 6 types of spinal fractures included in systemsystem• CompressionCompression• Flexion Flexion • Extension Extension • Lateral flexionLateral flexion• ShearShear• TorsionalTorsional

DENIS 3 Column ClassificationDENIS 3 Column Classification

AnteriorAnterior - Ant 1/3 of disc - Ant 1/3 of disc /VB + ALL/VB + ALL

MiddleMiddle - Post 1/3 of - Post 1/3 of disc/VB + PLLdisc/VB + PLL

PosteriorPosterior - Post Elements - Post Elements

McAfee ClassificationMcAfee Classification

• Six types

• CT based-100 patients

• Middle column most important

AO Mechanistic ClassificationAO Mechanistic ClassificationComplex subdivisions to include most Complex subdivisions to include most

fracturesfracturesTypes Groups Subgroups Specificastions

A1.1A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3

A1.3A2.1

A compression A2 split A2.2A2.3A3.1 A3.1.1, A3.1.2, A3.1.3

A3 burst A3.2 A3.2.1, A3.2.2, A3.2.3A3.3 A3.3.1, A3.3.2, A3.3.3

B1.1 B1.1.1, B1.1.2, B1.1.3B1 post ligamentous B1.2 B1.2.1, B1.2.2, B1.2.3

B2.1B distraction B2 post osseous B2.2 B2.2.1, B2.2.2

B2.3 B2.3.1, B2.3.2B3.1 B3.1.1, B3.1.2

B3 anterior B3.2B3.3

C1.1C1 A with rotation C1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4

C2.1 C2.1.1, C2.1.2, C2.1.3, C2.1.4B rotation C2 B with rotation C2.2 C2.2.1, C2.2.2, C2.2.3

C2.3 C2.3.1, C2.3.2, C2.3.3C3 shear C3.1

C3.2

Spinal Cord InjurySpinal Cord Injury

Accurately Document Neurological StatusAccurately Document Neurological Status

Remember SPINAL SHOCKRemember SPINAL SHOCK

Prognosis of deficit at 48hoursPrognosis of deficit at 48hours

Spinal Cord InjurySpinal Cord Injury

FRANKELFRANKEL

AA No motorNo motor No sensationNo sensation

BB No motorNo motor Min. sensationMin. sensation

CC Motor(2-3)Motor(2-3) SensationSensation

DD Motor(4-5)Motor(4-5) SensationSensation

EE NormalNormal NormalNormal

Spinal Cord InjurySpinal Cord Injury

A.S.I.A.A.S.I.A.

AA Complete - no motor or sensationComplete - no motor or sensation

BB Incomplete - sensation, no motorIncomplete - sensation, no motor

CC Incomplete - sensation, motor<3Incomplete - sensation, motor<3

DD Incomplete - sensation, motorIncomplete - sensation, motor33

EE NormalNormal

Spinal Cord Injury- PowerSpinal Cord Injury- PowerMRC MRC

GradeGrade

00

11

22

33

44

55

nonenone

visible contractionvisible contraction

contracts, not against gravitycontracts, not against gravity

contracts against gravity not contracts against gravity not resistanceresistance

contracts against resistancecontracts against resistance

normalnormal

TreatmentTreatmentSpine Trauma Severity Spine Trauma Severity

ScoreScoreDetermined by:Determined by:

Injury MorphologyInjury MorphologyNeurologyNeurologyLigamentous IntegrityLigamentous Integrity

Next Step - Direct TXNext Step - Direct TX

Assign Points

Conservative

Surgery

TreatmentTreatment

Injuries with Injuries with 3 points3 points or less or less = = non operativenon operative

Injuries with 4 points=Nonop Injuries with 4 points=Nonop vs Opvs Op

Injuries with Injuries with 5 points5 points or or more = more = surgerysurgery

Non – Operative Treatment Non – Operative Treatment OptionsOptions

No treatmentNo treatment

advice / restrict activityadvice / restrict activity

Spinal ‘immobilisation’Spinal ‘immobilisation’

Bed restBed rest

Lumbar pillow / Log rollingLumbar pillow / Log rolling

Casting / BracingCasting / Bracing

Combination treatmentCombination treatment

THE AIMS OF TREATMENTTHE AIMS OF TREATMENT

Prevent neurological deteriorationPrevent neurological deterioration

Minimise spinal deformityMinimise spinal deformity

Fracture healingFracture healing

Minimise complicationsMinimise complications

Acceptable functionAcceptable function

ComplicationsComplications

Bed rest sequelaeBed rest sequelae

Respiratory compromiseRespiratory compromise

Worsening of deformityWorsening of deformity

Neurological deteriorationNeurological deterioration

THANK YOUTHANK YOU