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Spine > Spine Trauma > Flashcards

Spine Trauma Flashcards

1
Q

When is Removal of cervical collar WITHOUT radiographic studies is allowed

A
  • patient is awake, alert, and not intoxicated AND
  • has no neck pain, tenderness, or neurologic deficits AND
  • has no distracting injuries
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2
Q

What to look for in the trauma setting on an X-Ray to R/O cervical Fx

A
  • soft-tissue swelling
  • Hypo-lordosis
  • disk-space narrowing or widening
  • widening of the interspinous distances
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3
Q

Incidence of Iatrogenic SCI?

A

it is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport.

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4
Q

What is the pathophysiology of SCI?

A

◦ primary injury

  • damage to neural tissue due to direct trauma
  • irreversible

secondary injuryinjury to adjacent tissue due to

  • decreased perfusion
  • lipid peroxidation
  • free radical / cytokines
  • cell apoptosis

methylprednisone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals

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5
Q

What are the risk factors for vertebral artery injury

A
  • Atlas fractures
  • Facet dislocations
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6
Q

What is the prognosis of SCI?

A

only 1% have complete recovery at time of hospital diagnosis

conus medullaris syndrome has a better prognosis for recovery than more proximal lesions

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7
Q

What is the definition of tetraplegic, paraplegic, Complete injury and incomplete injury

A

Tetraplegia: arms, trunk, legs, and pelvic organs

Paraplegia: Arm function is preserved

Complete injury: an injury with no spared motor or sensory function below the affected level.

patients must have recovered from spinal shock (bulbo-cavernosus reflex is intact) before an injury can be determined as complete

classified as an ASIA A

incomplete injury

an injury with some preserved motor or sensory function below the injury level

incomplete spinal cord injuries include

  • anterior cord syndrome
  • Brown-Sequard syndrome
  • central cord syndrome
  • posterior cord syndrome
  • conus medullaris syndromes
  • cauda equina syndrome
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8
Q

What are the steps for ASIA Classification?

A
  1. Determine if patient is in spinal shock
    * check bulbocavernosus reflex
  2. Determine neurologic level of injury

lowest segment with intact sensation and antigravity (3 or more) muscle function strength

in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.

  1. Determine whether the injury is COMPLETE or INCOMPLETE

COMPLETE defined as (ASIA A)

no voluntary anal contraction (sacral sparing) AND

0/5 distal motor AND

0/2 distal sensory scores (no perianal sensation) AND

bulbocavernosus reflex present (patient not in spinal shock)

INCOMPLETE defined as

voluntary anal contraction (sacral sparing)

sacral sparing critical to determine complete vs. incomplete

OR palpable or visible muscle contraction below injury level OR

perianal sensation present

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9
Q

ASIA Grades

A
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10
Q

What are the Stages of spinal shock?

A

Phase 1 -

hypo-reflexic

0 to 48 hours

Areflexia/hypo-reflexic

Phase 2 -

initial reflex return

1-2 days

polysynaptic reflexes return (bulbo-cavernous reflex)

monosynaptic (patellar) remain absent

Phase 3 -

initial hyper-reflexia

1-4 weeks

Phase 4 - spasticity

1 to 12 months

characterized by altered skeletal performance

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11
Q

What SCI require intubation?

A

above C5

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12
Q

What should seat belt sign (abdominal ecchymoses) raise suspicion for?

A

flexion distraction injuries of thoracolumbar spine

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13
Q

Recommended initial medical treatment?

A
  • DVT prophylaxis
  • Hypotension should be avoided
  • Decubitus ulcer prevention
  • acute closed reduction with axial traction
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14
Q

What are the surgical indications from GSW

A

Most incomplete SCI (except GSW)

decompress when patient hits neurologic plateau or if worsening neurologically

decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)

Most complete SCI (except GSW)

stabilize spine to facilitate rehab and minimize need for halo or orthosis

decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)

consider for tendon transfers

e.g. Deltoid to triceps transfer for C5 or C6 SCI

GSW with

progressive neurological deterioration with retained bullet within the spinal canal

cauda equina syndrome (considered a peripheral nerve)

retained bullet fragment within the thecal sac

CSF leads to the breakdown of lead products that may lead to lead poisoning

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15
Q

Function C1-C3 SCI

A
  • Ventilator dependent with limited talking.
  • Electric wheelchair with head or chin control
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16
Q

Function C3-C4

A
  • Initially ventilator dependent, but can become independent
  • Electric wheelchair with head or chin control
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17
Q

Function C5 SCI

A
  • Ventilator independent
  • Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself
  • Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function
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18
Q

SCI FUNCTION

A
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19
Q

What is the prognosis for complete injuries- Incomplete injuries- Conus medullaris syndrome?

A

• Complete Injuries

Improvement of one nerve root level can be expected in 80% of patients

improvement of two nerve root levels can be expected in 20% of patients

only 1% have complete recovery at time of hospital diagnosis

Incomplete Injuries

trends of improvement include

the greater the sparring, the greater the recovery

patients that show more rapid recovery have a better prognosis

when recovery plateaus, it rarely resumes improvement

Conus Medullaris syndrome:

has a better prognosis for recovery than more proximal lesions

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20
Q

What are the complications of SCI?

