Mike Gibson Glasgow Post Orthopaedic Training Program February 2011 Thoraco-Lumbar Fractures

Immediate Care and Assessment Investigation Classification Non Operative Treatment Surgical Treatment Cases

IMMEDIATE CARE ATLS Protocol –lateral XR’s thoracic and lumbar spine Spinal board Log rolling –enough people (5) High Index of Suspicion

Assessment of Spinal Fracture History Examination Imaging X Rays CT MRI

Examination Vertebral assessment – Log Roll –Inspection of spine Bruising, deformity –Palpation Localised tenderness, step-off, anal tone & sensation

Examination Neurological Assessment –Motor - voluntary contraction of muscles, graded In unconscious involuntary movement to pain Compare both sides of body –Sensation – soft touch in dermatomes –Autonomic function – bladder/bowel control, priapism

Clinical Features of Spinal Cord Injury Neurogenic Shock –Disruption of descending sympathetic pathways –Bradycardia, loss of smooth muscle tone →hypotension (fluid overload : inotropes) Spinal Shock –Loss of all cord function after injury causing flaccidity & loss of reflexes Abnormal Breathing –Lower Cx/upper thorx cause abd breathing & use of intercostals

Trunk Control Patient will comfortably roll themselves around the bed Useful sign of Stability ? Not early post injury Not in Intoxicated Not in Head injured or confused

Investigation of Spinal Trauma Plain X Rays, CT to Characterise the Fracture MRI if Neurological Deficit Standing X rays

Definition of Instability When subjected to normal physiological forces the fracture will not displace sufficiently to produce neurological deficit or a significant deformity. DEFINITION OF INSTABILITY

CLASSIFICATION SYSTEMS Convey information Produce treatment plan Monitor patient progress Research tool

CLASSIFICATION SYSTEMS Spinal Column Injury Spinal Cord Injury

2 Column Classifications Holdsworth AO

3 Column Classification Denis Anterior - Ant 1/3 of disc /VB + ALL Middle - Post 1/3 of disc/VB + PLL Posterior - Post Elements

Spinal Cord Injury Accurately Document Neurological Status Remember SPINAL SHOCK Prognosis of deficit at 48hours

Spinal Cord Injury FRANKEL ANo motorNo sensation BNo motorMin. sensation CMotor(2-3)Sensation DMotor(4-5)Sensation ENormalNormal

Spinal Cord Injury A.S.I.A. AComplete - no motor or sensation BIncomplete - sensation, no motor CIncomplete - sensation, motor<3 DIncomplete - sensation, motor  3 ENormal

Spinal Cord Injury Clinical Syndromes: Central Cord Anterior Posterior Brown-Sequard Conus/Cauda Equina

Spinal Cord Injury- Power MRC Grade none visible contraction contracts, not against gravity contracts against gravity not resistance contracts against resistance normal

CONCLUSIONS Core knowledge allows transfer of accurate information Monitor patients neurological status Remember SPINAL SHOCK Research tool

AO Classification AO 1994 (Magerl et al) Type A = vertebral body compression posterior column intact Type B = anterior and posterior column injuries with distraction Type C = anterior and posterior column injuries with rotation

AO Classification A A1 =Impaction # (wedge) A2 =Coronal split # A3 =Burst # axial compression forces +/- flexion mainly vertebral body no translation

AO Classification B B1 = posterior ligamentous mainly (flex-distract) B2 =posterior osseous mainly (flex-distract) B3 =anterior disc disruption (hyperextend-shear) bilateral subluxation/ dislocation facet fractures frequent neurological injury

AO Classification C C1 =type A with rotation C2 =type B with rotation C3 =rotational shear injuries high neural injury rate rotation and translation facets, TPs, ribs, neural arch #s all ligaments discs

AO alphanumeric system Type A – vert body compression 1 impaction 2 split 3 burst Type B – ant & post element inj with distraction 1 ligament 2 bony 3 + ant disruption Type C – ant & post element inj with rotation 1 Type A + rotation 2 Type B + rotation 3 rotational sheer

Non – Operative Treatment Options No treatment advice / restrict activity Spinal ‘immobilisation’ Bed rest Lumbar pillow / Log rolling Casting / Bracing Combination treatment

THE AIMS OF TREATMENT Prevent neurological deterioration Minimise spinal deformity Fracture healing Minimise complications Acceptable function

Indications - Clinical Other skeletal injuries Co-existing medical problems (Unfit) Co-operative patient Normal Trunk Control Age of patient Patient preference

