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

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

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

4. Assessment of Spinal Fracture History Examination Imaging X Rays CT MRI

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

6. 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

7. 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

8. 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

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

10. 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

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

13. CLASSIFICATION SYSTEMS Spinal Column Injury Spinal Cord Injury

14. 2 Column Classifications Holdsworth AO

15. 3 Column Classification Denis Anterior - Ant 1/3 of disc /VB + ALL Middle - Post 1/3 of disc/VB + PLL Posterior - Post Elements

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

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

19. 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

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

21. Spinal Cord Injury- Power MRC Grade 0 1 2 3 4 5 none visible contraction contracts, not against gravity contracts against gravity not resistance contracts against resistance normal

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

23. 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

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

30. 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

35. 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

40. 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

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

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

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

44. Stable Burst Fracture (A3)

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

46. Time for Conservative Treatment Bed rest range: 1 - 8 weeks usual: 4 - 6 weeks TLSO range: 6 - 26 weeks usual: 6 - 12 weeks

47. Complications Bed rest sequelae Respiratory compromise Worsening of deformity Neurological deterioration

48. Thoraco-Lumbar Fractures Unstable Displaced Neurological Deficit Surgical Management

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

50. Scoliosis Research Society Multicentre Spine Fracture Study Gertzbein Spine Vol 17;528-540

51. 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<0.00001) At 2 yrs Score 59% vs 16 (p,0.00003)

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

53. Neurological recovery improved?

56. Fixation Techniques for T/L Spine

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

58. 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. 1957 Extensile Exposure. Livingstone, Edinburgh.

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

60. USS2 Fracture Set – Fixation of A3 Fracture

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

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

63. 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

64. Posterior ligamentous disruption

66. A3 Fracture

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

69. Canal Clearance post Surgery Plus Transpedicular Bone Grafting

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

73. Anterior Ligamentous Injury

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

76. C Type Fracture L2

79. 24 yr old cyclist 5 level spinal injuries

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

83. 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

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

87. Anterior Compression with Progressive Neurological Deficit

88. Late Surgery

91. Post traumatic kyphus + partial Neuro Deficit

93. Thoraco-Lumbar Fractures Unstable Displaced Neurological Deficit Surgical Management

95. 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

99. 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

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

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

108. Spot the 7 mistakes

109. 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

112. Denis’ 3 columns