A
  1. Skin problems
  2. Venous Thromboembolism
  3. Urosepsis: common cause of death; strict aseptic technique when placing catheter; don’t let bladder become overly distended
  4. Sinus bradycardia: most common cardiac arrhythmia in acute stage following SCI
  5. Orthostatic hypotension: occurs as a result of lack of sympathetic tone
  6. Autonomic Dysreflexia; potentially fatal; presents with headache, agitation, hypertension; caused by unchecked visceral stimulation; check foley; disimpact patient; radiographs of lower extremity if there is concern for undiagnosed fracture
  7. Major depressive disorder: ~11% of patients with spinal cord injuries suffer from MDD; MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase.
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21
Q

3 things to check with Autonomic dysreflexia

A

unchecked visceral stimulation; check foley; disimpact patient; radiographs of lower extremity if there is concern for undiagnosed fracture

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22
Q

What are the 4 incomplete SCI

A
  1. Anterior cord syndrome
  2. Brown-Sequard syndrome
  3. central cord syndrome
  4. posterior cord syndrome
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23
Q

What is the most common ISCI? Population?

A

Central Cord Syndrome

  • Elderly with minor extension injury mechanisms
    • due to anterior osteophytes and posterior infolded ligamentum flavum
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24
Q

What is the pathophysiology of Central cord syndrome?

A

spinal cord compression and central cord edema

selective destruction of lateral cortico-spinal tract white matter

hands and upper extremities are located “centrally” in cortico-spinal tract

Weakness with hand dexterity most affected

Hyper-pathia

Burning in distal upper extremity

motor deficit worse in UE than LE (some preserved motor function)

hands have more pronounced motor deficit than arms

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25
Q

What is the prognosis of central cord syndrome?

A

good prognosis although full functional recovery rare

usually ambulatory at final follow up

usually regain bladder control

upper extremity and hand recovery is unpredictable and patients often have permanent clumsy hands

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26
Q

How does recovery occurs with central cord syndrome?

A

◦ recovery occurs in typical pattern

  • lower extremity recovers first
  • bowel and bladder function next
  • proximal upper extremity next
  • hand function last to recover
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27
Q

Particularities of anterior cord syndrome

A
  • Worst prognosis; 10-20% chance of motor recovery
  • motor dysfunction + dissociated sensory deficit below level of SCI
  • flexion/ compression injury
  • lower extremity affected more than upper extremity
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28
Q

Brown Sequard

Mechanism

Symptoms

Prognosis

A
  • Penetrating trauma
  • Ipsilateral deficit LCS tract
    • Motor function
      • dorsal columns
      • proprioception
      • vibratory sense
      • contralateral
      • deficitLST: pain, temperature
    • spinothalamic tracts cross at spinal cord level (classically 2-levels below)
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29
Q

True or False Improved Neuro outcome with early <24hours decompression

A

True

Fehlings et al. performed a multicenter prospective cohort study on the timing of intervention for spinal cord injuries. They found improved neurological outcome for patients with complete or incomplete spinal cord injuries that were decompressed within 24 hours compared to those that were decompressed at a later time. Additionally, they found no increased risk of mortality or complications for patients who underwent early surgical intervention.

STASCIS

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30
Q

Definition of ASIA B

A

no motor function preserved more than 3 levels below the affected neurological level is consistent with an ASIA B category injury.

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31
Q

Evidence on administering a dose of Methylprednisolone 30 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 24 hours

A

It is not supported by current literature - recent studies have shown an increased risk of complications with no clear evidence of benefits

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32
Q

What is Autonomic Dysreflexia?

Treatment

A

increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs (sweating, piloerection, facial flushing), or symptoms (headache, blurred vision, nasal congestion) due to a stimulus such as overdistended bladder or bowel impaction.

due to sympathetic decentralization leads to altered regulation of the autonomic function, despite the presence of intact parasympathetic (vagal) afferent and efferent pathways in patients with SCI.

Guidelines for treatment of autonomic dysreflexia include 1) patient immediately placed in a sitting position if the person is supine. 2) clothing or constrictive devices need to be loosened 3) troubleshoot etiologies for bladder distention or bowel impaction 4) a SBP >150 mmHg may need to be treated with nifedipine or nitrates 5) close monitoring of symptoms, blood pressure, and heart rate for at least 2 hours.

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33
Q

What is the most important predictor of her neurologic outcome

A

Severity of initial neurologic injury

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34
Q

When is Posterior deltoid-to-triceps transfer is considered

A

COMPLETE spinal cord injuries at C5 or C6 with 5/5 delt/biceps, but 0/5 triceps.

