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Thoracolumbar Fractures. Patient Evaluation and Management. Outline. Epidemiology Clinical evaluation ATLS Neuro exam Neurogenic / spinal shock Classification of spinal cord injury Grading system Complete VS incomplete Incomplete cord syndromes Pharmacological treatment. Outline.

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Thoracolumbar Fractures


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    Presentation Transcript
    1. Thoracolumbar Fractures Patient Evaluation and Management

    2. Outline • Epidemiology • Clinical evaluation • ATLS • Neuro exam • Neurogenic / spinal shock • Classification of spinal cord injury • Grading system • Complete VS incomplete • Incomplete cord syndromes • Pharmacological treatment

    3. Outline • Radiographic Evaluation • Plain Xray • CT • MRI • Mylography • Spinal Stability • Classification of Fractures • Treatment of Specific Injuries

    4. Epidemiology • Prevalence / Incidence • Bimodal Distribution • Cause • Multiple injury

    5. Clinical Evaluation • Trauma / ATLS • ABC / GCS / 2 survey • Spine exam • Red flags • Inspect and palpate entire spine • Be thorough

    6. Clinical Evaluation • Complete Neuro Evaluation • Dermatomal Sensory Testing • Assessment of Lumbar and Sacral motor root function • Reflex Examination

    7. Dermatomal Sensory Testing

    8. Lumbar and Sacral Motor Root Function

    9. Lumbar and Sacral Motor Root Function

    10. Reflex Examination

    11. Spinal Shock • Physiologic disruption of all spinal cord function • Present or not present • Bulbocavernosus Reflex

    12. Bulbocavernosus Reflex

    13. Spinal Shock • No BCR • Flaccid paralysis, hypotonia, areflexia • Hours to days • + BCR • Hyper reflexia, spasticity, clonus

    14. Neurogenic shock • Disruption of descending sympathetic outflow • No sympathetic response and unopposed vagal tone • Cardiovascular instability • treatment

    15. Classification of Spinal Cord injury • Many Grading Systems • Impairment Based • Frankel • ASIA • Yale • Motor Index • Function Based • Modified Barthel Index

    16. Grading of Spinal Cord Injury

    17. Grading of Spinal Cord Injury

    18. Complete VS Incomplete • Complete • No function below level of injury • Absence of sensation and voluntary movement in S4/5 distribution • Incomplete • Preservation of sensation in S4/5 distribution and voluntary control of anal sphincter

    19. Incomplete cord lesion • Determined by anatomic location of tissue injury • Must understand cord anatomy • Predictably pattern based on involvement

    20. Incomplete cord lesion

    21. Incomplete cord lesion

    22. Central Cord syndrome

    23. Anterior Cord Syndrome

    24. Posterior cord syndrome

    25. Brown Sequard Syndrome

    26. Cauda Equina Syndrome • Cord ends L1/2 disc space • Lower motor neuron axons • Perianal anesthesia, sphincter and bladder dysfunction

    27. Pharmacological Treatment • Modify 2 injury cascade • Many drugs • Corticosteroids • Antioxidants • Gangliosides • Opiod antagonists • Ca Channel Blockers • etc

    28. Pharmacological Treatment • NASCIS 3 • Steroids • Controversial study design • Accepted Treatment Protocol • Benefits • Contraindications

    29. Radiographic Evaluation • Trauma Series • Poor historians • Noncontiguous injury • AP / Lat entire spine

    30. Radiographic Evaluation • CT • All cases of suspected injury to posterior elements or posterior vertebral body

    31. Radiographic Evaluation • MRI • Indicated in all cases of neuro deficit? • Both intrinsic and extrinsic cord injuries • Mylogram • Replaced by MRI

    32. Spinal Stability • Holdsworth 1963 • 2 column theory • Post. ligaments

    33. Spinal Stability • Denis 1983 • CT Scan • 3 column theory

    34. Spinal Stability • Categorized major spinal injury into 4 groups: • 1. Compression Fracture • 2. Burst Fractures • 3. Flexion Distraction Injuries • 4. Fracture Dislocations

    35. Compression Fracture • Failure of anterior column • Stable: • Tlso, hyperextension bracing • Unstable (>50% height, >30% kyphosis, multi level) • Posterior instrumented fusion vs non OR • Progressive deformity

    36. Burst Fracture • Failure of anterior and middle column • Axial compression • +/- failure of posterior column • Compression or tensile force • Most common at T/L junction

    37. Burst Fracture • Neuro intact • <20-30 kyphosis, <45-50 canal compromise • >20-30 kyphosis, >45-50 canal compromise • Neuro compromised

    38. Decompression??? • Complete • Early stabilization • Neuro outcome not changed by decompression • Incomplete • Stabilization and decompression beneficial (no controversy) • How to do it (controversial)

    39. Decompression • Posterior • Indirect (distraction and ligamentotaxis) • Direct (transpedicle or posterolateral) • Anterior • Large / midline / incomplete • > 2 weeks since injury • Following posterior decompression • Partial / complete corpectomy

    40. Flexion Distraction Injury • Bone or soft tissue?

    41. Fracture Dislocation • High energy • Most have neuro deficit • Goal: • Stabilization for early mobilization • Incomplete deficit??

    42. Gun Shot Wounds • Where is the bullet? • Complete / incomplete? • Progressive deficit? • Bowel injury?

    43. THE END!!!

    44. Treatment Overview