Dorso-Lumbar Fractures

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Dorso-lumbar Fractures

• Evaluation Planning Treatment

Ezzat M. El-Hawi Prof. Orthop. Surgery Ain
Shams Univ.
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Incidence

• 50,000 new cases in USA / yr.
• Bimodal Distribution
• 15 -24 yrs. Violent trauma
• RTA 40 -55
• Falls 20 30
• Gun shots 12 -21
• Sports 6 -12
• gt 55 yrs. May be trivial

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Initial Management (1)
Ultimate outcome depends upon

• Early recognition
• Prompt med. Resuscitation
• Attainment of temp. stability
• Prevent further injury
• Avoid complications

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Initial Management (2)

• Evaluation
• Airway Breathing Circulation
• Life threatening injuries Abd, Brain, Chest
• Cord injuries
• Head to toe survey
• Resuscitation Oxygenation Perfusion Drugs
• Immobilization Firm Board e straps
• Transport 0 50 150

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Initial Management (3)

• Types of Shock
• Neurogenic
• Bradycard., hypotension
• Trendlenberg, atropine, cardiac pressor, days or
  months
• Hypovolemic
• Tachycard., hypotension
• Find site, replace Bl. Plasma
• Spinal
• Loss of all functions, 48 hrs.
• Bulbocav. Reflex, anal sens., anal sph. Control
• Lesions below L2 some lower motor
  integrity
• Drugs
• Steroids
• Before 3 hrs, ineffective after 8 hrs
• Start by large dose 30mg/kg over 15 min. then 5.4
  mg/kg/hr
• Others

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Neurolog. Evaluation (1)
Key muscle groups

• L2 Hip Flexor (iliopsoas)
• L3 Knee Extensor (quadriceps)
• L4 Ankle Dorsiflexor (tib. ant)
• L5 Toe Extensor (E H L)
• S1 Ankle Planter flexor (gastrocnaem)

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Neurolog. Evaluation (2)
Orientation of lumbar functions more central than
sacral, hence the importance of sacrally mediated
reflexes
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Neurolog. Evaluation (3)

• Anatomic
• Anterior
• Central
• Posterior
• Brown Sequard

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Neurolog. Evaluation (4)

• Functional
• Frankel (1969)
• A complete loss
• B some sensory sparing
• C non-functional motor sparing
• D functional motor
• E Normal

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Neurolog. Evaluation (5)

• Functional
• A S I A (1992) All below level of injury
• A complete s m loss
• B preserved s only
• C preserved s m (key m gr. lt grade 3 )
• D preserved s m (key m gr. gt grade 3 )
• E normal

Level of Lesion The most distal level e at
least grade 3 motor function according to MRC
ASIA American Spinal Injury Association
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Radiological Evaluation (1)
Plain X-ray
Notice

• 5-30 have multiple lesions
• Cross table lat. View of whole spine
• Sagit.align, tear drop, sp.process /wide, naked
  facet, vertical lines, canal compromise
• Missed lesions Head inj.- multitrauma -
  intoxicated
• SCIWORA children old osteop. Ank.spon.
  DISH
• AP views wide post elem., facet disruption,
  vert., horiz.lamina sp.process , wide IPD
  (burst)
• Oblique view pars

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Radiological Evaluation (2)
Facet dislocation
Wide IPD
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Radiological Evaluation (3)

• C T Scan
• Thin sliced images for facet evaluation
• Sagit. Reformating
• 2-D 3-D
• Naked facet

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Radiological Evaluation (4)

• M R I

• Contraindications
• Cardiac pacemakers
• Metal vascular clips
• Claustrophobia
• Pt. requiring mechanical vent.

• Indications
• S C I W O R A
• Inj-Trauama non-correlation
• Path. Fracture
• Suspect Disc herniation

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Radiological Evaluation (5)

• Visualize S.T. injury
• Prognostically significant
• Cord lesions
• Acute cord Hge. Medium intense T1-WI, hypointense
  T2-WIe hyper oedema around
• Cord oedema fusiform Hyperintense T2-WI
• Cord discontinuity
• Post-traumatic syrinx, sycatrix, epidural
  haematoma

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Stability Classifications (1)

• Were devised to
• correlate skeletal inj. e neurologic deficit
• contemplating treatment strategy
• Predict prognosis
• Many systems
• No system fulfilled all objectives

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Stability Classifications (2)

• Holdsworth (1963)
• Mechanistic flex, flex rot, ext, comp, disloc
• Main idea stability depends on intact post
  ligament complex
• Ext , Rot Disloc Unstable
• Copmression burst Stable