Activities such as dressing, controlling a power wheelchair and supporting oneself while sitting are dependent on the balanced forces provided by the triceps muscle. The transfer involves detaching the posterior deltoid muscle and anchoring the tendon sutured into the triceps muscle. It is the best choice as it will allow for opposing elbow extension to his maintained bicep function - which will help patients to perform reaching movements and improve level of functional independence.

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35
Q

2 types of Occipito-cervical instability

A

Traumatic occipito-cervical dislocation: most patients die of brainstem destruction

Acquired occipito-cervical instability: Down’s syndrome; occipital condyle hypoplasia

results in limited AOJ motion and basilar invagination

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36
Q

Associated Conditions with Occipito-cervical Instability & Dislocation

A
  • Atlanto-axial instability: also seen in Down syndrome patients
  • neurologic deficits
  • vertebral or carotid artery injuries
  • Down Syndrome
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37
Q

Atlas C1 anatomy

A
  • Ring containing two articular lateral masses
  • No vertebral body or a spinous process
  • anatomic variation: incomplete formation of the posterior arch is a relatively common; does not represent a traumatic injury
  • Ligamentous structures: transverse ligament; paired alar ligaments; apical ligament ; tectorial membrane
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38
Q

Types of Atlanto-occipital dislocation

A

Type I

Anterior occiput dislocation

Type II

Longitudinal dislocation

Type III

Posterior occiput dislocation

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39
Q

Measurements done in Atlanto-Occipital dislocation

A
  • Powers ratio = C-D/A-B

C-D: distance from basion to posterior arch

A-B: distance from anterior arch to opisthion significance ratio ~ 1 is normal

if > 1.0 concern for

  • anterior dislocation

ratio < 1.0 raises concern for

  • posterior atlanto-occipital dislocation
  • odontoid fractures
  • ring of atlas fractures
  • Harris rule of 12 basion-dens interval or basion-posterior axial interval

>12mm suggest occipito-cervical dissociation

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40
Q

Posterior Occipito-cervical fusion

A

Approach: midline posterior approach to base of skull

Instrumentation

  • rigid occipito-cervical screw-rod or plate construct
  • aim for 3 uni-cortical occipital screws on each side of the midline (total 6 screws in occiput)
  • some institutions prefer bi-cortical screws but they come at increase risk

extend to C2 or lower with polyaxial pedical screws to achieve fixation

  • Safe zone for Occipital screws : within 20mm lateral to the external occipital protuberance along the superior nuchal line

Structures at risk:

major dural venous sinuses located below the external occipital protuberance

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41
Q

structure at the greatest risk of injury with perforation of the anterior cortex at C1

A

Internal carotid artery

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42
Q

2 Processes that might lead to Atlanto-axial instability

A

Degenerative and traumatic processes

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43
Q

Adult and Pediatric causes of C1-C2 instability

A

Adult causes

Degenerative

Down’s syndrome

Rheumatoid Arthritis

Os Odontoideum

Traumatic

Type I odontoid fracture (very rare)

Atlas fractures

Transverse ligament injuries

Pediatric causes

Degenerative

JRA

Morquio’s Syndrome

lysosomal storage disorder

Trauma/infection

rotatory Atlanto-axial subluxation

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44
Q

C1-C2 instability Radiographics parameters

A
  • flexion-extension x-rays atlanto-dens interval (ADI) adult parameters

> 3.5mm considered unstable

> 10mm indicates surgery in RA

  • space-available-cord (SAC) = posterior atlanto-dens-interval (PADI)

in adults with RA < 14 mm associated with increased risk of neurologic injury and is an indication for surgery

  • sum of lateral mass displacement

if > 8.1 mm, then a transverse ligament rupture is assured and the injury pattern is considered unstable

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45
Q

Management of os odontoideum

A

Whether os odontoideum is congenital or the residual of a traumatic process is controversial.

Most authors support a post-traumatic etiology; however, some evidence exists to support a congenital origin.

  • Asymptomatic patients may be managed with cessation of contact sports alone.
  • Neurologic findings and widened ADI are both indications for a posterior C1-C2 fusion.
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46
Q

What is a hangman’s fracture?

A

bilateral fracture of pars inter-articularis of C2

Traumatic Spondylo-listhesis of Axis

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47
Q

What is the mechanism of hangman’s fracture?

A

◦ Hyperextension + Distraction injuries: leads to fracture of pars

secondary flexion: tears PLL and disc allowing subluxation

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48
Q

What is the classification for Hangman’s fracture and treatment according to fracture type

A

Levine and Edwards Classification

  1. Type 1: < 3mm displacement: Rigid collar
  2. Type 2: >3.5mm displacement: Halo/Surgery
  3. Type 2A: angulated >11deg: Reduction+Halo
  4. Type 3: Type 1 with associated bilateral facet dislocation: Surgical reduction of facet + stabilization
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49
Q

3 techniques for C2-C3 stabilization

A
  • anterior C2-3 interbody fusion
  • posterior C1-3 fusion
  • bilateral C2 pars screw osteosynthesis
50
Q

What is the mechanism of an atlas fracture?

