Spine Trauma. Vertebral Column Injuries

Spine Trauma Vertebral Column Injuries Srinivas Prasad, MS, MD Assistant Professor Neurologic and Orthopedic Surgery Thomas Jefferson University Staff Neurosurgeon St. Mary s Medical Center

Presentation Overview Spinal Anatomy Incidence Cervical fractures Thoracolumbar fractures

Spine Anatomy Overview Two Components Spinal Column Stack of blocks called vertebral bodies 24 vertebral bodies 3 Zones Cervical Thoracic Lumbar Neural Elements

Spine Anatomy Overview Two Components Spinal Column Neural Elements Spinal Cord Starts at the brainstem Ends around L1 Spinal Nerves Exit spine at each level Numbered according to level of spinal column they come out of

Spine Anatomy Spinal Column Overall 24 mobile vertebral bodies 3 Zones Cervical Spine 7 Vertebral Bodies Thoracic Spine 12 Vertebral Bodies Lumbar Spine 5 Vertebral Bodies

Spine Anatomy Spinal Column Vertebral Body Vertebral Bodies Body Pedicle Transverse Process Facet Joints Spinous Process

Spine Anatomy Intervertebral Disc Nucleus Pulposus: 70-90% water Annulus fibrosis: Concentric, oblique, overlapping lamellae Largest Avasular Structure in the Human Body

Spine Anatomy Alignment and Balance Lordosis Curved backwards Normal in: Cervical Lumbar Kyphosis Curved Forward Normal in Thoracic Aging is kyphogenic

Spine Anatomy Alignment and Balance Local Malalignment Causes compensatory changes May cause global Malalignment Sagittal Balance Very Important Coronal Balance Less Important

Spine Anatomy Spinal Column Protects nervous structures Supports the head: Vision Ambulation Respiration Stability Anterior column: Load-bearing Posterior column: Tension band

Spine Anatomy Occiput-C2 Complex OCC-C2 50% Flex/Ext 50% Rotation Transverse Atlanto- Axial Ligament Atlanto-Alar portion of Alar Ligament Apical Ligament C2 to clivus

Spine Anatomy Cervical Range of Motion Flexion-Extension C3-4 7-26 C4-5 13-29 C5-6 13-29 C6-7 6-26 C7-T1 4-7 White and Panjabi, Clinical Biomechanics of the Spine

Spine Anatomy Thoracic Spine 12 Vertebra Unique topography T1 to T9 T10-T12 Rib cage Increases stiffness 400% Facets Coronal plane

Concentrates at apex Spine Anatomy Thoracic and Thoracolumbar Biomechanics usually T6 T8 fracture focus Change in loading patterns thoracic = anterior lumbar = posterior thoracolumbar = middle

Spine Anatomy Lumbar Anatomy and Biomechanics 5 vertebrae kidney shaped Sagittal facet joints Increased loads No spinal cord

Neurological Exam C 5 C 6 C 7 C 8 MOTOR Deltoid/ Biceps Wrist Extensor/ Biceps Triceps/ Wrist Flexors Intrinsics/grasp REFLEX Biceps Brachioradialis Triceps Ø SENSORY DEFICIT Shoulder Thumb/ Index Long 4 th /5 th

Spinal Cord Injury

Spinal Cord Injury Demographics

Spinal Cord Injury Demographics

Spinal Cord Injury Frankel/ASIA Classification

Initial Mechanical Injury (Primary Injury) Acute Pathophysiologic Responses (Secondary Injury) -local ischemia -electrolyte imbalances -free radical formation/lipid peroxidation -inflammation/immunologic response -necrotic & apoptotic cell death Chronic Neuropathology -disrupted/demyelinated axons -glial scar & cystic cavitation

Spinal Cord Injury Timing of Decompression Animal Model 0 hr 2 hr 6 hr 24 hr improved neurorecovery 72 hr Dimar, et al. The influence of spinal canal narrowing & timing of decompression on neurologic recovery after Spinal cord contusion in a rat model. Spine 1999

Spinal Cord Injury Practice Patterns Timing of Surgery in Acute SCI Tator, Fehlings, et al, J Neurosurg, 1999 50 36 North American Centers 585 pts % of patients 40 30 20 24 16 19 42 10 0 <24h 25-48h 48-96h >5 days Time to surgery

Spinal Cord Injury Clinical Studies (2000-2005) Timing of Surgery Author No. Patients (level) Timing of intervention Study design (class of evidence) Conclusions McKinley (2004) 779(all):603 decompressed, 176 nonop 73 underwent decompression <24h Retrospective case series (III) Early (<72h) decomp did not improve neuro recov, but decreases complications/hosp stay LaRosa (2004) 1683(all):793 decompressed, 890 nonop 226 underwent decompression <24h Systematic lit review uo to 2000 (II) Early decomp improves neuro recov in incomplete injuries Pollard/Apple (2005) 412 (cervical) incomplete injuries Retrospective case series;baseline neuro assess NA in 51% of cases (III) Early decomp (<24h) not assoc w/ improved recovery: incomplete baseline and f/u assessments limit utility Papadopoulos (2002) 91 (cervical):66 decompressed, 25 nonoperative 34 underwent surgical decompression <10h Prospective, nonrandomized (II) Early decomp feasible, may improve neuro recov and decreases hosp stay Pointillart (2000) 106 (levels): 58 (cervical) 49 underwent surgical decompression <8h Prospective, nonrandomized (II) Early surgery did not improve neuro recovery

