spinal trauma helpful hints - briz brain & spine · •low-velocity trauma causing sci presents...
TRANSCRIPT
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Paediatric spine research group
Dr Geoffrey Askin
Orthopaedic Spinal Surgeon, Lady Cilento Children’s and
Mater Hospitals, Brisbane
Spinal Trauma – helpful hints
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Paediatric spine research group
Spinal Fractures
• Annual incidence of 64 per 100,000
• Neurological deficit in 10-20%
• Over a third will have additional injuries
• 54% of all patients with spinal fractures are able to return to previous level of employment
this doesn’t include pathological #’s
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Paediatric spine research group
3 components to spinal injury
• Vertebral injury (to the bone) can heal
• Neurological injury (to the spinal cord , cauda equina or nerve roots) - may or may not improve
• Ligament/disc injury – often heals in lengthened state
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Paediatric spine research group
4 parameters determine the injury
morphology • Patient age
• Velocity ( energy) of
trauma
• Direction of forces
• Health of bone
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Paediatric spine research group
Paediatric injuries
• Spinal fractures rare in children (<5%)
• Pts <15 yrs account for < 10% of all SCI
• 60 -80% of Paediatric spinal injuries occur in C spine (cf. 30-40% in adults)
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Paediatric spine research group
Anatomic variations
• < 8 year old - high head to body ratio
• (disproportionately large head and a small body )
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Paediatric spine research group
Anatomic variations
•Increased intrinsic elasticity
–Shallow facet joints
–ligaments and joint capsules are more
stretchable
–Absent uncinate process
–Weak nuchal muscles
•Anterior wedging of
vertebral bodies
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Paediatric spine research group
Paediatric injuries
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Paediatric spine research group
Paediatric injuries
<8 years high velocity
upper C-spine – 80%
ligament injuries - unstable
often paralysed
>8 years sub - axial
often low velocity
rarely paralysed
Cervical spine
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Paediatric spine research group
Paediatric injuries
• sudden deceleration injury
• no bony injury
• ligs. more elastic than cord
upper C-spine injuries
<8years
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Paediatric spine research group
Paediatric injuries
• sudden deceleration injury/ seatbelt
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Paediatric spine research group
PECARN High risk factors
• High risk MVA – >55mph
– ejection
– rollover
– death
• Diving / axial load
• Predisposing condition • Klippel Feil
• Downs Syndrome
• Altered mental status
• Substantial torso injury
• Focal Neurological deficit
• Torticollis
• c/o Neck pain
8 criteria
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Paediatric spine research group
Paediatric injuries
Cervical spine case
10 year old fall off trampoline
no spinal tenderness
full range of motion
normal neurology
exam
neck pain
stiffness
no neurolog. symptoms
no imaging needed
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Paediatric spine research group
Paediatric injuries
Cervical spine case
10 year old fall off trampoline
plain Xrays
CT only the area in ?
MRI preferrable
Refer on
investigation
2 PECARN points
neck pain
loss of range
neurology - normal Hx/exam
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Paediatric spine research group
Paediatric injuries
painful rye neck
Min. or no trauma
often assoc. with URTI
usually settles with analgesia/soft collar
plain Xrays suffice with AP open mouth
CT always shows rotatory subluxation
so DON’T CT
torticollis
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Paediatric spine research group
Paediatric injuries
no other PECARN parameters
torticollis
soft collar
review 1 week
if still symptomatic – refer on
other PECARN parameters
refer on
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Paediatric spine research group
Paediatric injuries
high velocity
flexion/distraction (seat-belt)
30% intra abdominal injuries
often paralysed
Thoracolumbar spine
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Paediatric spine research group
• sudden deceleration injury/ seatbelt
•SCIWORA
Paediatric injuries
Thoracolumbar spine
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Paediatric spine research group
• ligs. don’t heal • frequently require fixation/fusion • neuro. outcome better than adults • often develop scoliosis
Paediatric injuries
Thoracolumbar spine
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Paediatric spine research group
Adult injuries
young / healthy
elderly/infirmed
Cervical spine
normal bone
often pathological bone
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Paediatric spine research group
Adult injuries
• high energy
• often paralysed
diving injuries
(normal bone)
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Paediatric spine research group
Operative stabilisation
• Unstable spine
• Improved rehab potential with stable spine
• Easier to manage chest injuries on ICU
• Unlikely to recover neurological function as ASIA A
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Paediatric spine research group
Rugby in Australia
• 0.5 / 10000 player years • 115 admissions NSW 1984-1996 • 49 permanent quadriplegics
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Paediatric spine research group
Adult injuries
• low energy
• require urgent reduction
football injuries
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Paediatric spine research group
rugby injuries
• 32 patients were completely paralysed at the time of reduction (ASIA A)
– 8 were reduced within four hours of injury and 5 of them made a full recovery
– Of the remaining 24 who were reduced AFTER four hours of injury, none made a full recovery and only 1 patient made a partial recovery that was meaningful
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Paediatric spine research group
Rugby injuries
• Low-velocity trauma causing SCI presents an opportunity for secondary prevention of permanent injury (rugby, diving, other sports)
• Appears to result from secondary insult, rather than primary mechanical spinal cord damage
• Time from injury to reduction, and hence reperfusion is critical
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Paediatric spine research group
Adult injuries
hidden flexion injury
well documented injury
neck pain / tenderness
neuropathic pain
normal xray
refer for MRI ? ligament damage
flex/extension lat. Xray
repeat xray 2 weeks / 4 weeks
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Paediatric spine research group
Adult injuries
peg #’s
hyperextension injuries/central cord syndrome
elderly/infirmed
why did they fall?
