Transcript Slide 1
Spine fracture
Dakheel A. Al-Dakheel, MBBS, SSC(Ortho) Orthopaedic surgery department King Fahd Hospital of the University Khobar, KSA
NOTE : THIS PRESENTATION DOES NOT REPLACE ATTENDANCE OR INFORMATION GIVEN IN THE LECTURE.IT IS INTENDED AS A HIGHLIGHT FOR THE TOPIC
Thoraco-lumbar fracture
Incidence: • • • • • • Neurological deficit may occur in 10 – 25% 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 4:1. The overall survival rate for patients with spinal injuries is 86% at 10 years Incidence of noncontiguous, multilevel vertebral injuries is approximately 20%
Mechanism of injury
• MVA 50% • Falls 25% • Gunshot 15% • Sport 10%
• 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
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.
• 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
Multiple Spinal Fracture
• Calenoff, Chessare,& Rogers reported an incidence of 4.5%
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 1 st year.
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%
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
• Proper extraction • Intubation • Immobilization • Cervical collar, sand bag, tape, • ? Neck position • ?pediatrics
Emergency Assessment
• ATLS
• Evaluating spinal injury begins in the secondary survey • • History is taken & head to toe examination Obtain history from • Patient • Family members • Paramedical personnel
History
• • • • Mechanism of injury Position of the patient when found Transient motor or sensory loss Paradoxical breathing • Seat belt
Inspection
• • • • • All clothing should be carefully removed Any bleeding , abrasion or lacerations Limb asymmetry Voluntary limb movement Chest expansion
Palpation
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Cervical collar removed carefully Tenderness Interspinous widening Malialignement of spinouse process Step off
Neurological Evaluation
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Neurological examination Sensory evaluation Motor evaluation Reflexes
Spinal reflexes
Cresmatic reflex
• • • Stocking inner thigh & observing the scrotum movement Absence means UMNL Unilateral absence suggest LMNL
Sacral Sparing
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• • • 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
Skeletal Trauma
Bulbocavernosus reflex
• Pull glans or press clitoris anal contraction (int. sphincter) around gloved finger • Absence is indicator of spinal shock
RADIOLOGICAL ASSESMENT
• PLAIN FILM • AP & LATERAL
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
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
MRI
T1 T2 GRE
Classification of ThoracoLumbar spine Fracture
Compression Fracture
Burst Fracture
Fracture Dislocation
Flexion Distraction
Imaging
Non-Operative Management
Surgical intervention
Complications of spine fracture
• Neurological injury • Instability ( pain & deformity) • Complication of surgery