Spinal Cord Injuries; Spinal Cord Injuries; Thoracolumbar FracturesThoracolumbar Fractures

Donald S. Corenman, M.D., D.C.

Anatomy of the Cord and CaudaAnatomy of the Cord and Cauda Spinal cord from foramen magnum to L1 Conus at L1 for bowel and bladder (nervi

eriganties S1-S5) Peripheral nerves for lower extremities start from

T9-T12 L1 roots start innervation of lower extremities Thoracic blood supply to the cord tenuous at T10-

T12 (artery of Adamkowitz) Lumbar blood supply abundant

Physiological Anatomy of the Physiological Anatomy of the Thoracic SpineThoracic Spine

Facets lie in the frontal plane- allowing rotation Ribs resist rotation and add 3x the normal stiffness

in lateral rotation Kyphosis of the T spine loads the anterior column Lower 2 vertebra have floating ribs and no

costotransverse articulations Canal size in thoracic spine relatively small

Physiological Anatomy of the Physiological Anatomy of the Lumbar SpineLumbar Spine

Large discs allow more ROMFacets prevent rotationSpinal canal widerLordosis loads the facets

Thoracolumbar JunctionThoracolumbar Junction

Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress riser)

Lowest 2 thoracic vertebra have less extrinsic stability secondary to changes in facet orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to stabilize, therefore less rotational resistance)

In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into lordosis leaving the transition vertebra exposed to pure compression

Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2 vertebra at the thoracolumbar junction

Mechanisms of InjuryMechanisms of Injury How much energy was imparted into the

individual (fall from height vs fall from level skiing vs ejection from car)

What was the loading force (impact onto buttocks vs impact onto flexed neck vs impact from object)

What was the force trajectory (beam impact vs restrained MVA vs collision with tree)

What was the quality of the tissue of the recipient to resist force (young adult vs senior/ preexisting pathology)

Patient HistoryPatient History

Loss of consciousnessLoss of motor strength (temp or present)Sensory changes (temp or present)Incontinence (at scene vs current)Localized pain to other areasDyspnea (pneumothorax)Past medical history

Patient ExaminationPatient Examination ABCs first, then trauma examination Motor strength L1-S1(for suspected

thoracolumbar injury) Sensory C4-S3 Reflexes (hyperreflexia asso. with preexisting

myelopathy) Rectal exam (sensory, tone and contraction)

(missed conus injury) Bulbocavernosis (if necessary)

Neurologic InjuryNeurologic Injury

Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours

Only for central injuries- not peripheral nerve injuries (conus is central injury)

Concordant Spinal InjuriesConcordant Spinal Injuries

3 patterns Watch out for

distracting injuries 10% of patients can

have other spinal injuries

Severity of trauma- splenic/ liver and vessel injury

Classification SystemClassification SystemHoldsworth 2 column theoryDenis 3 column theory

Classification of InjuriesClassification of Injuries Simple Compression (1-2 column injury) Stable burst (2-3 column injury) Unstable burst (3 column injury) Flexion distraction (2 nonconjoined columns) Chance (3 column failure all in tension) Fracture dislocation (3 column injury) Pure Dislocation (rare) (3 column injury) Pathological (any and all) Insufficiency (any and all) Multiple contiguous fractures (nly 1-2 columns)

Compression FracturesCompression Fractures

Only anterior column injuryMiddle? and post. OKAnt. column less than 30%No more than 10 deg kyphosisNo neuro injury

Flexion distractionFlexion distraction Easy to miss- may

look benign Anterior column >

50% crushed Middle column mainly

intact Significant spinous

process widening Unstable

Stable BurstStable Burst

Both ant and middle column involvement

Minimal kyphosis No neuro involvement No laminar fracture

Unstable BurstUnstable Burst 3 column involvement Possible neuro

involvement Severe communition Significant pedicle

widening Look for laminar

fracture (asso. with root entrapment)

Chance FracturesChance Fractures Old “Seatbelt injuries” Center of rotation is

anterior to ALL May be “bony” chance or

purely ligamentous Normally neuro intact “Bony” stable,

ligamentous unstable even though all are 3 column injuries

Fracture DislocationsFracture Dislocations Translation in lower

lumbar spine may be developmental (nly L3-S1 spondylolysthesis)

Always abnormal in thoracic spine (ribs)

Unstable Normally- neuro deficit Can be hidden at mid

thoracic spine 3 column injury

Pathological Fractures Pathological Fractures

Normally in patient with history of CA

May be hard to distinguish from insufficiency fracture

May be multiple levels Fracture out of proportion

to force of trauma Suspicion calls for MRI

and ?Bx

Insufficiency FracturesInsufficiency Fractures Normally in elderly

females Osteopenia/malacia Bones have “washed out”

appearance Minimal force vectors Multiple levels (normally) Kyphosis greater than 70

degrees may need surgery ?Vertebroplasty

So how do you read the films?So how do you read the films?Look at alignment of vertebraOn AP- measure pedicle distance and look

for both SP splaying and laminar fracturesMeasure kyphosis from intact endplatesMeasure anterior and middle column heightLook for retropulsionHigh index of suspicion for other fractures

Look at alignmentLook at alignment

Look at how the anterior and posterior aspects of the body line up

Spinous Process SplayingSpinous Process Splaying

Indicative of either chance (stable) or flexion distraction (unstable) injury

Laminar SplitLaminar Split Associated with burst

or flex-distraction fractures

Look on exam for root injuries (they become entrapped in lamina)

Possible association with dural tear

Measure KyphosisMeasure Kyphosis

Measure from closest intact endplates

Measure Ant. and Middle Measure Ant. and Middle Column HeightsColumn Heights

Compare with vertebra above and below

Measure pedicle distancesMeasure pedicle distances

Compare to vertebra adjacent to injured one

Anterior Column Fx TreatmentAnterior Column Fx Treatment

Simple compressions can be placed in a Jewett or TLSO off the shelf brace and discharged from the ED or office as long as pain is controlled, fracture is stable with new standing x-rays in brace and they don’t have an ileus. Cannot treat fractures above T6 without cervical extension

Stable Bursts and Lateral Stable Bursts and Lateral Compression FracturesCompression Fractures

Admit- pain mgmt and neuro checks

Brace management -Off the shelf TLSO for simple compressions greater than 30% and lateral compressions, Custom TLSO for unusual body habitis, severe bursts and pts that need stability testing. CASH for insufficiency Fxs

Complications from FractureComplications from Fracture Pneumothorax (thoracic Fxs with asso rib Fxs)/ Ileus (30-60%) Splenic, liver and vessel injury (mechanism of injury) DVT/PE Decubitis UTI Pneumonia Renal failure (hydronephrosis from cauda equina

involvement)

Stress TestingStress Testing Fracture that may be

unstable in custom TLSO Bed rest until TLSO

arrives X Rays supine/ 45deg/ 90

deg/ upright Stop if neuro involvement,

sig. Pain increase or sig. Increased kyphosis

45 degrees vs upright45 degrees vs upright

Surgical IndicationsSurgical Indications Neurological Involvement Flexion distraction injury Greater than 50% canal compromise with

>15 degrees kyphosis >25 degrees kyphosis Failure of stress testing (severe pain,

angulation above 25 degrees, neuro symptoms)

Fracture dislocations Soft tissue “chance” fractures

Time to healingTime to healing

Most non-surgical fractures heal within 12 weeks Jewett/ TLSO on whenever upright When healed- 4 weeks of PT for deconditioning Residuals of barometric sensitive discomfort and

occasionally problems with lifting 10 % may need to go on to surgery from

instability pain

Thank YouThank You