A

Hyperextension

lateral compression

axial compression

51
Q

What are the associated conditions with C1 fx

A

◦ spine fracture

50% have an associated spine injury

40% associated with axis fx

52
Q

What is the Prognosis of C1?

A

◦ stability dependent on degree of injury and healing potential of transverse ligament

53
Q

Classification of C1 Fractures

A

Type I

Isolated anterior or posterior arch fracture. A “plough fracture is an isolated anterior arch fracture caused by a force driving the odontoid through the anterior arch. Stable. Treat with hard collar.

Type II

Jefferson burst fracture with bilateral fractures of anterior and posterior arch resulting from axial load. Stability determined by integrity of transverse ligament. If intact, hard collar. If disrupted, halo vest (for bony avulsion) or C1-2 fusion (for intrasubstance tear)(see Dickman classification below).

Type III

Unilateral lateral mass fx. Stability determined by integrity of transverse ligament. If stable, treat with hard collar. If unstable, halo vest.

54
Q

Radiographics measurements for C1 Fractures

A

atlantodens interval (ADI)

< 3 mm = normal in adult (< 5mm normal in child)

3-5 mm = injury to transverse ligament with intact alar and apical ligaments

> 5 mm = injury to transverse, alar ligament, and tectorial membrane

lateral mass displacement

if sum of lateral mass displacement is > 7 mm (8.1mm with radiographic magnification) then a transverse ligament rupture is assured and the injury pattern is considered unstable

55
Q

How to determine stability of C1 Fx

A

Transverse ligament integrity

56
Q

Non operative management of C1 Fx

Operative Management of C1 Fx

A

Hard collar vs. halo immobilization for 6-12 weeks

posterior C1-C2 fusion vs. Occipitocervical fusion

57
Q

Anderson and D’Alonzo Classification

Grauer Classification of Type II Odontoid fractures

A

Type I

Oblique avulsion fx of tip of odontoid. Due to avulsion of alar ligament. Although rare, atlantooccipital instability should be ruled out with flexion and extension films.

Type II

Fx through waist (high nonunion rate due to interruption of blood supply).

Type III

Fx extends into cancellous body of C2 and involves a variable portion of the C1-C2 joint.à

Type IIA

Non-displaced/minimally displaced with no comminution. Treatment is external immobilization

Type IIB

Displaced fracture with fracture line from anterosuperior to posteroinferior. Treatment is with anterior odontoid screw (if adequate bone density).

Type IIC

Fracture from anteroinferior to posterosuperior, or with significant comminution. Treatment is with posterior stabilization.

58
Q

Treatment algorithm of C2

A

Os Odontoideum

Observation

Type I

Cervical Orthosis for 6-12 weeks

Type II Young

Halo if no risk factors for nonunion

Surgery if risk factors for nonunion

Type II Elderly

Cervical Orthosis if not surgical candidates

Surgery if surgical candidates

Type III

Cervical Orthosis; no evidence to support Halo over hard collar

59
Q

Indications for anterior odontoid osteosynthesis

A
  • Type II fractures with risk factors for nonunion AND
  • acceptable alignment and minimal displacement
  • oblique fracture pattern perpendicular to screw trajectory
  • patient body habitus must allow proper screw trajectory
60
Q

3 posterior stabilization for C2 Fx

A
  1. Sublaminar wiring techniques (Gallie or Brooks)

require postoperative halo immobilization and rarely used

  1. posterior C1-C2 transarticular screws construct

contraindicated in patients with an aberrant vertebral artery

  1. posterior C1 lateral mass screw and C2 pedicle screw construct

modern screw constructs do not require postoperative halo immobilization

61
Q

What are the risk factors for C2 non-union?

A
  • ≥ 6 mm displacement (>50% nonunion rate): strongest reason to opt for surgery
  • age > 50 years
  • fx comminution
  • fracture gap > 1 mm
  • angulations > 10°
  • delay in treatment ( > 4 days)
  • posterior re-displacement ( > 2 mm)
  • smoker
62
Q

When does the secondary ossification center of C2 fuse?

A

C2 develops from five ossification centers:

  • body
  • two neural arches
  • odontoid
  • secondary ossification center

The subdental (basilar) synchondrosis is an initial cartilagenous junction between the dens and vertebral body that does not fuse until ~6 years of age.

The secondary ossification center appears around age 3 and fuses with the odontoid at around 12 years of age.

63
Q

Important consideration when performing C1-C2 trans-articular screws

A

aberrant vertebral artery

The vertebral artery is an important consideration when performing posterior cervical spine surgery. Injury to this artery can lead to stroke and death. Normally the vertebral artery travels superiorly in the transverse foramen of C6 to C2. At C2 the artery deviates laterally to the pass through the transverse foramen of C1 and then wraps medially on the superior surface of the posterior arch of C1 before ascending into the foramen magnum. Anomalous variants of the vertebral arery may be present in up to 30% of individuals, and may be intraosseous or extraosseous. Intraosseous variants may be injured during posterior cervical stabilization techniques. In patients with an aberrant vertebral artery, C1-C2 transarticular screws are contraindicated due to the risk of injury to the aberrant vertebral artery.

