Thoraco Lumbar Spine Fractures and Dislocations By Ass

Thoraco- Lumbar Spine Fractures and Dislocations By Ass. Prof. Dr. ZAID W. AL-SHAHWANII Consultant Orthopedic Surgeon Dec. 2014

Anatomy of Thoracic Spine Kyphosis is natural alignment Narrow spinal canal Facet orientation Rib factor on stability Conus at T 12 -L 1

Anatomy of Lumbar Spine Lordosis is natural alignment Larger vertebral bodies Facet orientation Cauda equina

Thoracolumbar Junction Transition Zone Kyphosis Lordosis Mechanical Difference: Lumbar spine less stiff in flexion

Mechanism of injury: ØSpinal injuries carry a double threat: damage to the vertebral column and damage to the neural tissues. There is always fear that movement may harm the cord; hence the importance of defining these injuries as Stable and Unstable. Ø A stable injury is one in which progressive displacement is unlikely; if the cord is not injured, there is little risk of later damage. Ø While an unstable injury progressive displacement may cause damage (or further damage) to the cord. Ø Fortunately, only 10 per cent of spinal injuries are unstable and less than 5 percent are associated with cord damage. ØHealing is usually slow. In fracture-dislocations new bone formation may lead to fusion of the damaged vertebrae; thus the spine will eventually stabilize itself, but not the ligaments. Violent free movements of the neck or trunk may injure the spinal segments.

Anatomic Classification 2 Column Theory Holdsworth 62 2)Posterior 1) Anterior 1) Anterior- vertebral body, ALL, PLL Supports compressive loads 2 1 2) Posterior- facets, arch, Inter-spinous ligamentous complex Resists tensile stresses Stressed importance of posterior elements …. . If destabilized, must consider surgery

Anatomic Classification/3 Column Theory (( Denis 83 )) C B A A) Anterior- ALL , anterior 2/3 body B) Middle - post 1/3 body, PLL C) Posterior- all structures posterior to PLL. Posterior injury-not sufficient to cause instability Spinal stability is dependent on at least two intact columns. When two of the three columns are disrupted, it will allow abnormal segmental motion, i. e. instability.

In Iraq the most common causes are Gunshot , explosion & war injuries

Types of injuries & fractuers according to the mechanizum are (1) Hyperextension. (2) Flexion. (3) Flexion combined with rotation. (4) Axial displacement ('compression'). 1. Hyperextension: is rare in the thoracolumbar region but quite common in the neck; a blow on the face or the forehead forces the head backwards and there is nothing to restrain the occiput until it strikes the upper part of the back. The anterior ligaments and the disc may be damaged or the neural arch (posteriorly) may be fractured. Usually the injury is stable, but fracture of the pedicle of. C 2 ('hangman's fracture') is often unstable

2. Flexion if the posterior ligaments remain intact, forced flexion will crush the vertebral body into a wedge; this is a stable injury and is by far the most common type of vertebral fracture. If the posterior ligaments are torn, the upper vertebral body may tilt forward on the one below ; this type of subluxation is often missed in the neck because by the time an x-ray is taken the vertebrae have fallen back into place. If the ligaments are torn and the vertebral body is also fractured the lesion is unstable.

3. Flexion-rotation : most serious injuries of the spine are due to a combination of flexion and rotation. The ligaments and joint capsules are strained, the facets may fracture or the top of one vertebra may be sliced off. The result is a forward shift or dislocation of the vertebra above, with or without bone damage. All fracture-dislocations are unstable.

4. Axial displacement (compression) Vertical force acting on a straight segment of the cervical or lumbar spine will compress the vertebral body and may cause a comminuted (or 'burst') fracture. A large fragment(s) may be driven backwards into the spinal canal this will makes these fractures dangerous ; there is a high incidence of neurological damage.

Thoraco lumber fractuers & injuries

Common thoraco lumber inj.

Wedge compression fracture: 48% This is by far the most common vertebral fracture and is due to spinal flexion with the posterior ligaments remaining intact. The front of the vertebra is crushed. Pain is usually quite marked but the fracture is stable. The patient is kept in bed for a week or two until pain subsides. Once the patient gets up, a corset or belt give additional comfort and security.

Vertical compression fracture; ('burst‘ fr. )14% Fracture that results from axial compression. Usually result in failure of the anterior and middle columns. Injury to spinal cord, secondary to displacement of posterior fragments, is common. CT is required for all patient to evaluate extent of injury TREATMENT: If the fracture is stable with no neurological damage, the patient is kept in bed and is then mobilized in a thoracolumbar brace or body cast which is worn for about 12 weeks. If there is neurological symptoms further imaging by CT scann & MRI; anterior decompression & stabilization may then be needed.

