Mike Gibson Glasgow Post Orthopaedic Training Program February 2011

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

2. Thoraco- Lumbar Fractures • 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 DEFINITION OF INSTABILITY When subjected to normal physiological forces the fracture will not displace sufficiently to produce neurological deficit or a significant deformity.

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 A No motor No sensation B No motor Min. sensation C Motor(2-3) Sensation D Motor(4-5) Sensation E Normal Normal

19. Spinal Cord Injury A.S.I.A. A Complete - no motor or sensation B Incomplete - sensation, no motor C Incomplete - sensation, motor<3 D Incomplete - sensation, motor3 E Normal

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

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

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

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

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

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

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