64
Q

What are the criterias of instability for lateral cervical mass fracture separation?

A

>3.5mm displacement

>10deg kyphosis

>10deg rotation difference compared with adjacent vertebra

65
Q

Surgical treatment of lateral cervical mass fracture separation

A
  1. posterior decompression and 2 level instrumented fusion
  2. 2 level ACDF
  3. Anterior and posterior decompression and fusion
66
Q

Mechanism of injury cervical lateral mass fracture?

A

hyperextension, lateral compression and rotation

67
Q

4 types of subaxial cervical fractures

Mechanism

Prognosis

Treatment

A

1- compression fracture:

without retropulsion into canal; often associated with posterior ligamentous injury

2- burst fracture : fracture extension through posterior cortex with retropulsion into the spinal canal; often associated with posterior ligamentous injury; often associated with complete and incomplete spinal cord injury; unstable and usually requires surgery

3- Flexion teardrop fracture:

Anterior column failure in flexion/compression

Posterior portion of vertebra retropulsed posteriorly

Posterior column failure in tension

Larger anterior lip fragments may be called ‘quadrangular fractures’

Prognosis: associated with SCI

Treatment: unstable and usually requires surgery

4- Extension teardrop avulsion: fracture characterized by small fleck of bone is avulsed of anterior endplate

usually occur at C2

must differentiate from a true teardrop fracture

Mechanism: extension

Prognosis: stable injury pattern and not associated with SCI

Treatment: cervical collar

68
Q

What are the indications for non-operative treatments for subaxial cervical fractures?

A
  • Stable mild compression fractures (intact posterior ligaments & no significant kyphosis)
  • anterior teardrop avulsion fracture
69
Q

Surgical treatment indication for subaxial cervical fractures?

A
  1. compression fracture with 11 degrees of angulation or 25% loss of vertebral body height
  2. unstable burst fracture with cord compression
  3. unstable tear-drop fracture with cord compression

Treatment :

1- Decompression: Early decompression (< 24 hours) has been shown to improve neurologic outcomes compared with delayed (>/ 24 hours) decompression

2- Anterior decompression, corpectomy, strut graft and fusion with instrumentation

OR

Posterior decompression, & fusion with instrumentation

if significant injury to posterior elements

and anterior decompression not required

70
Q

Location of the majority of cervical facet dislocations and fractures

A

17% C7-T1 junction

71
Q

Which facet is most commonly fractures in cervical facets fx/dislocation?

A

more frequently involves superior facet

72
Q

Uni vs bilateral facet dislocation on Xray

A

unilateral facet dislocation

leads to ~25% subluxation on xray

associated with monoradiculopathy that improves with traction

inferior facet of the cephalad vertebrae encrouches the neuroforamina

bilateral facet dislocation

leads to ~50% subluxation on xray

often associated with significant spinal cord injury (~80% of cases)

73
Q

Mechanism of injury of cervical facet dislocation

A

▪ flexion and distraction forces +/- an element of rotation

rotational moment associated with unilateral facet dislocation

74
Q

Clinical presentation unilateral versus bilateral facet dislocations?

A

monoradiculopathy

seen in patients with unilateral dislocations

C5/6 unilateral dislocation

presents with a C6 radiculopathy

weakness to wrist extension

numbness and tingling in the thumb

C6/7 unilateral dislocation

presents with a C7 radiculopathy

weakness to triceps and wrist flexion

numbness in index and middle finger

spinal cord injury—> bilateral dislocations

75
Q

Timing Of MRI in cervical facet dislocations

A

Controversial

▪ an MRI should always be performed prior to open reduction or surgical stabilization

if a disc herniation is present with compression on the spinal cord, then you must go anterior to perform a anterior cervical diskectomy

76
Q

fixation in lateral cervical facet fracture versus in cervical facet dislocation?

A

important to identify as cervical lateral mass fracture separations require fusing two levels while a facet dislocation only requires fusing a single level

77
Q

indicaitons for emergent closed reduction, emergent MRI, then urgent surgical stabilization

A

▪ bilateral facet dislocation with deficits in awake and cooperative patient

▪ unilateral facet dislocation with deficits in awake and cooperative patient

78
Q

Problem of Halo immobilization in lower cervical spine

A

▪ requires close radiographic follow-up; risk of re-dislocation or subluxation

morbidly obese patients may not fit or be adequately stabilized in a halo brace

79
Q

Factors to take into consideration for surgical treatment

A
  1. Disc herniation
  2. Difficulty to reduce from the front
80
Q

Closed reduction technique for cervical facet dislocation

A

▪ Application of Gardner-Wells tongs

1 cm above the pinna and in line with the external auditory meatus

below the equator of the skull

avoids pin migration and slippage

gradually increase axial traction with the addition of weights

usually in 5 to 10 lbs increments

can add up to 140 lbs of weight or 70% body weight

average weigh required for reduction ~9.4 to 9.8 lbs per segment above the injury level

a component of cervical flexion can facilitate reduction

flexion moment can be created with pulley system or posterior placement of the Gardner-Wells tongs pins

once reduced, decrease traction weight be 10-15 lbs and apply an extension moment to the cervical spine

adjusting pulley system

placing pad underneath thorax

perform serial neurologic exams and plain radiographs after addition of each weight additionabort if there is over distraction of the spinal segment