Cervical spine
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Paediatric spine research group
Adult injuries
elderly/infirmed
non union rate high
myelopathy rate low
surgical complications high
supervised neglect
Cervical spine
peg #’s
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Paediatric spine research group
Adult injuries
elderly/infirmed
low energy fall
min. bone injury
pre-existing canal stenosis
vascular component
preserved LL function
loss upper limb function
non-op. treatment
Cervical spine
hyperextension injuries
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Paediatric spine research group
Adult cervical injuries
•unstable
collars?
surgery / halo brace
•stable soft collar / no splint
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Paediatric spine research group
Conclusions
• HARD COLLARS DO NOT IMMOBILISE THE UNSTABLE SPINE
• In-line stabilisation/soft collar/sandbags is just as effective as hard collar
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Paediatric spine research group
Adult injuries
falls
bone/ligament. disruption
10% neurological injury
management contraversial
Thoraco-lumbar spine
flexion/compression injuries burst #s
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Paediatric spine research group
Adult Thoracolumbar injuries
• 62 Year old male
• Window cleaner
• Fell from 10 feet – T12 vertebral #
• No significant co-morbidities
• Neurological injury - T12 ASIA E (normal)
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Paediatric spine research group
Burst # neurologically normal
natural history •will kyphosis cause pain? •will retropulsed bone cause neuro. loss?
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Paediatric spine research group
Clinical Series
Mumford et al Spine • 2 year follow up burst fractures treated
conservatively • 66% good / very good clinical results • 90% return to their previous jobs
Weinstein et al (1998) • Burst fractures treated conservatively • 88% return to their previous jobs • Average kyphosis 26.4 degrees at end of follow-up
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Paediatric spine research group
Wood JBJS (A) 2003
• Prospective, randomised
• All burst fractures, stable and unstable with normal neurology
• Based on functional and radiographic scores
• Some operated anteriorly some posteriorly
• Hooks, screws, fibular struts, range of levels
• No benefit from surgery
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Paediatric spine research group
• Shen, Spine (2001) – 80 patients
– Prospective, almost randomised (singer paraplegic)
– Closed, burst fractures
– Normal neurology
– Initial improvement with surgery (3-6 months) • Pain
• Kyphosis
– No significant functional difference at 2 years
– Operative treatment – Cost x4
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Paediatric spine research group
Siebenga Spine 2006
• Prospective randomised
• A type fractures with normal neurology
• All operated posteriorly – short segment
• Functional and radiographic parameters
• Better outcome with surgery for A3 subtype
• Pain, kyphosis, return to work
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Paediatric spine research group
If you asked 100 spine surgeons if a burst fracture needed surgery how
many answers would you get?
200
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Paediatric spine research group
stabilise
• decompression will not influence neurol. outcome
• stabilization allows early mobilisation
neurologically complete burst #’s
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Paediatric spine research group
burst #’s
classification
neurologically incomplete
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Paediatric spine research group
anterior reconstruction
• complete decompression
• recon. anterior column
neurologically incomplete burst #’s
? influences neurol. outcome
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Paediatric spine research group
Adult injuries
osteoporotic crush #’s
Thoraco-lumbar spine
mechanical pain
progressive deformity
rarely neurological compromise
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Paediatric spine research group
Adult injuries
osteoporotic crush #’s
pain management
exclude malignancy
?bracing
osteoporosis management
vertebroplasty/kyphoplasty
Thoraco-lumbar spine
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Paediatric spine research group
Thank you