Spine fracture

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Spine fracture

• Dakheel A. Al-Dakheel, MBBS, SSC(Ortho)
• Orthopaedic surgery department
• King Fahd Hospital of the University
• Khobar, KSA

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NOTE THIS PRESENTATION DOES NOT REPLACE
ATTENDANCE OR INFORMATION GIVEN IN THE LECTURE.IT
IS INTENDED AS A HIGHLIGHT FOR THE TOPIC
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Thoraco-lumbar fracture

• Incidence
• Neurological deficit may occur in 1025 of
  patients with spinal trauma
• Incidence of spinal injury in the US is between 4
  and 5.3 per hundred thousand of population
• The common causes of spinal trauma include
  Road traffic accidents
  - 45
  Falls - 20
  
  Sports -15
• The male to female ratio is 41.
• The overall survival rate for patients with
  spinal injuries is 86 at 10 years
• Incidence of noncontiguous, multilevel vertebral
  injuries is approximately 20

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Mechanism of injury

• MVA 50
• Falls 25
• Gunshot 15
• Sport 10

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• Most of patient with spine injury have an
  associated injuries
• 80 multiple injuries
• 26 head face injury
• 16 major chest injury
• 10 major abdominal injury
• 8 long bone/ pelvic fractures

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Incidence of missed spinal fracture

• The prevalence of delay in diagnosis of trauma
• cervical spine is 22-33
• thoracolumbar spine is 5.
• 22 in tertiary centre.

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• The main causes are -
• a low level of suspicion
• failure to take proper radiographs
• poly trauma
• failure to interpret the x ray
• intoxication
• decrease level of consciousness

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Multiple Spinal Fracture

• Calenoff, Chessare, Rogers reported an incidence
  of 4.5

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Demographics

• SCI is predominantly a disease of young men.
• Average age at injury is 29.7 years.
• Median age is 25 years
• 82 male.
• Occurrence increase with increase daylight.

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Medical problems in SCI

• The leading cause of death in acute phase is
  respiratory failure pneumonia.
• Pulmonary problems also the leading cause of
  readmission in the 1st year.

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Leading cause of death in SCI

• Respiratory disease 20.5
• Accident, poisoning, violence 9.7
• Circulatory disease 8.8
• Infections
  8.8
• Genitourinary disease 4.0
• Neoplasm
  3.9

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Approach to Spine Trauma
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• Pre Hospital Care
• The aim is to retrieve the patient from the site
  of injury safely and rapidly
• Transfer to a suitable facility.
• spinal trauma should be suspected in
• all unconscious patients
• High energy trauma
• Evidence of neurological deficit
• Multiple injuries

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• Proper extraction
• Intubation
• Immobilization
• Cervical collar, sand bag, tape,
• ? Neck position
• ?pediatrics

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Emergency Assessment

• ATLS

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• Evaluating spinal injury begins in the secondary
  survey
• History is taken head to toe examination
• Obtain history from
• Patient
• Family members
• Paramedical personnel

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History

• Mechanism of injury
• Position of the patient when found
• Transient motor or sensory loss
• Paradoxical breathing
• Seat belt

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Inspection

• All clothing should be carefully removed
• Any bleeding , abrasion or lacerations
• Limb asymmetry
• Voluntary limb movement
• Chest expansion

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Palpation

• Cervical collar removed carefully
• Tenderness
• Interspinous widening
• Malialignement of spinouse process
• Step off

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Neurological Evaluation
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• Neurological examination
• Sensory evaluation
• Motor evaluation
• Reflexes

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Spinal reflexes
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Cresmatic reflex

• Stocking inner thigh observing the scrotum
  movement
• Absence means UMNL
• Unilateral absence suggest LMNL

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Sacral Sparing

• Perianal/perineal sensation
• Rectal tone
• Big toe flexion
• Implies partial structural continuity of white
  matter long tracts
• May be only evidence of incomplete injury?higher
  chance of recovery
• Essential to check and document

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Bulbocavernosus reflex

• Pull glans or press clitoris ? anal contraction
  (int. sphincter) around gloved finger
• Absence is indicator of spinal shock

Skeletal Trauma
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RADIOLOGICAL ASSESMENT

• PLAIN FILM
• AP LATERAL

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CT

• Injury suspected on plain films
• Better visualize fracture (specificity and
  sensitivity)
• Unable to adequately assess on plain films
• Fracture or soft tissue injury in the plane of
  the CT can be missed

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MRI

• Invaluable for assessing cord and soft tissues
• R/O associated disc herniation ( facet
  dislocations)
• Hemorrhage vs edema in soft tissues ????
• Ligamentous tears and facet capsule disruptions
  visualized with fat suppression
• May allow prognostic assessment of final motor
  function
• Intrasubstance hematoma

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MRI
T1
T2
GRE
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Classification of ThoracoLumbar spine Fracture
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Compression Fracture
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Burst Fracture
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Fracture Dislocation
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Flexion Distraction
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Imaging
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Non-Operative Management
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Surgical intervention
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Complications of spine fracture

• Neurological injury
• Instability ( pain deformity)
• Complication of surgery

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