Dislocation and fracture-dislocation: 16% In these severe flexion-rotation injuries the posterior ligaments are completely torn and one vertebra is markedly displaced upon the one below. The injury most commonly occurs at the thoracolumbar junction and is usually associated with damage to the lower most part of the cord or to the cauda equina. The fracture is always unstable. The patient should be nursed with the greatest care so as not to injure the cord or the nerve roots any further. Pelvic traction is applied while the patient's condition is assessed. Further treatment depends on the nature of the injury.

Combined flexion and posterior distraction These are most typically in lap seat-belt injuries In neurologically intact patients, most fracture dislocations treated by early surgery. In fracture-dislocation with paraplegia or with a partial neurological deficit, there is no benefit from surgical stabilization and decompression so we only do conservative treatment.

Diag: nosis v Every patient who has suffered a major accident should be fully examined for spinal injury. v Any complaint of pain or stiffness in the neck or back should be taken seriously, even if the patient is walking or moving without apparent difficulty. v Enquire about numbness, paraesthesia or weakness in the limbs. v The history of the accident may contain important clues: a fall from a height, a diving injury, or a ceiling collapsing on the patient, or a sudden jerk of the neck following a R. T. A. collision (whiplash injury) these are all common causes of spinal damage.

LOOK: v Bruising of the face or a superficial abrasion of the forehead should hyperextension force. v The neck may be held skew ﻣﺎﺋﻞ , or the patient may be supporting the head with his hands. v With the patient supine, the chest and abdomen can be examined for associated injuries. v. Next the limbs are quickly examined for evidence of neurological damage. v. To examine the back, the patient is log-rolled onto one side with extreme care , , , Bruising indicates the probable level of injury. FEEL: Ø The spinous processes are carefully palpated Sometimes a gap can be felt where ligaments are torn Ø A haematoma over the spine is a significant feature. the bones soft tissues are gently tested for tenderness MOVE: Movement of the spine can be dangerous — it may endanger the cord so it is avoided until a diagnosis has been made. If there is a suggestion of cord injury, a detailed neurological examination is essential.

IMAGING: The X-ray examination is crucial. It should be carried out with the least possible manipulation of the neck or back Lateral views of the cervical spine must include all the vertebrae from Cl (Atlas) to T 1; otherwise low cervical injuries can be missed. Anteroposterior views must include the odontoid process of C 2 (Axis) Oblique views also may he necessary. CT is very useful for showing fractures of the vertebral body and neural arch or encroachment of the spinal canal. MRI is helpful in displaying the soft tissues (intervertebral discs and ligamentum) and lesions in the cord, its especially indicated in patients with deteriorating neurological signs,

Principles of management A. First aid: 1) The first priority is to ensure that the airway is free and the patient can breathe. 2)Patients with suspected spinal injuries should be moved as little as possible, only In one piece' so that there is no intervertebral movement. 3)The neck should be supported during transport.

B. Early management in hospital Ø * General assessment is carried out. Often there are Ø Ø severe associated injuries. If the patient needs resuscitation or tracheal intubation, beware the dangers of flexing or extending the neck! *Ventilation must be ensured, and shock and hemorrhage are treated. The patient is carefully assessed for spinal injury and a neurological examination is carried out; this will serve as an important baseline in future management. * X-rays are taken. The neck and back are held in the anatomical position with pillows and supports, and definitive treatment of the spinal injury is deferred until a full diagnosis has been * Other fractures are splinted. * Patients with cord damage need special attention to prevent pressure sores and bladder complications.

C. Definitive treatment 1) Patients with no bony damage and only mild soft-tissue injuries may be dealt with in the accident department and sent home, with instructions to return for assessment a week later. 2) Severely injured patients should be nursed, unclothed, on a firm mattress. If there are neurological changes, special attention should be paid to the skin and bladder. Analgesics are given but narcotic drugs should be avoided. 3)Stable fractures can be left as they are, & treated by supporting the spine in a position that will cause no further strain. 4) Dislocations and subluxations must be reduced by traction or by open operation. 5) Unstable fractures should be held secure until the tissues heal and the spine becomes stable. This is done by traction, external or internal fixation. 6) Complete neurological lesions are usually established at the time of admission and there is rarely any chance of improving them, the fracture should be stabilized and rehabilitation "commenced as soon as possible.

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