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Stability Classifications (3)

• Kelly Whiteside (1968)
• 2 Colum Theory
• Body for Wt. bearing
• Post osteoligament complex for tension resistance
• Either can take over when one fails
• Fell into same dispute

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Stability Classifications (3)

• Denis (1983)
• Used X-ray C.T
• 3 Column theory
• Classified inj to minor major
• Minor sp pr, tr pr, pedicle, facet
• Major comp, burst, seat belt, fr. disloc. (flex
  rot, shear, flex dist) All columns fail
• Burst classified accord to middle column
• Seat belt ligametous osseous (Chance)

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Stability Classifications (4)

• McAfee et al (1983)
• 6 patterns accord to failure of middle column
• Compression only ant. Column
• Burst (stable) ant. mid. Columns
• Burst (unstable) 3 column failure in compr.,
  lat. Flex or rotation. Indications of
  instability
• prog.N.deficit
• segm. Kyphosis gt 20
• gt50 ant height loss
• free bone fragment inside sp. canal
• Chance flex distr. of Denis
• Flex Distr. Seat belt of Denis
• Translation failure in shear or rotation

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Stability Classifications (5)

• Ferguson Allen (1984)
• 7 patterns according to force applied and
  guidance to operative non operative ttt.
• Comp flex inj. ant. C. fails in comp
• Type I only ant. C.
• Type II post. C. tension failure
• Type III mid. C. fails in tension or
  blowout height N/ , most common, 48
• Dist-Flex inj. Tension failure all columns
• Flex-dist. Fracture dislocation
• Seat belt injury

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Stability Classifications (6)

• Ferguson Allen (1984) Cont.
• Lat. Flex. Inj.
• Unilat. Comp. failure ant.mid. Clumns
• Contralat. Dist. Failure post. Complex e facet
  disloc.
• Translation inj. AP or Lat. Shear
• Vertical compression (pure) uncommon, all
  osseous failure, mid. C. height retropulsion
  of fragment
• Tortion flex. inj. ant. C. comp.rot. (slice)
  post. C. tension rot. Mid. C. affected (most
  unstable)
• Dist-Extension inj. rare, ant. C. tension
  failure comp. failure post. C.

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Stability Classifications (7)

• Gertzbein (1992)
• 3 main categoies e subcat.
• Comp. inj. of body under axial load
• Distraction inj. Ant. And Post.
• Multidirectional Rot. And Transl.
• Ascending order of severity of skeletal neurol.
  Lesions and Instability
• Descriptive but lengthy

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Treatment Options (1)

• Conservative
• Minor injuries Sp.pr., tr. Pr., lamina, pedicle
• Comp-Flexion inj. With lt30 deg. Kyph., no neurol.
  Deficit
• Contiguous lesions ? Add kyphosis
• Stable Burst no deficit, canal frag. lt50,
  canal can remodel
• Usually need bed rest, analgesics, followed by
  TLSO
• Follow up with dynamic films for progression

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Treatment Options (2)

• Surgical Notes
• Canal can remodel
• Comlete lesions in Dorsal sp. seldom recover
• incomplele lesions benefit from decompression
• Ant. Decomp. Gives better recovery
• Stabilization is mandatory
• Polytrauma pt. needs stabilization
• If distraction is diagnosed, compression instrum.
  Is needed
• Fusion should be added

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Treatment Options (3)

• Immediate Stabilization
• Flexion-Distraction
• Tranlational
• Shear
• Direct indirect Reduction
• Ant Decompression in
• Central comp
• Above cauda
• gt2 wks

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Treatment Options (4)

• Ant. Or Post. Short or Long fixation ?
• Gaines (1994) Load Sharing Classif.
• Classification of fr. According to liability to
  pedicular screw failures in short construct
• Proved effective in pre-operative planning to add
  ant. Strut grafting
• Used to decrease pseudoarthrosis,recurrent
  kyphosis screw failures

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Treatment Options (5)
Comminution/envolvemnt sagittal C T Scan Little
1 lt30 More 2 30 60 Gross 3 gt 60
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Treatment Options (5)
Spread/ apposition of fragments Minimal
1 Spread 2 2mm displacement of lt 50 of cross
section of body Wide 3 2mm displacement of gt
50 of cross section of body
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Treatment Options (6)
Deformity correction 1 3 kyphotic
correction post-op. 2 4 - 9 3
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Treatment Options (7)

• According to the load sharing classification
• Patients having 6 or less points can be safely
  treated by short posterior fixation and fusion.
  Patients having a score of 7 or more should have
  anterior strut grafting with or without
  instrumentation in addition

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Thank you