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ANDALIB,ALI.MD

FELLOWSHIP OF SPINE SURGERY

MEDICAL UNIVERSITY OF ISFAHANKASHANI HOSPITAL

Lumbar spine fracture and dislocation

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Age : male under 30 yrs old1. MCA2. Fall from height3. Sport

Geriatric populationFalling from standing position

Holdsworth’62

Kelley & Whitesides ’68

Denis ‘83

McAfee ‘83

Ferguson & Allen’84

Anatomic Classification

2 or 3 Columns

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3 Column Classification

DenisAnterior - Ant 1/2 of

disc /VB + ALL

Middle - Post 1/2 of disc/VB + PLL

Posterior - Post Elements

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Mc Afee classification

1. Compression FX

2.Burst Fx

3.Flex-Distraction

4.FX-Dx

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Mechanism of injury and classification

Wedge compression fx

1. Isolated failure of ant column

2. Forward flex

3. Neurologic injury rare except multiple adjucent vertebra

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Wedge compression fx

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Wedge compression fx

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BURST FX

key features : posterior vertebral

body cortex fracture with retropulsion of bone into the canal

widening of the interpedicular distance relative to the adjacent

levels

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Stable burst fx Ant and mid column fail in

compression

Unstable burst fx Ant and mid column fail in

compression and post column fail in compression,lat flex or rotation and not fail in distraction

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Burst fx

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Burst fx

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Burst fx

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FLEX-DISTRACTION

Flex distraction injury(bony or soft tissue)

Flex axis post to ALLAnt column fail in compressionMid and post column fail in tensionUnstable pattern( PLC failed)

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PLC

POSTERIOR LIG. COMPLEX(PLC):

• SUPRASPINOUS LIG

• INTERSPINOUS LIG

• LIGAMENTUM FLAVUM

• FACET JOINT CAPSULE

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Flex distraction injury

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CT SCAN

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MRI(flex-Distraction)

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Traslational injury(fx -dx injury)

Malalignment neural canal

Three column fail in shear

Displacment in transverse plane

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Traslational injury(fx dx injury)

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Primary care

ABC and ATLS

hypovolemic shock vs neurogenic shock

Log rolling technique and back board

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Logrolling technique

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Associated injury 45% seat belt fx intra abdominal

injury(spleen,liver) 20% noncontiguous spinal fx(total

spine x ray) Head injury and fx of extremities

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History and physical exam

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Cauda Equina Syndrome

Cord ends L1/2 disc space

Lower motor neuron axons(nerve roots from L1-5 and S1-5)

Perianal anesthesia(saddle anesthesia), sphincter and bladder dysfunction,severe LBP,motror defecit

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Imaging

AP x ray:interpedcular widening(burst fx),

Increased interspinous process distance(damage of PLC)

Lat x ray:kyphotic deformity(cobb angle),vertebral collapse, PVB

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% Anterior Height Loss=A1[(a'+a")/2] x 100% Posterior Height Loss=P/[(p'+p")/2] x 100

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PVB

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CT scan

Comminution of vertebral bodyRetropulsed fragment(size,location)Post element fxHelical CT scan choice in polytrauma

pt

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Burst fx

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MRI

Disc herniationEpidural hematoma Lig injury(PLC) -fat suppressed T2-

weighted image(STIR)Intrasubstans alteration of spina

cord(myelomalacia)SCIWORAGun shot(contraversial)

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Treatment goals:

Maintain or restore spinal stability Correct deformity(coronal,sagital) Maximum neurologic recovery Improve pain Prompt rehabilitation

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T.L fx treatment is controversial

1. operation vs nonoperation?

2. optimal approach for patients who will be

treated operation?(Ant vs Post)

3. direct decompression vs indirect decompression ?

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no definitive literature

most spine surgeons would not recommend

allowing persistent neural compression in the presence of a neurological deficit.

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the treatment of thoracic and lumbar fractures

Neurological status of a patient(spinal cord, conus medullaris, or cauda equina injuries)

Global imbalance in the sagittal or coronal plane ( No regional deformity)

injury to the PLC

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Non operative

Indication Close observe

Intact PLC stable burst fx, normal neurologic

exam stable burst and

complete spinal cord injury

Height loss>50% Focal kyphosis>25deg PLC disruption Obvious instability

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Nonoperative treatment

Jewett brace or TLSO(caudal to T7)

L5-S1 segment not sufficiently stabilized

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Jewett brace (lateral bending is less of a concern)

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TLSO

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Compression fx treatment

TLSO 12 weeks Pain improve 3 to 6 week Upright radiograph after brace

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OPERATIVE TREATMENT(Ant vs post) Short segment posterior

instrumentation

the most common construct used, but specific construct design is dictated by

the injury pattern and

the neurology of the patient

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SURGICAL APPROACH

posterior approach is often favored with disruption of the PLC

anterior approach in an incomplete neurologic injury with obvious anterior thecal sac compression.

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POST APPROACH ONLY

With PLC disruption

Rotational and shear injury

Canal compromise <50% with neurologic deficit

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POST APPROACHligamentotaxis

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Short or long costruct?

Advantage of short costruct

Less fused segment

Short surgical time Low cost

Disadvantage High failure rate and

psudoarthrosis

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Always long

Osteoprosis

Sever kyphosis

Thoracolumbar junction

Sever comminution

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Short costruct in Post app. Low lumbar FX

360 fusion

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ANT APPROACH

Canal compromise>67% and neurologic deficit

Sever comminutted fx

More than 5 days and neurologic deficit

Kyphosis>30 and neurologic deficit

Reverse cortical sign

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REVERSE CORTICAL SIGN

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Post app in severe neurologic deficit

In pt with poor prognosis(Fx-DX)

Fx in proximal of thoracic vertebra decompresion with laminectomy

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Contraindication of Ant.

Post instability 1.kyphosis>30 2.v.body collapse>50% 3.Translation>2.5mm 4.PLC disruption Sever osteoprosis Chest &abdomen injury Sever obesity &pulmonary disease L4-L5 fx

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Take home message

Anatomical fracture reduction, although desirable, has not been the primary treatment objective.

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Thank you for attention