>1.5 times that if the adjacent uninjured disc space

can switch to carbonfiber Gardner-Wells tongs if need to obtain MRI in traction

traction limit ~80 lbs

abort if neurologic exam worsens and obtain immediate MRI

81
Q

Indications for anterior cervical discectomy and fusion +/- open reduction

A

▪ Facet dislocations reduced through closed methods with a MRI showing cervical disc herniation with significant compression on the spinal cord

Unilateral facet dislocations that fail closed reduction with a disc herniation with significant compression on the spinal cord

82
Q

Techniques for anterior reduction of facets

A

▪ unilateral dislocations can be reduced by distracting vertebral bodies with caspar pins and then rotating the proximal pin towards the side of the dislocation

bilateral dislocations are reduced by placing converging Caspar pins (10-20° angle) and then compressing the ends together to unlock the facets

posterior directed force applied to rostral vertebral body with currette

alternatively, lamina spreaders applied to the endplates

not effective for reducing bilateral facet dislocations

83
Q

Technique for posterior reduction of cervical facet dislocation

A

▪ reductionPenfield 4 inserted between facets and used to lever back into position

can remove the superior aspect of the superior facet of the caudad vertebrae to facilitate difficult reductions

distraction of the affected level between the affected spinous processes or lamina with use of lamina spreaders

usually have to fuse two levels due to inadequate lateral mass purchase at level of dislocation

84
Q

More severe neurological outcomes unilateral or bilateral cervical dislocations?

A

Bilateral

85
Q

An awake and cooperative patient presents to the emergency room with bilateral C5-6 facet dislocation. Prior to the CT scan he had an ASIA Impairment Scale of E. Upon returning from the CT scanner he has an ASIA Impairment Scale of D. What is the most appropriate first step in management?

A

immediate closed reduction with cervical traction

86
Q

For what type of fractures is an Halo orthosis ideal for?

A

Ideal for upper C-spine injury

Ideal for controlling Rotation at the atlantoaxial joint

Allows intercalated paradoxical motion in the subaxial cervical spinetherefore not ideal for lower cervical spine injuries (lateral bending least controlled) “snaking phenomenon”

recumbent lateral radiograph shows focal kyphosis in mid-cervical spine

yet, upright lateral radiograph shows maintained lordosis in mid-cervical spine

87
Q

Absolute and Relative contraindications for Halo Vest?

A

Absolute

  • cranial fractures
  • infection
  • severe soft-tissue injury

especially near proposed pin sites

Relative

  • Polytrauma
  • severe chest trauma
  • barrel-shaped chest
  • obesity
  • advanced age

recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)

88
Q

Imaging before Halo application

A

CT scan prior to halo applicationindications

clinical suspicion for cranial fracture

children younger than 10 to determine thickness of bone

89
Q

Technique for Adult and Pediatric Halo Vest

A

Adults

Torque: tighten to 8 inch-pounds of torque

4 pins

2 anterior pins safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or below the equator of the skull

this is anterior and medial to temporalis fossa/temporalis muscle

this is lateral to supraorbital nerve

2 posterior pins: placed on opposite side of ring from anterior pins

followup care

can have patient return on day 2 to tighten again

proper pin and halo care can be done to minimize chance of infection

Pediatric Technique

Pediatrics torque more pins with less torque

total of 6-8 pins

lower torque (2-4 in-lbs or “finger-tight”)

90
Q

8 Complications of Halo Vest

A

Higher complications in children (70%) than adults (35%)

1- Loosening (36%): treated with retightening; if continues to loosen, should be treated with pin exchange

2- Infection (20%)posterior pin in temporalis fossa because

pins hidden in hairline

bone is thin

temporalis muscle moves with chewing

can be treated with oral antibiotics if pin not loose

if pin infection and loose then pin should be removed

3- Discomfort (18%): treated by loosening skin around pin

4- Dural puncture (1%)

5- Abducens nerve (Cranial Nerve VI) palsy most commonly injured cranial nerve with halo

traction injury; diplopia; loss of lateral gaze on affected side; observation most resolve spontaneously

6- Supraorbital nerve palsy: injured by medially placed anterior pins

7- Supra-trochlear nerve palsy: injured by medially placed anterior pins

8- Medical complications

pneumonia

ARDS

arrhythmia

91
Q

Placing a pin for a halo vest orthosis in the red zone places what structures at risk?

A

Supraorbital and supratrochlear

92
Q

Consequences of using a higher halo torque Halo vest in pediatric population

A

Due to reduced thickness of the pediatric skull, higher rate of pin site infections and skull puncture, and unreliability of many torque wrenches, current recommendations are to use a higher number of pins (8 to 12) with lower insertional torque (1 to 5 in-lb) in case pins need to be removed or exchanged.

