Dislocations of Thoracic and Lumbar Spine - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Treatment of Fractures and Dislocations of the Thoracic and Lumbar Spine Docsity.com Spinal Stability • Mechanical stability: maintain alignment under physiologic loads without significant onset of pain or deformity • Neurologic stability: prevent neural signs or symptoms under anticipated loads Docsity.com How Can We Determine Stability? • Dynamic: deformity worsens under physiologic loads – acute kyphosis with standing – progressive kyphosis over time • Static: Inferred from x-rays – Plain films- widened spinous processes, biplanar deformity – CT - facet complex disruption – MRI- disrupted PLC Docsity.com Deformity (Kyphosis) • Initial radiographs usually supine • Alignment can appear acceptable without load • Upright loading can increase deformity • If unstable, deformity will progress or neurological signs will occur Docsity.com Instability (textbook definition) • Relies on ‘accepted’ standards >50 % loss of height implies PLC injury >30 º Cobb kyphosis implies PLC injury • Direct MRI visualization of a disrupted PLC However, little clinical data to support these values. Docsity.com How Do We Achieve These Goals? • Ensure PLC is intact (x-ray, MRI, physical exam) • Brace/Cast: prevents kyphosis? • Analgesics • Progressive mobilization/physical therapy Docsity.com Goals of Surgical Treatment •To “stabilize” the unstable spine •To restore/ improve sagittal balance •To decompress a progressive neural deficit •To protect intact or incompletely injured neural elements Docsity.com How Do We Achieve These Goals? • Decompression • Fixation for acute correction and stability • Fusion with bone graft for long- term maintenance of reduction/ stability Docsity.com Decision to Decompress • Location of SCI – Little functional benefit seen with 1 or 2 level improvement in upper thoracic (>T9) cord injuries – Conus (T10-L1) lesions are critical: bowel/bladder – Low lumbar--roots more accommodating to canal compromise, and more apt to recover • Completeness of SCI Docsity.com Methods of Decompression • Anterior Decompression = “Gold Standard” – Most common in thoracic and thoracolumbar regions – Direct visualization of cord with removal of fractured body – Readily combined with reconstruction and fusion – Treatment of choice for burst fractures with incomplete SCI – In presence of posterior lig injuries may require A/P surgery Docsity.com Methods of Decompression • Laminectomy alone: Contraindicated !!! – Further destabilizes an unstable spine, may lead to post-traumatic kyphosis – Provides access to allow visualization and repair of dural tears-- Be aware of the clinical triad of neurological injury and concomitant lamina fracture with burst pattern (Cammisa, 1989)---trapped roots Docsity.com Indication for Early/Emergent Decompression • Progressive neurologic deficit associated with canal compromise from retropulsed fragments or spinal mal-alignment (fx/dislocation) Docsity.com Timing of Surgical Stabilization • Benefits of early surgery : – facilitates aggressive pulmonary toilet – decreases risk of DVT/PE with mobilization – prevents likelihood of decubitus ulcers – facilitates earlier rehab Surgery should be delayed until: – Hemodynamically/medically stabilized – An experienced surgeon/ team is available Docsity.com Specific Thoracolumbar Injuries • Compression fractures • Burst fractures • Flexion-distraction/Chance injury • Fracture-dislocations • Gunshot wounds to the spine Docsity.com Compression Fractures • Non-operative treatment – TLSO or Jewitt extension bracing – Frequent radiographic follow-up – Deformities can progress • Advantages: avoid surgical complications and muscle injury 20 to surgery • Disadvantages: post-traumatic kyphosis Docsity.com Compression Fractures Outcomes and Complications • Most common sequelae is BACK PAIN – does not correlate with severity of deformity (Young, 1993, Hazel, 1988) – Lumbar worse than thoracic (Day, 1977) Docsity.com Specific Thoracolumbar Injuries • Compression fractures • Burst fractures • Flexion-distraction/Chance injury • Fracture-dislocations • Gunshot wounds to the spine Docsity.com Stable Burst Fractures • Criteria (burst with intact PLC) – <20-30 º kyphosis (controversial) – <50% lumbar canal compromise – <30% thoracic canal compromise • TLSO/Jewitt brace for comfort Docsity.com Stable Burst Fractures • Radiographic follow-up to follow potential deformity progression • Repeat CT to monitor canal resorption • Same treatment principles as compression fracture Docsity.com Surgical Approaches Posterior Approach – Fractures at T6 or above – Posterior ligament complex injury – Multi-level injury – Associated chest trauma Anterior Approach – Ideal for T6 and lower – Decompression via corpectomy – Reconstruction with strut graft and anterior instrumentation – May combine with post stabilization Docsity.com Specific Thoracolumbar Injuries • Compression fractures • Burst fractures • Flexion-distraction/Chance injury • Fracture-dislocations • Gunshot wounds to the spine Docsity.com Chance (Flexion-Distraction) Injury • “Seatbelt” injury • Trans-abdominal ecchymosis • Common in children (seatbelt higher up) • 0-30% neurologic injury • Most common associated non-spinal injury: perforated viscus (pressure) Docsity.com Chance Injury • Injury involves 3-columns • Usually little comminution • Center of rotation: ALL • PLC disrupted or posterior neural arch fractured transversely Docsity.com Surgical Approach • Posterior approach • Relies on intact ALL • If burst component present, optimal treatment with pedicle screws (maintain anterior column length, don’t over compress--- increase retropulsion ) Docsity.com Chance Fractures Outcomes and Complications • 10-20% residual pain • 65% functional recovery • 35% diminished function Docsity.com Specific Thoracolumbar Injuries • Compression fractures • Burst fractures • Flexion-distraction/Chance injury • Fracture-dislocations • Gunshot wounds to the spine Docsity.com • Posterior constructs provide stability after re-alignment – little chance for neuro recovery • Rarely require anterior decompression/ reconstruction Docsity.com Fracture-dislocations Outcome and Complications • Severity of SCI --main predictor of outcome Docsity.com Specific Thoracolumbar Injuries • Compression fractures • Burst fractures • Flexion-distraction/Chance injury • Fracture-dislocations • Gunshot wounds to the spine Docsity.com