1. Thoracolumbal Injury Team VI Chief : MH Members: ET/MB/RF Moderator : SG Supervisor : DR.dr.Karya Triko Biakto, Sp.OT(K) Spine Thursday, December 15th 2017

2. There are approximately 11,000 new spinal cord injuries requiring treatment each year. Delayed diagnosis of vertebral injury is frequently associated with loss of consciousness secondary to multiple trauma or intoxication with alcohol or drugs. The ratio of male to female patients sustaining vertebral fractures is 4:1. EPIDEMIOLOGY

3. In older patients (>75 years of age), 60% of vertebral fractures are caused by a fall. For patients with a spinal cord injury, the overall mortality during the initial hospitalization is 17%. Approximately 2% to 6% of trauma patients sustain a cervical spine fracture. EPIDEMIOLOGY

4. 12 thoracic vertebrae 5 lumbar vertebrae Thoracic level  kyphotic, much stiffer than the lumbar spine in flexion-extension and lateral bending, reflecting the restraining effect of the rib cage as well as the thinner intervertebral discs of the thoracic spine The lumbar region  lordotic ANATOMY

7. The conus medullaris is found at the L1-L2 level. Caudal to this is the cauda equina, which comprises the motor and sensory roots of the lumbosacral myelomeres ANATOMY

8. Anterior longitudinal ligament, anterior half of the vertebral body, and anterior annulus Posterior half of vertebral body, posterior annulus, and posterior longitudinal ligament

9. Posterior neural arches – pedicles, – facets, – laminae, – posterior ligamentous complex supraspinous ligament, interspinous ligament, ligamentum flavum, facet capsules

10. Flexion Extension Compression Distraction Torsion Shear MECHANISM OF INJURY

11. Clinical Evaluation ATLS Procedure  airway, breathing, circulation, disability, and exposure Initiate resuscitation: Address life-threatening injuries. Maintain spine immobilization. Watch for neurogenic shock (hypotension and bradycardia). Assess head, neck, chest, abdominal, pelvic, and extremity injury. Ascertain the history: Assess the mechanism of injury, witnessed head trauma, movement of extremities/level of consciousness immediately following trauma, etc. Handbook of fracture 5Ed. Thoracolumbar fracture.

12. Clinical Evaluation Physical examination – Back pain and tenderness – Lacerations, abrasions, and contusions on back – Abdominal and/or chest ecchymosis from seat belt injury (also suggestive of liver, spleen, or other abdominal injury) Neurologic examination – Cranial nerves – Complete motor and sensory examination – Upper and lower extremity reflexes – Rectal examination: perianal sensation, rectal tone – Bulbocavernosus reflex In the alert and cooperative patient, the thoracic and lumbar spine can be “cleared” with the absence of pain or tenderness or distraction mechanism of injury and a normal neurologic examination. Otherwise, imaging is required. Handbook of fracture 5Ed. Thoracolumbar fracture.

14. Motoric Function Handbook of fracture 5Ed. Thoracolumbar fracture.

15. Sensoric Function Handbook of fracture 5Ed. Thoracolumbar fracture.

16. Sacral Sparing Handbook of fracture 5Ed. Thoracolumbar fracture.

17. Bulbocavernosus Reflex Handbook of fracture 5Ed. Thoracolumbar fracture.

18. Imaging and Other Diagnostic Studies Radiographs – obtain radiographs of entire spine (concomitant spine fractures in 20%) CT scan indications – fracture on plain film – neurologic deficit in lower extremity – inadequate plain films MRI useful to evaluate for – injury to anterior and posterior ligament complex – spinal cord compression by disk or osseous material – cord edema or hemorrhage Handbook of fracture 5Ed. Thoracolumbar fracture.

19. Thoracolumbar Injury Classification and Severity Score Rockwoood : Fracture in Adult. Thoracolumbal Fracture

20. ALGORITM OF TLICS SCORE Rockwoood : Fracture in Adult. Thoracolumbal Frature

21. Spinal injury is considered unstable if normal physiologic loads cause further neurologic damage, chronic pain, and unacceptable deformity STABILITY

22. Factors indicative of instability in burst fractures: – >50% canal compromise – >15 to 25 degrees of kyphosis – >40% loss of anterior body height STABILITY

23. Three degrees of instability : First degree (mechanical instability): potential for late kyphosis – Severe compression fractures – Seat belt type injuries Second degree (neurologic instability): potential for late neurologic injury – Burst fractures without neurologic deficit Third degree (mechanical and neurologic instability) – Fracture-dislocations – Severe burst fractures with neurologic deficit STABILITY

24. Flexion–compression injury Minimal wedging and a stable fracture – Kept in bed for a week or two until pain subsides – No support is needed TREATMENT

25. Flexion–compression injury Moderate wedging (loss 20-40% anterior vertebral height) – Thoracolumbar brace / body cast for 3 months – Flexion–extension x-rays StableUnstable Brace discardedOperative TREATMENT

26. Flexion–compression injury Loss of anterior vertebral body height (>40%) – Posterior ligaments have been damaged by distraction – Surgical correction and internal fixation is preferred treatment TREATMENT

27. Axial compression or burst injury Failure of both the anterior and the middle columns Minimal anterior wedging + stable + neurologic deficit (-) Inline immobilization Mobilized in a thoracolumbar brace or body cast for 12 weeks TREATMENT

28. Jack-knife injury Lap seat-belt injuries body thrown forward against the restraining strap Chance fracture Flexion-extension lateral views StableUnstable Body castOperative TREATMENT

29. THANK YOU