Thoracolumbar trauma Flashcards by Sally-Anne Phillips

What are osteoportic vertebral compression fractures?

A fragilility fracture of the spine

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What is the epidemiology of osteoportic vertebral compression fx?

vertebral compression fx most common fragility fx
700,000 VCF per yr in US
70,000 hospitalisation
15 billion in annual costs in us
affects 25% pt over 70years
afects 50% over 80 years

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What are the risk factors of vertebral compressono fx?

hx of 2 VCF is the strongest predictor of future vertebral fx in post menopausal women

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What is the pathoanatomy of vertebral compression fx?

Osteoporosis
- bone normal quality but decrease quantity
- cortices are thinned
- cancellous bone has decreased trabecular continuty
- WHO osteoporosis T score -2.5 SD below normal
- BMD peaks at 25-30
  - decreases with age
  - correlates well w bone strength
  - gd predictor of fragility fx

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What are the associated conditions of osteoportic vertebral compression fx?

Compromised pulmonary function
- inceaed kyphosis can effect pulmonary function
- each VCF leads to 9% reduction in FV

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What is the prognosis of osteoportic vertebral compression fx?

with VCF mortality increases significantly - even greater than hip fractures at 2 years

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What are the signs and symptoms of osteoportic vertebral compression fx?

Symptoms

Pain
- 25% of VCR painful enough pt seek medical advice
- pain usually localised around area of Fx
- may wrap around rib cage

Signs

Focal tenderness
local kyphosis
spinal cord injury- v rare
nerve root deficites
- may lead to foraminal stenosis

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what imaging is useful for osteoportic vertebral compression fx?

xrays
- entire spine
- concomitant spine fx 20%
- loss of anterior, middle , post vertebral height by 20% or at least 4mm
Ct/MRI
not normally necessary
labs
- crp/esr- rule out infection
- urine/serum protein electrophoresis - rule out multiple myeloma
- FBC, Ca Po43-

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What is the ddx of a osteoportic vertebral compression fx?

Metastatic cancer of spine
- must be considered and ruled out
- suspicious if
  - fx above T5
  - atypical radiological findings
  - failute to thrive/consittutional symptoms
  - younger pt with no hx of fall

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What is the tx of osteoportic vertebral compression fx?

Non operative

Observation, bracing, medical mx
- majority tx this way
- gradual return to activity
- Bisphosphonates
  - prevent fragility fx risk
- some pt benefit - extension orthosis

Operation

Vertebroplasty
- no recommended
- rct no benefits of vertebroplasty
- higher rate of cement extravasation assoc complx than kyphoplasty
Kyphoplasty
- if pt still has pain 6 wks post fx
- cavity created by expansion balloon adn therfore cement can be injected less pressure
- pain relief by elimination of micromotion
Surgical decompression and stabilisation
- v rare only if progressive neurology, PLL injury and unstable spine

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What is the difference between kyphoplasty vs vertebroplasty?

performed under flouroscopic guidance
percutaneous transpedicular approach used for cannula

vertebroplasty

PMMA injected directly into cancellous bone without cavity creation
requires greater pressure and therefore risk of extravasation into spinal canal is greater

kyphoplasty

cavity created with expansion device (e.g., balloon) prior to PMMA injection
may be possible to obtain partial reduction of fracture with ballon expansion

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What are the complx of vertebral compression fx?

Neurological injury
- by extravasation of PMMA during vertbroplasty or kyphoplasty
- NB notice defects in post cortex of vertebral body

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What is a thoracolumbar burst fx?

Vertebral fx with compromise of anterior and middle column

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What is the mechanism of injury to obtain a thoracolumbar fx?

axial load with flexion
canal can be compromised by retropulsion of fx
maximal retropulsion at time of injury
reabsorption of retropulsed fx does occur over time, rarely caused neurological compromise

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What was Denis 3 column theory?

aim at determining stability of fx

anterior column

ant 2/3 vertebra and annulus
ALL

middle column

post 1/3 of vertebra and annulus
PLL

posterior column

pedicels
facets
ligamentum flavum
spinal processes
post ligament complex- infraspinous, supraspinous, lig falvum, facet capsule- meant to be critical predictor of stability of fx

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What is seen on imaging?

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Xray
- intraspinal distance increases
- pedicles widening- AP
- kyphosis
- Retropulsion
- >50% loss in height

What classificaiton system is useful to aid tx of thoracolumbar fx?

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ThoracoLumbar Injury Classification Severity Score= TLICSS
Varacco et al modified
Modification of the Thoracolumbar Injury Severity Scale (TLISS) based on observations from the TLISS validation study
Modifications to improve validity and reliability
Fracture mechanism category changed to fracture morphology
Subcategory summation discarded (previously multiple injuries within a category were summed to a total point value.
Lateral compression category discarded (weak reliability)

Describe the TLICSS ?

