Spine Trauma: When to Transfer. Alexander Ching, MD Director, Orthopaedic Spine Trauma OHSU

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1 Spine Trauma: When to Transfer Alexander Ching, MD Director, Orthopaedic Spine Trauma OHSU

2 Disclosures Depuy Spine Consultant (teaching and courses) Department education and research funds Atlas Spine Consulting Orthopaedic Research and Education Foundation Department education and research funds

3 Disclosures Take 2 I am a spine surgeon I like spine trauma surgery I believe in spine surgery I make a living performing and researching spine surgery

4 Outline When to Transfer Stable vs Unstable Fractures Definition of stability Cervical Thoracic Lumbar Non-Fractures Central Cord Syndrome Cauda Equina Syndrome Other

5 When to Transfer Very Simple: When you are uncomfortable, we will be happy to take care of it. If it does not need acute transfer, we may recommend clinic followup We prefer to manage definitively (operatively) ourselves Difficult communication with family and coordination of care when the spine fracture has been surgically managed elsewhere Caveat: These are generalizations, when in doubt, let a spine surgeon evaluate I almost always recommend followup with a spine surgeon, at minimum

6 SPINAL BIOMECHANICS (IN 6 SLIDES)

7 Definition of Spinal Stability The ability of the spine under physiologic loads to limit patterns of displacement so as not to damage or irritate the the spinal cord or nerve roots and to prevent incapacitating deformity or pain due to structural changes White & Panjabi Clinical Biomechanics of the Spine 1990

8 Normal Spinal Alignment Cervical Lordosis Thoracic Kyphosis Wide range around 40 degrees Lumbar Lordosis Averages around 60 degrees Plumb Line Dropped from the middle of the C7 body should intersect within 2.5 cm of posterosuperior corner of S1

9 Lumbar vs. Cervical 10X Load 5X Surface Area Cervical Cervical Thoracolumbar Thoracolumbar Lumbar Lumbar

10 Principles of Spinal Structure Anterior and Posterior columns Passive function of the anterior column Vertebral bodies and intervertebral discs Passive and active function of the posterior column Passive elements Facets, and ligaments Compressive elements Spinal musculature Tension band principle

11 Tension Band Principle Compression of posterior elements aligns the functional spinal units Relies on an intact anterior column to sustain load Can have a significant impact on implant failure/spinal stability

12 Three Column Theory Anterior column - ALL, - Anterior 1/2 vertebral body and disk. Middle column - Posterior 1/2 vertebral body and disk - PLL Posterior column - Pedicles, facets, spinous processes/ligaments Unstable if 2 or more columns involved Denis Spine 1989

13 Quick and Dirty Indicators of Instability Neurologic deficit Gross deformity Three column injury?poly-trauma? May not be formally unstable, but probably going to recommend spine surgeon evaluation during hospital stay OHSU vs local spine surgeon available in morning

14 Radiographic Evaluation Plain films versus CT scan Dealers choice Imaging of ENTIRE spine Noncontiguous injuries in 10% 15 missed fractures 25% neurologic deterioration TL injuries and sacral or pelvic fractures 26% of sacral fractures, 7.7% of pelvic fractures 5 missed injuries Vaccaro et al, J Spinal Disord, 1992 Albert et al, Spine 1993

15 Cervical Injuries - Stable Unilateral facet injuries Odontoid fractures Maybe Spinous process fractures Maybe, if isolated

16 Cervical Injuries - Unstable Most other things Perched, dislocated facets Bilateral facet fractures Floating lateral masses Extension fractures Body fractures

17 Beware! The severely degenerative spine that appears to have no fracture with severe neck pain Extension fractures can be very subtle on imaging Very high rate of neurologic deterioration if diagnosis is delayed

18 Cervical Fractures in DISH or Ankylosing Spondylitis Do not underestimate the instability of such fractures!! The fused spine that fractures behaves more like a long bone

