Spine Fractures

Spine fractures

Anatomy :

• Cervical - 7 vertebrae• Thoracic - 12 vertebrae• Lumbar - 5 vertebrae• Sacral - 5 fused vertebrae
• Coccyx - 4 fused vertebrae

• Incidence:

4-5 per 100,000.
18 - 35 years.
Male\ Female = 4:1
Neurologic injury  25% of cases.


• 65% of TL#s occurs between the T9&L2 vertebrae. (thoracolumbar Junction) .. Why ?

• The transition from a relatively rigid thoracic kyphosis to a more mobile lumbar lordosis occurs at T11–12.

• The lowest thoracic ribs (T11 and T12) provide less stability at the thoracolumbar junction regioncompared to the upper thoracic region, becausethey do not connect to the sternum and are free floating.

Etiology

• High energy trauma like RTAs• Fall from height• gunshot wound and missile injuries
• osteoporosis
• tumors• other underlying conditions that weaken bone

Classification:

Denis Three column theory : The vertebral column is divided into three columns
1. ANTERIOR2. MIDDLE3. POSTERIOR Columns

When the spine injury is considered unstable:

• When more than one column involved
• Anterior vertebral height loss > 50%.
• Canal compromise > 50%.
• Kyphosis>20degrees.
• Neural compression.

Compression( wedge ) fracture

45% of TL#s
Failure of anterior column
The middle column is intact and acts as a hinge.
Low risk of Neurological deficits .

Burst fractures

• 15 % of TL#s• Anterior&middle column failure.
(Axial compression)
• Most common at T/L junction
• Neurological deficit incidence is higher.

FLEXION-DISTRACTION = SEAT-BELT-TYPE = CHANCE # :

• Posterior &middle columns failure. (hyperflexion then tension forces)
• Anterior column functions like a hinge.

Fracture-Dislocation:

• Failure of all columns (compression, tension,rotation, or shear).• anterior hinge is disrupted.
• Dislocation.• the highest incidence of neurological deficit.

Approach to Spine Trauma

Pre Hospital Care:
• Proper extraction &Immobilization
Cervical collar
- Hard board (log roll)
- Sand bag and Tape
• Airway protection.• Rapid & safe transfer  for suitable facilities.

Log rolling

Emergency Assessment

Primary survey : ABCs
Secondary Survey:
Brief history (Mechanism, movement, position)
Examination : The inspection and palpation of the spine should include the search for:
Swellings, Tenderness , skin bruises, lacerations, ecchymoses , open wounds , hematoma and spinal (mal)alignment

neurogical examination :

Neurological injuries may be complete or incomplet
Complete - flaccid paralysis + total loss of sensory & motor functions
Incomplete - mixed loss- Anterior spinal cord syndrome- Posterior spinal cord syndrome- Central cord syndrome- Brown sequard’s syndrome
- Cauda equina syndrome

Investigations :

• plain X-rays: - A-P & Lateral views
• CT • MRI studies

Plain x ray

CT Scan :

Accurate assessment of bone.
1- Comminution.2- Canal compromise.

MRI :

Accurate assessment of soft tissue.
1 - Neurological or cord injury .2 - Ligament injury.3 - Disc herniation.
4 - Hematoma.

Treatment of spine injuries

Non-operative treatment :
Indications:
Ant. vertebral height loss < 50%.
Canal compromise < 50%.
kyphosis<20degrees.
No neurological compromise


Strict bed rest for 3- 4 weeks.
Bracing for 6-8 weeks.
Pain killers
Patient care

Spinal Cord Injury medical treatment :

Methylprednisolone 30mg/kg iv bolus over 15min. 5.4 mg/kg/h infusion over 23 hrs
Proton pump inhibitor
LMW Heparin ( thrombo prophylaxis )

Operative treatment :

Ant. vertebral height loss > 50%.
Canal compromise > 50%.
Kyphosis>20degrees.
Neural compression ( especially if progressive ).

Surgical options

Posterior Fixation
Anterior Fixation
Combination of both

Rehabilitation

• DVT prevention.
• Bed sore prevention: Postural change/2h, Air mattress, High protein diet.
• Chest physiotherapy. • Bladder dysfunction: Intermittent cath. • Bowel dysfunction: high fluids, fibers, Prokinetic.
• Spasticity: Stretching exercises, Baclofen.