93
Q

What is the most common neuro complication of Halo vest application?

A

Cranial nerve VI palsy

94
Q

Most common location for thoraco-lumbar dislocation?

Mechanims of injury

A

Thoraco-lumbar junction

Acceleration/deceleration injuries

Hyperflexion, rotation and shearing

95
Q

TLICS classification

A

1- Morphology

  • compression (+1 point)
  • burst (+2 points)
  • rotation/translation (+3 points)
  • distraction (+4 points)

2- Neurologic status

  • Intact (0 point)
  • Nerve root (+2 points)
  • Incomplete Spinal cord or conus medullaris injury (+3 points)
  • Complete Spinal cord or conus medullaris injury (+2 points)
  • Cauda equina syndrome (+3 points)

3- posterior ligamentous complex integrity

  • intact (0 point)
    • no interspinous ligament widening seen with flexion views. MRI shows no edema in interspinous ligament region
  • suspected/indeterminate (+2 points)
    • MRI shows some signal in region of interspinous ligaments
  • disrupted (+3 points)
    • widening of interspinous distance seen

TLICS treatment implications score < 4 points

nonsurgical management

score = 4 points

nonsurgical or surgical managment

score > 4 points

surgical management indicated

96
Q

Mechanism of injury of a chance Fracture

A

flexion-distraction injury

associated with a center of rotation anterior to the spine (frequently being associated with bowel or other abdominal organ injury).

97
Q

Associated Fractures with Thoraco-lumbar Burst Fractures

A

concomitant spine fractures: occurs in 20%

traumatic durotomy

lamina fracture is associated with dural tear and entrapped nerve roots

be aware when spit spinous process

chest and intra-abdominal injuries:

common

flexion-distration and fracture-dislocations

bowel rupture, major vessel injury, upper urinary tract injury, hepatic, splenic, and pancreatic lacerations

long bone fractures

98
Q

Consideration of Conservative Treatment in thoraco-Lumbar Burst fracture

A

▪ patients that are neurologically intact and mechanically stable

posterior ligament complex preserved

no focal kyphosis on flexion and extension lateral radiographs

kyphosis < 30° (controversial)

vertebral body has lost < 50% of body height (controversial)

TLICS score = 3 or lower

99
Q

Consideration for surgical treatment of bust fractures according to level of injury

A

posterior approach favored when

below conus –> possible to medialize thecal sac to perform decompression of canal / posterior corpectomy and expandable cage

injury to PLC

fracture dislocations

anterior/direct lateral approach favored when

above the conus medullaris (above L2)

allow for thorough decompression of the thecal sac

substantial vertebral body comminution in order to reconstitute the anterior column

kyphotic deformity >30°

chronic injuries

greater than 4-5 days from the injury

100
Q

Anterior Approach to the spine according to the level of injury

A

lumbar spine: Anterior Retroperitoneal or transperitoneal approach

Left paramedian incision

suitable for levels below L1

thoracolumbar junction : lateral lumbotomy

suitable for injuries at T11-L1

left-sided approach to avoid liver obstructing access

thoracic spine: lateral thoracotomy

right-sided approach to avoid major vessels

appropriate for injuries above T11

101
Q

Complications of posterior fusion spine for Brust Fx

A

1- Entrapped nerve roots and dural tear

from associated lamina fractures

can be iatrogenic from decompression

decreased risk of dural tears with anterior approach due to improved visualization of the thecal sac during decompression

requires closure primarily or reinforced with dural patch

prolonged recumbency postoperatively

2- Pain

most common; over distraction with instrumentation

3- Progressive kyphosis

common with unrecognized injury to PLL

increased comminution of the vertebral body

loss of anterior column support

4- Flat back

leads to pain, a forward flexed posture, and easy fatigue

post-traumatic syringomyelia

5- Surgical site infection: can occur in up to 10% of cases trauma predisposes to infection

catabolic state

increased soft tissue damage

requires irrigation and debridement with culture specific antibiotics

6- Pseudo-arthrosis: can result from overdistraction instrumentation

7- Iatrogenic neurologic injury

can occur in 1% of cases

causes include

over medialized pedicle screws

inadvertant manipulation of the spinal cord

102
Q

TLSO for burst fracture? Does it make a difference

A

Bailey et al. conducted a multicenter, randomized controlled trial of T11-L3 burst fractures without neurologic deficit treated with or without TLSO and early mobilization. They found equivalent disability scores between the groups at 3 months, indicating that the discomfort and deconditioning associated with brace use might be avoidable.

103
Q

Most common site for burst fractures?

A

T12 and L2

104
Q

What is the Most common fragility fracture ?

A

Osteoporotic Vertebral Compression Fracture

105
Q

What are the Changes seen in osteoporotic bone?

