Thoracic & Lumbar Spine Conditions 005.07

1. Thoracic & Lumbar SpineConditions 005.07

2. Fractures

3. Rib Fractures General: • Most occur from direct blow/ blunt trauma • Can occur with rapid movement • Usually occur at angle of the rib • Seldom result in severe displacement • Fragments held together by a “muscle sandwich” • Usually very painful

4. Rib Fractures Clinical Features: • Consider mechanism of injury – fall from chair or MVA • Severe pain, worsened by: deep breathing, coughing, sneezing, laughing and trunk movement • Marked pain palpating over # site • Pain with compression (lateral or AP) of thorax • Pt often presents splinting the injured side • Confirmed by x-ray – I don’t always take

5. Fractured ribs

6. Fractured Ribs Treatment: • Rib fractures unite spontaneously – reassure Pt! • Analgesics • Remind them they will have pain for 4-6 wks • Breathing exercises to ensure fully expand lungs •  activity level • Avoid body contact activities

7. Rib Fractures Potential Complications: • Pneumothorax • Hemothorax • Liver laceration • Pneumonia – from splinting rib cage Treatment (if complications): • Protect the airway • Needle decompress • Chest tube • ATLS protocols as required

8. Fractured Sternum General: • Uncommon – very difficult bone to # • High energy injury • Can cause life threatening complications given the close proximity of vital structures the sternum normally protects: • Heart • Lungs • Major vessels

9. Fractured Sternum Mechanisms: • Direct trauma: • can be isolated • often associated with multiple rib fractures – creating a flail anterior segment of the chest wall – “Stove-in chest” • Indirect trauma: • vertical compression of the thorax • often associated with a fracture of thoracic spine • Most occur at the sterno-manubrial joint

10. Sternum Fracture Treatment: • High index of suspicion for underlying injury to heart, lungs and vessels • Uncomplicated fracture: • Pain control • Avoid body contact sports, for 8-10 wks • Depressed fracture with cardiovascular compromise: • Need to move sternum forward

11. Sternum Fracture Treatment: • Flail Anterior Segment: • Airway protection – ventilation, suction, tracheostomy? • Needle decompression – for tension pneumothorax • Chest tube • Stabilize flail segment • Surgical rigid wiring may be needed

12. Vertebral Fractures

14. Spinal canal

15. Wedge Fractures General: • Most are inherently stable as posterior ligaments are intact • Signs and Symptoms • May be minimal • Pain at # site • Prominent spinous process on palpation • Painful limitation of movement • Tenderness on palpation

16. Wedge fracture

17. Wedge Fracture

18. Wedge Fractures Treatment: • Pain control – often very painful • For severe pain- a brace may help by  trunk motion • Physiotherapy - to mobility and strengthen muscles • Surgical intervention - should be considered when: • Vertebral body height - 50% • Subsequent kyphosis exceeds 30°

19. Burst Fractures General: • Less common variant of the wedge fracture • Spine column straight at the time of injury • Axial compression force acts in line with vertebral bodies • Disc is driven into the vertebral body • Causes a comminuted fracture (Bursting) • Fragments are driven outward in all directions • Unfortunately the spinal cord is close by

20. Burst Fractures Burst fracture x-ray and CT scan

21. Burst Fractures Clinical concerns: • Posterior fragments can be driven into spinal cord • These are inherently unstable fractures and fragments can shift to injure the spinal cord • Often heal with significant change in vertebral anatomy – wedging and stenosis • Change in anatomy and biomechanics -  risk of DDD • CT or MRI to see if fragments encroaching on cord

22. Burst Fracture Treatment: • Inherent instability demands great caution • Should be managed by neurosurgeon or orthopedic surgeon • With no neurological impairment - conservative measures as with wedge # • With neurological impairment - surgical intervention

23. Fracture / Dislocation General: • Occurs when a vertebra is forced anteriorly relative to the vertebra below it • 1 of 2 things must happen to permit anterior displacement: • Fracture of the articular processes • Facet joints dislocate and articular processes over ridden. • The lower vertebra is fractured near its upper surface • # line is typically horizontal • Posterior ligaments are always torn • Creates a very unstable spine – further displacement possible • Occurs most often in the mid thoracic and thoraco-lumbar region

24. # articular process Fracture dislocation

25. Fracture/Dislocation General: • Cause is nearly always combination flexion / rotation force • Almost always associated with spinal cord injury • Cord injury usually a complete transection • In the lumbar region often complicated by injury to the Cauda Equina ( T12 / L1 )

26. Fracture Dislocation Diagnosis: • High index of suspicion especially in high energy injury • X-rays • CT, MRI Treatment: • Immobilization • Emergency transfer to neurosurgeon or orthopedic surgeon • Corticosteroids given in first 8 hrs might help