Spinal Cord Injury STASCIS Surgical Trial in Acute SCI Study PI: Michael Fehlings (U of T) Alex Vaccaro (TJU) Prospective cohort study Cervical Trauma with SCI and Cord Compression Multivariate analysis to examine affect of timing of decompression on outcome after SCI Krembil Foundation American Spinal Injury Association AANS/CNS Section on Neurotrauma and Critical Care

Spinal Cord Injury STASCIS Early vs Delayed Surgery Potential Covariates ISS Scores; Charleston Comorbidity Index: NSD

Spinal Cord Injury STASCIS One Year Outcomes AIS N=118; 1 yr f/u Poisson regression p<0.005

Spinal Cord Injury STASCIS One Year Outcomes AIS There was a trend for higher complications rates (46%) in the late group compared to the early group (36%) main difference: reduction in ventilator associated pneumonia Complications Prior to Discharge by Time to Decompression Were there any complications prior to discharge? Yes No Total Time to Decompression Early Late Total Count Column N % Count Column N % Count Column N % 53 36.1% 56 45.5% 109 40.4% 94 63.9% 67 54.5% 161 59.6% 147 100.0% 123 100.0% 270 100.0%

Spinal Cord Injury Spinal Instability Difficult to define Anatomic disruption Spinal malalignment

Thoracolumbar Trauma White-Panjabi Definition of Stability Definition the ability of the spine under physiologic loads to prevent initial or additional neurologic damage, severe intractable pain, and gross deformity White and Panjabi, Clinical Biomechanics of the Spine 1990

Routine Trauma Workup

Routine Trauma Protocols C-Spine Clearance Algorithms NEXUS criteria (No Films): 1. No neurologic abnormalities 2. No evidence of intoxication 3. No posterior midline cervical spine tenderness 4. No other distracting injuries Dynamic flex/ext (Timing?) Unconscious patient Static bump induced flexion views Dynamic fluoroscopic exam-timing? Eastern Association for the Surgery of Trauma c-spine clearance guidelines Schenarts PJ. J Trauma. Oct 2001.?

Routine Trauma Protocols C-Spine Plain Film Landmarks ADI < 3 mm in adult < 5 mm in children Soft tissue retropharyngeal space C2 < 6 mm Retrotracheal space C6 < 22 mm in adult < 14 mm in children

Prospective unblinded c-spine evaluation 667 trauma patients (Blunt trauma 99%) Average age was 35.4 years and 70% were male Cervical three-view plain films Multidetector CT scan (MCT) Final discharge diagnosis based: clinical data MCT Plain films Sixty of 667 (9%) sustained acute c-spine injuries MCT had a sensitivity of 100% and specificity of 99.5% Plain films had a sensitivity of 45% and specificity of 97.4% Plain radiography missed 15 of 27 (55.5%) clinically significant c-spine injuries. J Trauma: Vol 62(6), 2007

Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures Lee HM, et al: Spine. 2000 Aug 15;25(16):2079-84 34 patients with thoracolumbar spinal fractures evaluated Palpation of the interspinous gap, Plain radiography MRI before operation with fat-suppressed T2-weighted sequence Wide interspinous gap was palpated in 14 patients Plain radiography noted 21 patients MRI suspected injury Supraspinous ligament - 27 patients Interspinous ligament - 30 patients Ligamentum flavum - 9 patients Operative findings 28 supraspinous ligament injuries 29 interspinous ligament injuries 7 ligamentum flavum injuries

Spine Trauma Injury Patterns and Management

Spine Injury Management Management Principles Goals of treatment Maximize neurologic recovery Prevent decline and deformities (i.e. stabilize spine) Maximize pain relief Instability Mechanical Neurologic Both Mechanical and Neurologic

Pre-hospital and Emergency Room Care

Non-Operative Treatment Immobilization Collars and Braces

Non-Operative Treatment Immobilization Collars and Braces

Non-Operative Treatment Immobilization Halo Vest

Operative Treatment Surgical Approach Posterior (Dorsal) Anterior (Ventral) Combined

Operative Treatment Factors affecting Surgical Approach Column(s) disrupted Site of neural compression Upper cervical vs subaxial Spinal deformity Degree of spinal instability

Operative Treatment The Role of Instrumentation Instrumentation provides for maturation of fusion

Common Injury Patterns and Management

Atlanto-Occipital Dislocation Occipito-Cervical Fusion

Jefferson (C1) Fracture Axial load injury Jefferson G, Br J Surg, 7:407, 1920.