A

bone is normal quality but decreased in quantity

cortices are thinned

cancellous bone has decreased trabecular continuity

106
Q

bone mineral density in the lumbar spine (BMD):

Peak-

A

peaks at: between 33 to 40 yrs in women; between 19 to 33 years in men

correlate well with bone strength and is a good predictor of fragility fracture

107
Q

Definition of osteoporosis

A

T score below -2.5

108
Q

What is complication related to vertebral compression fractures?

A

compromised pulmonary function

increased kyphosis can affect pulmonary function

each VCF leads up to 9% reduction in FV

increased risk of mortality from pulmonary dysfunction

109
Q

What is the prognosis after a vertebral compression fracture?

A

mortality

1-year mortality ~ 15% (less than hip fx)

2-year mortality ~20% (equivalent to hip fx)

110
Q

What is the use of MRI in vertebral compression fractures?

A
  • acute vs chronic nature of compression fracture
  • injury to anterior and posterior ligament complex
  • spinal cord compression by disk or osseous material
  • cord edema or hemorrhage
111
Q

What variables should raise suspicion for metastatic cancer to the spine?

A
  • fractures above T5
  • atypical radiographic findings
  • failure to thrive and constitutional symptoms
  • younger patient with no history of fall
112
Q

3 treatments for Vertebral Compression Fractures?

A

1- Observation, bracing and medical management

2- Kyphoplasty

3- Surgical decompression and stabilization

113
Q

What is the conservative treatment of vertebral compression fractures?

A

Observation, bracing, and medical management

majority of patients can be treated with observation and gradual return to activity

PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)

Calcitonin- Biphosphonates- Extension orthosis

114
Q

When can calcitonin be used for vertebral compression fractures?

A

if the fracture is less than five days old ; calcitonin can be used for four weeks to decrease pain

115
Q

Surgical decompression and stabilization indications in vertebral compression fractures?

A

▪ very rare in standard VCF

progressive neurologic deficit

PLL injury and unstable spines

techniqueto prevent possible failure due to osteoporotic bone

consider long constructs with multiple fixation points

consider combined anterior fixation

116
Q

What is the difference between Kyphoplasty vs. Vertebroplasty

A

under fluoroscopic guidance; percutaneous trans-pedicular approach used for cannula

Vertebroplasty

PMMA injected directly into cancellous bone without cavity creation

performed when cement is more liquid

requires greater pressure because no cavity is created

increased risk of extravasation into spinal canal is greater

Indications: controversial; AAOS recommends strongly against the use of Vertebroplasty in 2011 but then changed their stance in 2014 based on recent studies

Outcomes: randomized, double-blind, placebo-controlled trials have shown no beneficial effect of Vertebroplasty ; Vertebroplasty has higher rates of cement extravasation and associated complications than Kyphoplasty

Kyphoplasty

cavity created with expansion device (e.g., balloon) prior to PMMA injection

performed when cement is more viscous

may be possible to obtain partial reduction of fracture with balloon expansion

Indications: patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment: AAOS recommend may be used, but recommendation strength is limited

117
Q

When to consider kyphoplasty?

A

patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment:

118
Q

What is Kummell’s disease?

A

Vertebral body osteonecrosis (aka Kummell’s disease)

Delayed post-traumatic osteonecrosis

119
Q

What is that sign?

A

The MR fluid sign is highly suggestive of an osteoporotic vertebral compression fracture (VCF).

  1. MR signs suggestive of a benign, osteoporotic VCF include:
  • band-like low T1 signal
  • fluid sign
  • retropulsion of a vertebral bone fragment.
  • Acute fractures show low signal on T1-weighted and high signal on T2-weighted and STIR images.

2- MR signs suggestive of malignant VCF

  • complete replacement of normal marrow signal
  • convex posterior vertebral border
  • pedicle involvement
  • focal paraspinal mass
  • epidural mass.
120
Q

AAOS recommendations clinical practice guidelines for osteoporotic spinal compression fractures

A
  1. “strong recommendation”: was AGAINST the use of vertebroplasty.
  2. “moderate recommendation: The use of calcitonin for acute injuries (presenting within 5 days of symptom onset) received a Calcitonin directly inhibits osteoclast activity by binding to surface cell-surface receptors.
  3. limited evidence or were simply inconclusive: ibandronate or strontium use, bed rest and opiate analgesics, L2 nerve block for a L3 or L4 fracture, exercise program, electrical stimulation, kyphoplasty, use of a brace, improvement of kyphosis angle, any treatment in a patient with concomitant neurological deficits.
121
Q

Results of studies on vertebroplasty

A

Buchbinder et al. performed of randomized, double-blind, placebo-controlled trial. Patients were given a sham procedure to greaten the double blind effect. Outcomes were assessed at 1 week and at 1, 3, and 6 months. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at 3 months. They found vertebroplasty did not result in a significant advantage in any measured outcome at any time point. There were significant reductions in overall pain in both study groups at each follow-up assessment.

122
Q

mortality rate of fragility fractures in DECREASING order?

A

Hip fracture > vertebral compression fracture > distal radius fracture

Spine (6 decks)

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