Objectives. Spinal Fractures: Classification Diagnosis and Treatment. Level of Fracture. Neuro exam Muscle Grading

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1 Objectives Spinal Fractures: Classification Diagnosis and Treatment Johannes Bernbeck,, MD Review and apply the understanding of incidence and etiology of VCF. Examine conservative and operative management of VCF. Discuss conservative (rest, bracing, physical therapy, medications, vertebroplasty, kyphoplasty) ) and operative management of VCF. Manage VCF patients Level of Fracture Cervical higher incidence of instability risk of spinal cord injury risk to vertebral arteries higher incidence of requiring surgery brace with cervical collar Thoracic (T1 to T10) instability or deformity are uncommon lower risk of spinal cord injury than cervical ribs act as a natural stabilizer brace with TLSO Thoracolumbar Junction (T11 to L1) higher risk of kyphotic deformity or retropulsion spinal cord is at risk brace with TLSO (down as far as L3) Lumbar spine (L2 to S1) spinal cord is not at risk (cauda equina [lower motor neuron]) transverse proc. Fx can be a sign of other injuries (get CT) brace with TLSO with thigh cuff (for L4L5S1) Neuro exam Muscle Grading 0: no evidence of contraction 1: twitch but no joint motion 2: complete joint motion without gravity 3: complete motion against gravity 4: complete motion against some resistance 5: complete motion against full resistance 1

2 Neuro Exam (cervical) C5 Deltoid muscle Biceps DTR Lateral upper arm sensation C6 Wrist extension Brachioradialis DTR Lateral (radial side) forearm and thumb sensation C7 Wrist flexion Triceps Tendon DTR Long finger (middle finger) sensation C8 Finger flexion No DTR Sensation over small finger and ulnar side of forearm Neuro Exam (lumbar) L4 Tibialis anterior (foot inversion) Patellar tendon dtr Medial calf ankle and foot sensation L5 EHL, EDL (toe extension) No dtr Middle dorsum of foot sensation S1 Peroneals (foot eversion) ) or gastrocs Achilles dtr Lateral calf ankle and foot sensation Neuro Exam (sacral) Sacral roots primarily supply the perineal region and are responsible for urinary control Usually urinary retention (sometimes with overflow incontinence) Do not insert foley right away Check for post void residual (>500ml is concerning) Perineal exam with labial/scrotal and perianal sensation, tone, wink, bulbocavernosis reflex and test for volitional control of sphincter When to consult spine surgeon When there is a neurologic deficit When there is retropulsion into the spinal canal When there is dislocation or traumatic listhesis When there is persisting pain beyond 3 months from a seemingly otherwise routine fracture 2

3 Radiographic workup Cervical: Xray ap lat Xray flex ext if pt is able to comply MRI if neuro deficit or if unstable on flex/ext CT if fx seen on xray Thoracic and lumbar Xray ap lat MRI if neuro deficit CT if fx seen on xray (beware high incidence of missed injuries with TP fractures) Cervical Incidence MVA 38% Fall 26% Diving 11% Sports 3% GSW 4% Pedestrian 3% Other 15% Classification Cervical Fxs Jefferson (C1 burst) Hangmans (C2 pars fx) Odontoid (type 1,2,3) Flexion distraction Anterior compression Compression axial load Acute treatment of C-spine C fractures Stabilization Collar Halo Realignemt if dislocated Traction with gardner wells tongs surgery 3

4 Bilateral jumped facet joints Unilateral facet dislocation Flexion-axial load injury Clay shoveler s fracture 4

5 Teardrop The 3 Columns of the Spine Anterior Middle Posterior Thoracolumbar fractures Compression Anterior 2/3 of vertebral body involved Does not cause neurologic deficits Burst Spinal canal is involved Sometimes causes neurologic deficits Chance (flexion distraction) Bony (acutely unstable, chronically stable) Ligamentous (acute and chronic instability) 5

6 Osteoporotic compression fracture (insufficiency fracture) Osteoporotic bone Vertebral Compression Fx stats 700,000 VCF annually in US 25% of postmenopausal women have VCF 40% of 80 y.o.. women have VCF Women with VCF have 15% higher mortality Annual direct medical cost $746,000,000 Annual total cost $1.5 billion in US 35% of women above age 65 have osteoporosis Osteoporosis 6

7 Osteoporotic insufficiency fractures L1 compression fracture Compression Fx management Rest (minimal) and pain meds Mostly opiates Recommend against NSAIDS acutely Brace if at the thoracolumbar junction or lumbar spine TL junction: Jewett or similar brace Lumbar: Corsett or chairback Physical therapy Acutely, only for Gait Training and ADL training After fx heals, then core strengthening and postural exercises Osteoporosis workup (Dexa( scan) Treat for osteoporosis Compression Fx Followup Xrays Acute 3 months 6 months DC Brace after 3 months If pain persists beyond 3 months then consider referral for vertebroplasty If neuro-deficit develops, get MRI If visible significant deformity develops or neuro deficit, then refer to surgeon 7

8 Surgical treatment Anterior spinal recon. Goal Stabilize spine Decompress nerves Decrease deformity Techniques Posterior stabilization Laminectomy Anterior vertebrectomy with anterior column reconstruction Anterior spinal recon. Vertebroplasty and kyphoplasty in the treatment of compression fractures 8

9 Burst Fracture with Retropulsion Spinal Dislocation With Burst fracture and Retropulsion Spinal dislocation (traumatic spondylolisthesis) Compression fx These can be treated in an extension brace or TLSO It takes 3 months for the fracture to fully consolidate in most cases Vertebroplasty and Kyphoplasty have very limited role if any Dexa scan 9

10 Fracture healing and factors which affect it Kyphosis Treatment Cervical: call neurosurgeon Some are treated in brace, but get advice Thoracic and lumbar Compression fx: : CASH brace, jewett or TLSO for TL junction Transverse process fx get CT to rule out other injuries Burst fx or Chance fx: : call spine surgeon Some are treated in TLSO, some get acute surgery vs late surgery 10

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