Stable Burst Fracture (A3)

Stable A3 Fracture Bed Rest until Normal Trunk Control Standing X Rays ? Use extension Brace or Cast

Time for Conservative Treatment Bed rest range: weeks usual: weeks TLSO range: weeks usual: weeks

Complications Bed rest sequelae Respiratory compromise Worsening of deformity Neurological deterioration

Thoraco-Lumbar Fractures Unstable Displaced Neurological Deficit Surgical Management

Advantages of Instrumentation Simplify care Early mobilisation Improve anatomical result Better neurological recovery? SPINAL TRAUMA

Scoliosis Research Society Multicentre Spine Fracture Study Gertzbein Spine Vol 17;

Gertzbein- Neurology Surgical had greater % improvement in Function. At one year surgical group signifigantly greater relative improvement in motor score. Score 69.2% vs 14 (p< ) At 2 yrs Score 59% vs 16 (p, )

Gertzbein - Pain Kyphotic Deformity < 30 2 yrs had significantly more pain Overall surgical group had less pain than non surgical group.

Neurological recovery improved?

Fixation Techniques for T/L Spine

Choice of Approach Provide optimal exposure, Anatomically based, Extensile, Appropriate to pathology, Safe, Low morbidity, Fast and simple.

Extensile Approach Exposure that will vie effectively with the “Great arsenal of chance” must be a match for every shift, and therefore have a range, extensile like the tongue of the chameleon, to reach where it requires. Henry A.K Extensile Exposure. Livingstone, Edinburgh.

Posterior Fixation of Fractures Short Segment Fixation Restoration of Sagittal Alignment Stable Fixation Maintain Correction

USS2 Fracture Set – Fixation of A3 Fracture

Treatment of A fractures A1 Conservative A2 Mostly Conservative (Depends on Displacement on Standing X Rays) A3 ?Conservative if posterior column intact

Treatment of A3 Fractures Retropulsed fragment relevant only if neuro deficit! (Fidler 1987) Middle column does not exist

A3 Fractures Indications for surgery Neuro Deficit Loss of 50% Ant body height Kyphosis > 25 degrees Canal Encroachment > 50% Persistent Post Tenderness Slow to regain trunk control

Posterior ligamentous disruption

A3 Fracture

Neurological Deficit Complete -Stable Short Segment Fixation usually Front and back Incomplete- Posterior fixation repeat CT scan if necessary second stage anterior decompression

Canal Clearance post Surgery Plus Transpedicular Bone Grafting

Treatment of B Fractures Difficult to diagnose Easy to fix Close gap in posterior elements to restore tension band function of posterior elements

Anterior Ligamentous Injury

Treatment of C Fractures Grossly Unstable Comminuted Rotational Injuries Usually Require either; Longer Fixation Front & Back Fixation

C Type Fracture L2

24 yr old cyclist 5 level spinal injuries

Timing of Surgery Optimal Conditions usually next day Influence of Associated Injuries Beware early Anterior Surgery

Displaced Unstable Thoracic Fractures 50% have neurological deficit All have associated chest injury Chest condition deteriorates after 1 st 24 hrs Early surgery simplifies patient care Displaced Sternal fracture always exclude upper thoracic fracture

Indications in spinal trauma Anterior compression with progressive neuro deficit. Late surgery. Anterior decompression required. Anterior column support in comminuted # ANTERIOR INSTRUMENTATION

Anterior Compression with Progressive Neurological Deficit

Late Surgery

Post traumatic kyphus + partial Neuro Deficit

Thoraco-Lumbar Fractures Unstable Displaced Neurological Deficit Surgical Management

Spinal Trauma Case 1 15 year old girl jumped/fell 30 feet Skull fracture small extradural Alert, orientated but irritable with headache and minor meningism No neurological function below fracture

Spinal Trauma 50 year old woman Referred to spinal surgeon 3 weeks post fracture Mechanism fall down 3 stairs Bilateral foot drops but still ambulant Neurological deficit apparently increased

Spinal Trauma 15 year old RTA Neurologically intact 2 Previous attempts at fixation failed Referred for conservative treatment

Spinal Trauma 19 Year old Skiing Accident Fracture L1 Treated in France Neurologically Normal Undisplaced A3 Fracture Neurosurgical fixation

Spot the 7 mistakes

The 7 Errors Didn’t need Fixing Didn’t need Decompression Rods too thin Screws too short Screws too thin Screws in fractured vertebra Left L2 screw missed

Denis’ 3 columns