Thoraco lumbar fractures

ThoracolumbarFractures

Thoracic and lumbar fractures account for 50% of all spinal traumatic fractures.

• Incidence.

4-5 per 100,000.

18 - 35 years.

Male\ Female = 4:1

Neurologic injury 25% of cases.

• 65% of TL#s occurs between the T9&L2 vertebrae.

(thoracolumbar Junction)

Functional spinal unit

Composed of: • 2 adjacent vertebrae • Facet joint• Inter vertebral disc • Intervening ligaments

4

This unit is responsible for Movement of spine

Thoracic Spine

• Kyphotic Curve.

• Ribs more stiffness, resist rotation.

• T11,T12 have floating ribs;

No costotransverse articulations.

No sternal attachement.

•Facet orientation limited flexion/extension.

•Canal is relatively small.

Lumbar Spine

• Lordotic Curve.

• Large discs More mobility

• Spinal canal wider.

• Spinal cord ended at L1.

• Facet orientation more

flexion/extension.

•Transition between the stiff kyphotic thoracic spine

and mobile lordotic lumbar spine.

• In trauma;

Thoracic spine deforms into kyphosis,

Lumbar spine into lordosis leaving,

Junction exposed to pure compression.

• T11, T12 are less stable less resistance to

rotation more stress.

Why Thoraco-lumbar junction is more succeptible?

ETIOLOGY

• High energy trauma (RTA 50%)

• Falls.

• Sports accident.

• Gunshot injury.

• Osteoporosis

• Tumors

• Weak bone(malnutrition,renal,RA,DM,endocrine).

– 16% major chest injury

– 10% major abdominal injury

– 8% long bone/ pelvic fractures

Spinal fracture should be suspected in;1. Comatosed patient.

2. High energy trauma.

3. Evidence of neurological deficit.

4. Multiple injuries:

Missed TL#s reach 5%, And reach 22% in cervical fractures.

The main causes are,

• Poly trauma.

• low level of suspicion.

• Intoxication \ unconsciousness

• Failure to take proper radiographs.

• Failure to interpret the x ray.

CLASSIFICATION

Three column theory

ANTERIOR COLUMN

MIDDLE COLUMN

POSTERIOR COLUMN

• 45% of TL#s.

• Anterior column failure

(Anterior or lateral flexion)

• Middle, Post. Column intact.

• Usually no Neurological deficits.

COMPRESSION (WEDGE) FRACTURE

Burst fractures

• 15 % of TL#s

• Anterior& middle column failure.

(Axial compression)

• Most common at T/L junction

• Neurological deficit.

FLEXION-DISTRACTION = SEAT-BELT-TYPE = CHANCE #

• Posterior &middle columns failure.

(hyperflexion then tension forces)

• Anterior column

- partial damage.

- functions like a hinge.

Fracture-Dislocation

• Failure of all columns (compression, tension,

rotation, or shear).

• anterior hinge is disrupted.

• Dislocation.

• Severe neurological deficit.

Approach to Spine

Trauma

Pre Hospital Care

• Proper extraction & Immobilization;

Cervical collar

Hard board (log roll)

Sand bag

Tape

• Airway protection.

• Rapid & safe transfer for suitable facilities.

Emergency Assessment

ABCs & Immobilization Hemodynamically stable

Secondary Survey:

1-Log roll technique

2-Remove the spinal board

3-Remove cervical collar carefully

4-Brief history (Mechanism, movement, position)

Inspection

• Clothes removed.

• Bleeding , abrasion or lacerations.

• Deformity, Swelling.

• Limb asymmetry (movements).

• Chest expansion, Paradoxical breathing.

Palpation

1. Tenderness.

2. Swelling.

3. Interspinous widening (>7mm).

4. Malialignement of spinouse process .

5. Step off.

Initial Neurological Assessment

Initial Assessment:Motor Examination

Initial Assessment:Motor Examination

Initial Assessment:Sensation

Initial Assessment:Reflexes

1. Babiniski sign.

2. Perianal/perineal sensation

3. Rectal tone

4. Cresmatic reflex

RADIOLOGICAL ASSESMENT

X-RAYS Lateral View

• Alignment.

• Contour of bodies.

• Disc spaces.

• Angulation.

• Encroachment on canal.

• Loss of vertebral body height.

X-RAYS Lateral View

• Measurement of degree of vertebral body compression.

• Look at how the ant.& post. aspects of the body line up.

X-RAYS Lateral View

X-RAYS Lateral View

• Measure Kyphosis.

• Measure from closest intact endplates.

• Alignment

• Symmetry/ Shape of pedicles

• Interpedicular distance

• Position of spinous process

• Contour of bodies

X-RAYS A-P view

X-RAYS A-P view

• Lateral vertebral body height.

• Interpedicular

distance.

• Distance between the spinousprocesses.

CT Scan

• Accurate assessment

of bone.

1- Comminution.

2- Canal compromise.

3- Dislocation.

MRI

• Accurate assessment

of soft tissue.

1- Neurological deficits.

2- Cord lesion.

3- Ligament injury.

4- Disc herniation.

5- Hematoma.

Treatment

Goals

1. Maximise neurological recovery .

2. Maintain or restore spinal alignment.

3. Obtain a healed and stable spinal column.

4. Prevent future deformity.

Spinal Cord Injury

Methylprednisolone

• 30mg/kg iv bolus over 15min.

• 5.4 mg/kg/h infusion over 23 hrs (first 3 hours).

• 5.4 mg/kg/h for 47hrs (if > 3 – 8 hrs passed).

Proton pump inhibitor & LMW Heparin

Non-operative treatment

Indications:• Ant. vertebral height loss < 40%.

• Canal compromise < 40%.

• kyphosis < 25 degrees.

Bed Rest• Strict bed rest for 3- 4 weeks.

• Avoid flexion, sit-ups, & spinal rotation.

• Avoid weight bearing.

• Bed rolling encouraged.

Bracing

• Treated with brace for 6-8 weeks.

• Wear on whenever upright.

• Ambulation & Transfers.

• Solid healing 8-12 weeks.

Operative treatment

Indications:• Ant. vertebral height loss > 40%.

• Canal compromise > 40%.

• Kyphosis > 25 degrees.

• Neural compression.

Aim

• Neural Decompression.

• Stabilization.

• Solid fusion.

Surgical options

Anterior FixationPosterior Fixation

Vertebroplasty

Kyphoplasty

Rehabilitation

• Physiotherapy.

• Bladder dysfunction: Intermittent cath.

Supra-pubic cath.

• Bowel dysfunction: high fluids, fibers, Prokinetic.

• Spasticity: Stretching exercises, Baclofen, surgical.

• DVT prevention.

• Chest physiotherapy.

• Bed sore prevention: Postural change/2h, Air mattress,

High protein diet.