spinal cord injuries | spine fracture | thoracolumbar fracture | colorado spine surgeon
DESCRIPTION
Colorado spine surgeon, Dr. Donald Corenman, M.D., D.C. (http://neckandback.com), is an expert in treating spinal cord injuries associated with a traumatic fall, sports related injury or accident. Many spine fractures include a thoracolumbar fracture, which is a break in one or more of the thoracic and lumbar vertebrae. Spine fractures can be very serious but are also treatable in many cases. This presentation on spinal cord injuries, spine fractures and thoracolumbar fractures details events that can lead to this injury, symptoms and treatment options. Dr. Corenman is a renowned Colorado spine surgeon and also is an expert at all spine conditions and disorders including scoliosis, degenerative disc disease, spinal stenosis, sciatica, herniated disc, slipped disc and spondylolythesis. He is also a sports medicine specialist and treats athletes with traumatic sports related injuries. He recently launched his own website (http://neckandback.com) to educate patients on spine disorders and to offer second opinions to physicians and colleagues who are seeking additional information on specific spine injuries and treatment options.TRANSCRIPT
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Spinal Cord Injuries; Spinal Cord Injuries; Thoracolumbar FracturesThoracolumbar Fractures
Donald S. Corenman, M.D., D.C.
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Anatomy of the Cord and CaudaAnatomy of the Cord and Cauda Spinal cord from foramen magnum to L1 Conus at L1 for bowel and bladder (nervi
eriganties S1-S5) Peripheral nerves for lower extremities start from
T9-T12 L1 roots start innervation of lower extremities Thoracic blood supply to the cord tenuous at T10-
T12 (artery of Adamkowitz) Lumbar blood supply abundant
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Physiological Anatomy of the Physiological Anatomy of the Thoracic SpineThoracic Spine
Facets lie in the frontal plane- allowing rotation Ribs resist rotation and add 3x the normal stiffness
in lateral rotation Kyphosis of the T spine loads the anterior column Lower 2 vertebra have floating ribs and no
costotransverse articulations Canal size in thoracic spine relatively small
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Physiological Anatomy of the Physiological Anatomy of the Lumbar SpineLumbar Spine
Large discs allow more ROMFacets prevent rotationSpinal canal widerLordosis loads the facets
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Thoracolumbar JunctionThoracolumbar Junction
Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress riser)
Lowest 2 thoracic vertebra have less extrinsic stability secondary to changes in facet orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to stabilize, therefore less rotational resistance)
In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into lordosis leaving the transition vertebra exposed to pure compression
Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2 vertebra at the thoracolumbar junction
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Mechanisms of InjuryMechanisms of Injury How much energy was imparted into the
individual (fall from height vs fall from level skiing vs ejection from car)
What was the loading force (impact onto buttocks vs impact onto flexed neck vs impact from object)
What was the force trajectory (beam impact vs restrained MVA vs collision with tree)
What was the quality of the tissue of the recipient to resist force (young adult vs senior/ preexisting pathology)
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Patient HistoryPatient History
Loss of consciousnessLoss of motor strength (temp or present)Sensory changes (temp or present)Incontinence (at scene vs current)Localized pain to other areasDyspnea (pneumothorax)Past medical history
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Patient ExaminationPatient Examination ABCs first, then trauma examination Motor strength L1-S1(for suspected
thoracolumbar injury) Sensory C4-S3 Reflexes (hyperreflexia asso. with preexisting
myelopathy) Rectal exam (sensory, tone and contraction)
(missed conus injury) Bulbocavernosis (if necessary)
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Neurologic InjuryNeurologic Injury
Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours
Only for central injuries- not peripheral nerve injuries (conus is central injury)
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Concordant Spinal InjuriesConcordant Spinal Injuries
3 patterns Watch out for
distracting injuries 10% of patients can
have other spinal injuries
Severity of trauma- splenic/ liver and vessel injury
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Classification SystemClassification SystemHoldsworth 2 column theoryDenis 3 column theory
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Classification of InjuriesClassification of Injuries Simple Compression (1-2 column injury) Stable burst (2-3 column injury) Unstable burst (3 column injury) Flexion distraction (2 nonconjoined columns) Chance (3 column failure all in tension) Fracture dislocation (3 column injury) Pure Dislocation (rare) (3 column injury) Pathological (any and all) Insufficiency (any and all) Multiple contiguous fractures (nly 1-2 columns)
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Compression FracturesCompression Fractures
Only anterior column injuryMiddle? and post. OKAnt. column less than 30%No more than 10 deg kyphosisNo neuro injury
