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