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Uses point system to guide management and is based on 3 categories: fracture morphology, neurologic status, and integrity of the posterior ligamentous complex.

f_racture morphology_

Compression fx 1
Burst Fx 2
Translational/ Rotational 3
Distraction 4

Neurology

Intact 0
Nerve root 2
Complete SPI 2
Incomplete SPI 3
Cauda Equina 3

Posterior ligamentous complex intact

Intact 0
Injury suspected/indeterminate 2
Injured 3

Summation of points

3 or less = non operative
4 non vs surgery
5 or more =surgery
*

What tx available for thoracolumbar fx?

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Non operative

to protect neural elements
prevent further collapse
restore biomechanics
Juwett brace- 3 point fixation: pelvis, chest and lumbar spine

Surgery

Anterior decompression and stabilization
for neurology with ant compression
no evidence for early surgery
invoves corpectomy, cage
Posterior decompression and instrumental fusion
use to instrument 3 levels above and 2 below but now with pedicles screws one above is fine

Complications of thoracolumbar fx?

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Pain
Progressive Kyphosis
- common with unrecognised injury to PLL
Flat back
- leads to pain

What is a chance fx?

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A flexion distraction injury- seatbelt injury
- maybe bony injury
- may be ligamentous injury
  - more difficult to heal
- middle and posterior columns fail under tension
- anterior column fails under compression

What are chance fx associated with?

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High rate of gastrointestinal injuries 50%

What is seen of imaging for chance fx?

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Xrays
- lat and ap- see below
MRI
- important to evaluate injury to posterior elements
CT
- important to evaluate degree of bony injury/retropulsion of post wall into canal

What is the tx of chance fx?

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non operative

Immobilisation in cast or TLSO in extension
- neuro intact pt
- stable fx with intact post elements
- Bony chance fx
- must follow up for non union/kyphotic deformities

Operative

Surgical decompression and stabilisation
- unstable fx with injury post ligaments
- anterior decompression & stabilisation
  - with vertebrectomy & strut grafting+ instrumentation
- posterior decompression, stablisation and compression

What are the complx of chance fx?

* **Pain** * **Deformity** * scoiliosis * progressive kyphosis * unrecongised PLL injury * Flat back * -\> pain, forward flexed posture , easy fatigue * post traumatic Syringomyelia * **Non union**

What is this?

* **Thoracolumbar fracture- dislocation** * assoc with **posterior facet dislocation occuring thru the thoracolumbar junction**

What is the epidemiology of thoracolumbar fracture dislocations?

* Approx 4% spinal cord injuries admitted to level 1 trauma centres * **50-60%** of fx-dislocations assoc with **SCI** * **Male 4:1 female** * most occur at thoracolumbar junction **T10-L12** * Risk factors * **High energy injuries** * RTA * Falls * Motor sports * Violence

What is the pathophysiology of thoracolumbar fx dislocations?

* **Acceleration/deceleration injuries** * resulting in **hyperflexion, rotation** and **shearing** of spinal column * happens T10-L2 * greater moblity in lumbar spine than thoracic * -\> area _vunerable to shearing forces_ * **high risk of injury to spinal cord, conus or cauda equina** depending on pts anatomy/degree of dislocation

What investigations are useful in thoracolumbar spine fx dislocations?

* xrays * ap, lateral of thoracolumbar spine * note fx pattern, type, dislocation * CT scan * better info of fx pattern, type * MRI * better visualisation of spinal cord and supporting ligamentous structures * evaluate injury to PLL

What is the tx of thoracolumbar dislocations?

* **Posterior open reduction w instrumental fusion** * most pt with this injury * midline incision identify fracture-dislocation site * use pedicle screws for distraction to obtain anatomical reduction * insert posterior instrumentation two levels above and two levels below the site of injury *

What are the outcomes of surgery in thoracolumbar fx dislocation?

* Early decompression & instrumental fusion has been shown to have better outcomes than delayed surgery or non op tx

What are the complx of thoracolumbar fx dislocation?

* **Neurological injury** * **cauda equina syndrome** * **DVT** * **non union after spinal fusion** * **post traumatic pain** * greater and increased risk of kyphotic deformity * **Deformity** * scoilosis * progressive kyphosis * flat back * post traumatic syrinomyelia

What is the epidemiology of thoracic fx?

* Rare as increased rigidity with articulation with ribs, ribs with sternum, disc thin ( increased stiffness/rotational stability) * T2-T10 * types * burst * compression * fx dislocation * watershed vascular area in middle thoracic spine * so vascular injury -\> cord ischaemia

Name a classification system of thoracic fx?

* **Magerl** * **type a- compression** * Type b * **B1- ligamentous distraction injury posterior** * **B2- osseoligamentous distraction injury posterior** * Type C * **Multidirectional injuries often fx dislocation**

Describe the tx for thoracic fx?

* tx varies by condition but consider * spinal stability * degree of neurological deficit * degree of cord compression _Non op_ * _most thoracic burst & compression if neurology intact_ * tx with **orthosis 6-12 weeks** _Operative_ * for progressive neurology * myelomalacia on MRI * spinal instability * posterior osseoligamentous stability compromised * approach to do with decompression * midline posterior- posterior decompression * Costotransverse * transthoracic

Thoracolumbar trauma Flashcards

(35 cards)