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Flexion distractionFlexion distraction Easy to miss- may
look benign Anterior column >
50% crushed Middle column mainly
intact Significant spinous
process widening Unstable
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Stable BurstStable Burst
Both ant and middle column involvement
Minimal kyphosis No neuro involvement No laminar fracture
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Unstable BurstUnstable Burst 3 column involvement Possible neuro
involvement Severe communition Significant pedicle
widening Look for laminar
fracture (asso. with root entrapment)
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Chance FracturesChance Fractures Old “Seatbelt injuries” Center of rotation is
anterior to ALL May be “bony” chance or
purely ligamentous Normally neuro intact “Bony” stable,
ligamentous unstable even though all are 3 column injuries
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Fracture DislocationsFracture Dislocations Translation in lower
lumbar spine may be developmental (nly L3-S1 spondylolysthesis)
Always abnormal in thoracic spine (ribs)
Unstable Normally- neuro deficit Can be hidden at mid
thoracic spine 3 column injury
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Pathological Fractures Pathological Fractures
Normally in patient with history of CA
May be hard to distinguish from insufficiency fracture
May be multiple levels Fracture out of proportion
to force of trauma Suspicion calls for MRI
and ?Bx
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Insufficiency FracturesInsufficiency Fractures Normally in elderly
females Osteopenia/malacia Bones have “washed out”
appearance Minimal force vectors Multiple levels (normally) Kyphosis greater than 70
degrees may need surgery ?Vertebroplasty
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So how do you read the films?So how do you read the films?Look at alignment of vertebraOn AP- measure pedicle distance and look
for both SP splaying and laminar fracturesMeasure kyphosis from intact endplatesMeasure anterior and middle column heightLook for retropulsionHigh index of suspicion for other fractures
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Look at alignmentLook at alignment
Look at how the anterior and posterior aspects of the body line up
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Spinous Process SplayingSpinous Process Splaying
Indicative of either chance (stable) or flexion distraction (unstable) injury
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Laminar SplitLaminar Split Associated with burst
or flex-distraction fractures
Look on exam for root injuries (they become entrapped in lamina)
Possible association with dural tear
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Measure KyphosisMeasure Kyphosis
Measure from closest intact endplates
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Measure Ant. and Middle Measure Ant. and Middle Column HeightsColumn Heights
Compare with vertebra above and below
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Measure pedicle distancesMeasure pedicle distances
Compare to vertebra adjacent to injured one
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Anterior Column Fx TreatmentAnterior Column Fx Treatment
Simple compressions can be placed in a Jewett or TLSO off the shelf brace and discharged from the ED or office as long as pain is controlled, fracture is stable with new standing x-rays in brace and they don’t have an ileus. Cannot treat fractures above T6 without cervical extension
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Stable Bursts and Lateral Stable Bursts and Lateral Compression FracturesCompression Fractures
Admit- pain mgmt and neuro checks
Brace management -Off the shelf TLSO for simple compressions greater than 30% and lateral compressions, Custom TLSO for unusual body habitis, severe bursts and pts that need stability testing. CASH for insufficiency Fxs
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Complications from FractureComplications from Fracture Pneumothorax (thoracic Fxs with asso rib Fxs)/ Ileus (30-60%) Splenic, liver and vessel injury (mechanism of injury) DVT/PE Decubitis UTI Pneumonia Renal failure (hydronephrosis from cauda equina
involvement)
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Stress TestingStress Testing Fracture that may be
unstable in custom TLSO Bed rest until TLSO
arrives X Rays supine/ 45deg/ 90
deg/ upright Stop if neuro involvement,
sig. Pain increase or sig. Increased kyphosis
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45 degrees vs upright45 degrees vs upright
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Surgical IndicationsSurgical Indications Neurological Involvement Flexion distraction injury Greater than 50% canal compromise with
>15 degrees kyphosis >25 degrees kyphosis Failure of stress testing (severe pain,
angulation above 25 degrees, neuro symptoms)
Fracture dislocations Soft tissue “chance” fractures
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Time to healingTime to healing
Most non-surgical fractures heal within 12 weeks Jewett/ TLSO on whenever upright When healed- 4 weeks of PT for deconditioning Residuals of barometric sensitive discomfort and
occasionally problems with lifting 10 % may need to go on to surgery from
instability pain
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Thank YouThank You