Atlanto-Axial Instability

Odontoid Fractures 10-15% of all cervical fractures Flexion > extension injury Estimated 25-40% fatality Anderson and D Alonzo classification Crockard HA et al., J Neurosurg, 78: 579-86, 1993.

Odontoid Fractures Type I Fractures Rare Upper tip of dens Avulsion of alar ligament Stable fracture by itself? May be a manifestation of atlanto-occipital dislocation. Scott EW, et al., J Neurosurg, 72:488-92, 1990.

Odontoid Fractures Type II Fractures Type II Lower half of dens Unstable fracture High non-union rate Type II a 3% of type II fractures Comminuted fracture Free fracture fragments Hadley MN, et al., Neurosurgery, 22:67-71, 1988.

Odontoid Fractures Type III Fractures Not a true odontoid fracture Fracture through body of C2 Greater/large surface area Cancellous bone Better vascular supply Usually heal non-operatively

Odontoid Fractures General Treatment Considerations Type I stable? Type II surgery vs external immobilization Age of patient (>40-55) Age of fracture (> 2weeks) Displacement of Dens (>4 6 mm) Posterior displaced Tobacco use Type IIa Type III - surgery vs external immobilization Displacement of Dens

82 y/o female with posterior displaced odontoid fracture s/p fall

Odontoid Fractures Surgical Management Odontoid Screw

Odontoid Fractures Surgical Management Posterior C1-2 Fusion

Hangman s Fractures Fracture through C2 isthmus Judicial Distraction and shearing Accidental vary by type Neurological Intact Effendi B, J Bone Joint Surg, 63-B(3):319-27, 1981.

Hangman s Fractures Controversial treatment Type I collar Type II halo for 3-5mm subluxation with <10º angulation Operative fixation if > 5mm or > 10º Type IIa halo vest with compression Type III require surgical intervention Francis WR, et al., J Bone Joint Surg, 63B:313-18, 1981.

Central Cord Syndrome Incomplete Spinal Cord Injury

Central Cord Syndrome Incomplete Spinal Cord Injury

Central Cord Syndrome Surgical Management

Cervical Burst Fracture Potential for Spinal Cord Injury

Cervical Burst Fracture Surgical Management

Cervical Burst Fracture Surgical Management

Cervical Facet Dislocation Fracture Morphology

Unilateral Facet Dislocation Fracture Morphology 25% Subluxation of vertebrae

Bilateral Facet Dislocation Fracture Morphology

Closed Reduction Techniques Prerequisites Awake, cooperative patient Experienced physicians Dedicated radiology technician Complete cervical spine series No evidence of skull fracture Vaccaro, Spine 1999

Closed Reduction Techniques Early Closed Reduction Reduction < 8 hrs post injury Greater Neuro recovery compared to age, injury matched controls Cotler, NASS 92

Thoracolumbar Fractures Denis Classification Major injuries divided into four categories: Compression fractures Burst fractures Seat belt-type injuries Fracture-dislocations 16 Subtypes 3-5 Subtypes each Denis, Spine, 1983

Thoracic Compression Fractures Kyphoplasty Pre-operative Post Vertebral Kyphoplasty Augmentation

Thoracic Compression Fractures Kyphoplasty Pre-operative Post Vertebral Kyphoplasty Augmentation

Thoracolumbar Burst Fractures Fracture Morphology

Thoracolumbar Burst Fractures Conservative Management 12 1 3 2 + = 4 5

Thoracolumbar Burst Fractures SCI Surgical Management L1 Burst Fracture Conus Injury T12 Body L2 Body

Thoracolumbar Burst Fractures Progressive Kyphosis Surgical Management 8 26 A B

Thoracolumbar Burst Fracture Surgical Management Anterior Approach Visualization of pathology & more consistent decompression of spinal cord Reconstruction of anterior column

Thoracolumbar Burst Fracture Surgical Management Anterior Approach

Thoracolumbar Burst Fracture Surgical Management Anterior Approach

Thoracolumbar Burst Fracture Surgical Management Anterior Approach

Thoracolumbar Burst Fracture Surgical Management Anterior Approach Plate Dura

Thoracolumbar Burst Fracture Surgical Management Anterior Approach Screws 45 and 40mm Bicortical Screws No coronal abnormality Plate Flate Graft in position Screws not in the canal End plates parallel

Thoracolumbar Burst Fracture Surgical Management Posterior Approach

Thoracolumbar Burst Fracture Surgical Management Posterior Approach

Thoracolumbar Burst Fracture Surgical Management Anterior & Posterior

Conclusions Spine Trauma is common and increasing in incidence Prompt immobilization is essential until comprehensive workup is complete Fracture Morphology and Neurological status are central factors in management Hospital care makes a big difference in minimizing secondary injury

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