19 Thoracic Injuries Stable TP fractures Spinous process fractures Low energy compression fractures Unstable Rotational or shear injuries Burst fractures Extension fractures

20 Thoracic Injuries - Stable Isolated transverse process fractures Isolated spinous process fractures Low energy compression fractures

21 Beware! Multiple levels of transverse or spinous process fractures Scapula body fractures Isolated thoracic vertebral compression fractures in young people Often represent very high energy trauma to the chest wall Suspect not isolated injuries

22 Lumbar Injuries - Stable See thoracic spine Isolated TP and spinous process fractures Low energy compression fractures Some burst fractures Minimal canal compression Minimal kyphosis or collapse Probably should get evaluated by a spine surgeon

23 Lumbar Injuries - Unstable Some burst fractures 3 columns Injuries with posterior column involvement Neurologic injury 30/50/50 30 degrees of kyphosis 50% height loss 50% canal compromise Lumbo-sacral injuries Junctional injuries are always more unstable

24 Extension fractures

25 Cervical Fracture in DISH or Anky DISH LOW ENERGY MAY BE UNAWARE OF DISH 70 year old male, Trip and fall Neck and forehead pain No weakness or numbness No previous neck symptoms EXTENSION MECHANISM OFTEN NEURO INTACT Walks into emergency.

26 Ankylosing Spondylitis 41% delayed diagnosis of fracture Imaging very hard to interpret 16% developed delayed neurologic deficit High complication rate Milicic et al., Medicinski Pregled 1995 Broom et al., Spine, 2005

27 Extension Fractures Can also happen in other regions of the spine Often adjacent to a solid fusion

28 NON-FRACTURES

29 Cauda Equina Syndrome Syndrome Variable presentation and pathology Can be subtle presentation Average delay in diagnosis of 9 days in one study

30 Pathology Most commonly disk herniation Other causes Tumor Hematoma Infection Stenosis Fracture Iatrogenic Lumbar spine surgery Hematoma Compression

31 Presentation Classically Back Pain Urinary dysfunction Saddle anaestheisa Variable leg dysfunction (pain, numbness, weakness) Classically bilateral Reported Bladder dysfunction required Acute versus Chronic presentation Chronic may be insidious Chronic more likely to be delayed diagnosis Back pain may resolve or be long-standing Can have NO leg symptoms

32 Bladder Dysfunction Neurogenic Bladder Urinary Retention Overflow incontinence Can be challenging to identfiy Spinal tumor studies show need massive compression for bladder dysfunction

33 Evaluation Detailed neurologic exam Rectal Exam Peri-rectal pin-prick sensation Most sensitive Tone Difficult to interpret Bulbocavernosus reflex Post-void residual Should be less than 100 Over 250 is very concerning Imaging MRI or myelogram

34 Treatment Surgery All trials have excluded diagnosis of cauda equina Timing is debatable Generally regarded as emergency/urgency Data supports within 48 hours Animal data implies earlier is better Open (instead of minimally invasive)

35 Outcome Variable Bladder function: 17/22 recovered completely Motor function: 13/17 recovered completely Sensory function: 14/21 recovered completely Residual sexual dysfunction: 26-50% Bad prognostic indicators Advanced age?preoperative back pain? Delay in surgery over 48 hours

36 Central Cord Injury Commonly elderly patients Extension injury mechanism Pre-existing narrow spinal canal

37 Presentation Weakness greater in arms than legs Variable sensory changes Long tract findings common

38 Treatment Variable prognosis Many recover quickly without intervention Some very dense central cord injuries have limited recovery Treatment is aimed at managing underlying spinal stenosis Steroids and timing of surgery is controversial Pathophysiology matches suspected mechanism of steroids Early data suggests benefit of early surgery versus late, but not definitive

39 Other Disc herniation Epidural hematoma/abscess Tumor

40 Thank You Alexander Ching, MD Assistant Professor Director, Orthopaedic Spine Trauma Department of Orthopaedics and Rehabilitation Oregon Health and Sciences University Portland, Oregon