27. Transverse Process Fracture General: • Occur most often in lumbar spine • Caused by a heavy blow or fall • Often involve more than 1 transverse process • May damage the spleen or kidney given their close proximity

28. Transverse process fractures of L4 and L5

29. Transverse Process Fracture Treatment: • Pain control • Watch for signs of abdominal organ injury • Physio for pain  and restoration of full function • Exercises for paraspinal muscles -  as pain subsides

30. Sacral Fractures General: • Uncommon • Mechanism: fall or direct blow to sacral region • Usually a crack with no displacement Treatment: • Pain control • Limited activities • If no complications - no special treatment is required

31. Sacral Fractures Sacral fracture after 8 meter fall

32. Coccyx Fractures General: • Uncommon • Mechanism: fall or direct blow • Pain usually subsides without treatment • Can result in chronic coccydynia • May require corticosteroid injection • Displaced # may injury the cauda equina • Coccyx excision is rarely required

33. Back Pain Syndromes Can be caused by many things: • Structural Anomalies • Mechanical Low Back Pain • Degenerative Diseases • Sciatica • Trauma • Tumors

34. Structural Anomalies • Scoliosis • Lordosis • Kyphosis • Spina Bifida • Spondylolysis • Spondylolisthesis • Spinal Stenosis

35. Scoliosis General: • Lateral curvature of the spine • Several classification systems based on: • Age of onset – ie: infantile • Location of the curve- ie: thoracic • Cause • Primary or idiopathic • Secondary structural • Compensatory • Sciatic

36. Idiopathic Scoliosis General: • Most common and most important type • Begins in childhood or adolescence • Progressively  until end of skeletal growth • Can progress to severe deformity • Etiology unknown • More common in girls then boys

37. Idiopathic Scoliosis Pathology: • Any part of lumbar/thoracic spine may be involved • Primary structural curve, with secondary compensatory curves above and below • Lateral curvature is always accompanied by rotation of the vertebra

38. Idiopathic Scoliosis Clinical features: • Onset mid-childhood/adolescence • In children deformity is often the only symptom • Pain can occur in adults with long standing deformity • Curvature tends to  with spinal growth • Progression depends on: • Age of onset – later onset better prognosis • Site of primary curve – thoracic scoliosis is worse

39. Idiopathic Scoliosis Diagnosis: • Obvious curvatures can be noted on clinical exam • Can rule out a compensatory scoliosis such as a length length discrepancy by having bend forward: • Structural scoliosis - rib cage becomes prominent on one side • Functional scoliosis - it will not • X-rays

40. Severe scoliosis

41. Idiopathic Scoliosis Treatment: • Depends on age of onset, site and rate of progression • Mild cases (lumbar): • Conservative treatment with 6 mo. reviews by orthopedics • Severe cases (thoracic): • Bracing • Surgical intervention • Pins • Rods • Fusion of affected segments

42. Rods for scoliosis

43. Secondary Structural Scoliosis General: • Spinal curvature caused by underlying condition • Three most common causes are: • Hemi-vertebra – angulation at site of anomaly • Poliomylitis – unequal pull of muscles on both sides of spine • Neurofibromatosis – can cause severe deformity • Deformity may be the only symptom • Age of onset, nature, site, andseverity vary with the underlying cause

44. Hemi-vertebra

45. Secondary Structural Scoliosis Potential complications: • Severe long standing angulation may cause cord and spinal nerve impingement and neurological symptoms • Severe cord compression – can cause paralysis below the level of the angulation Treatment: • Address secondary cause if possible • Same as for idiopathic cases

46. Compensatory Scoliosis • Results from a lateral pelvic tilt compensating for conditions such as: • unequal leg lengths • fixed adduction or abduction of hip • Spine is actually straight and corrects itself when the tilt is corrected. • Left uncorrected it can become permanent

47. Sciatic Scoliosis • Also called “Listing” • Pt leans away from the affected side • Curve is in the lumbar region • Very common posture for acute disc injury • Abnormal posture to  pain • Resolves when the pain resolves

48. Lordosis General: • Excessive anterior curvature of the spine • Normally seen in lumbar region Causes: • Imbalances of core stabilizing muscles • Heavy abdomen – pregnancy or obesity • Occasionally compensates for kyphosis • Fixed flexion deformity of the hip Molson’s Lordosis

49. Kyphosis General: • Excessive posterior curvature of the spine • In elderly women is commonly referred to as a Dowager’s Hump • Looks like a “Hunched Back” • For cervical and lumbar spine, a kyphosis is a reversal of normal lordotic curvature • T - spine is considered kyphotic if the normal curvature is excessive.

50. Kyphosis Causes: • Manifestation of an underlying condition of the spine such as: • Wedge # • Scheuermann’s kyphosis • Ankylosing Spondylitis • Osteoporosis • Tumours