Trauma and Paraplegia (original) (raw)
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• The thoracolumbar junction is a flexible transition region in the spine, susceptible to injury due to the transfer of kinetic energy. • Clinicians should maintain a high suspicion of injury with thoracolumbar trauma because the incidence of a second vertebral fracture is 10% to 15%, and soft tissue injury may be as high as 50%. • The most common mechanism of abdominal injuries is distraction or seat-belt injuries. Blunt abdominal aortic dissections are associated with distraction-rotational injuries of the thoracolumbar region. • The three-column model of spine injury suggests that when all three columns are injured, surgery may be necessary. Goals of surgery should be restoration of stability, balancing of opposing biomechanical forces, and decompression of the spinal canal with the aim to improve neurologic outcome. • Dorsal decompression via multilevel laminectomy alone after thoracic and thoracolumbar injuries has been shown to be ineffective and should not be performed as an isolated treatment strategy. Pedicle screw fixation provides for instrumentation of vertebrae with fractured or absent laminae, with purchase through all three columns. Increased rigidity by pedicle screw fixation permits fewer segments of fixation. 1-5 A pproximately 160,000 patients a year in the United States suffer traumatic spinal column injuries, with 10% to 30% of them having a concurrent spinal cord injury. 6-9 Although most of these injuries involve cervical (C1-C2) and lumbar (L3-L5) spine fractures, 15% to 20% of traumatic fractures occur at the thoracolumbar junction (T11-L2), whereas 9% to 16% occur in the thoracic spine (T1-T10). 10-13 Paraplegia secondary to thoracic fractures have a first-year mortality rate of 7%, 6,14 illustrating the devastating effects of thoracolumbar trauma. The thoracic spine and thoracolumbar junction presents a unique regional anatomy, with resulting biomechanical characteristics that predispose this area to traumatic injury. Primary goals in thoracolumbar trauma patients are prompt recognition and treatment of associated injuries and expeditious stabilization of the spine and protection of the neural elements. Biomechanics Forces along the long, rigid kyphotic thoracic spine catalyze an abrupt switch into the shorter, mobile lordotic lumbar spine at the thoracolumbar junction (Fig. 30.1). Biomechanically, this transition zone is susceptible to injury and is the most commonly injured portion of the spine. High-energy trauma (motor vehicle accidents) is the leading cause of injury over this region, followed by falls and sports-related injuries. 2-5 Owing to the higher energy mechanisms of injury, additional organ systems are often injured in up to 50% of thoracolumbar trauma patients. 14 The vertebral body is the primary load-bearing structure of the spine, with the intervertebral disk transferring all forces applied to the adjacent vertebral bodies. 15-17 The annulus fibro-sus of the intervertebral disk supports a significant portion of all applied axial and lateral loads and resists tension and shearing. 18 The spinal ligamentous structures are essential in maintaining overall sagittal balance. The posterior longitudinal ligament (PLL) is a relatively weak ligament that provides some restriction to hyperflexion, along with the ligamentum flavum. The thick anterior longitudinal ligament (ALL) functions to resist spinal hyperextension and distraction. 19 The thoracic spine differs from the remainder of the spinal column because it is supported by and maintains articulations with the ribs. The intact rib cage increases the axial load-resisting capacity of the thoracic spine by a magnitude of four. The rib cage and facet articulations limit rotation, and therefore most thoracic spine fractures occur from a flexion or axial compression force vector. 20 Most of stability in flexion is provided by the costovertebral articulations. 21 A significant factor in the degree and extent of fracture character is the rate of force impact loading. 22 The thoracolumbar vertebrae are at an increased risk for developing compression fractures after trauma as a þÿ D o w n l o a d e d f o r A h m e d G ü l (a h m a d _ w a r d 1 5 @ e r d o g a n. e d u. t r) a t R e c e p T a y y i p E r d o a n U n i v e r s i t y f r o m C l i n i c a l K e y. c o m b y E l s e v i e r o n M a r c h 0 6 , 2 0 2 0. For personal use only. No other uses without permission.
Epidemiology of Thoracolumbar Spine Injury in Blunt Trauma
Academic Emergency Medicine, 2001
Objective: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. Methods: Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. Results: Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. Conclusions: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.
Spinal injuries affecting the thoracic and thoracolumbar spine
Orthopaedics and Trauma, 2016
Thoracic and thoracolumbar fractures range from low impact osteoporotic compression injuries to high-energy fracture/dislocations with spinal cord injury. Assessment can be broadly divided into two sections. Primary assessment should follow the principles of Advanced Trauma Life Support. The secondary assessment should relate to the spinal fracture itself. In determining the optimal treatment, the stability of the injury must be assessed by following a complete clinical and radiographic evaluation. The thoracolumbar junction (T10eL2) is a transitional region between the rigid thoracic spine and the more flexible lumbar spine and hence is susceptible to injury. The thoracic spine (T1eT9) is relatively protected area, due to the rib cage; when injuries do occur they commonly involve visceral and spinal cord injury. Many classifications exist, however the AO and Thoracolumbar Injury Classification and Severity (TLICS) systems are the most clinically useful. Although they are based on thoracolumbar injuries they are commonly extended to thoracic fractures. The majority of fractures can be managed non-operatively with early mobilization and bracing. Surgical stabilization is indicated in unstable fractures. Posterior stabilization with pedicle screws is the most widely used technique; simultaneous decompression can also be achieved with this approach. Anterior surgery has biomechanical advantages and has been shown to be equally effective.
Clinical profile of patients treated for thoracic and lumbar spine injuries
International Journal of Orthopaedics Sciences, 2016
Introduction: Approximately 90% of all spinal fractures occur in the thoracic and lumbar spines. In fact, the majority of thoracic and lumbar injuries occur within the region between T11 and L1, commonly referred to as the thoracolumbar junction Methodology: A general physical examination which included nourishment status, height, weight, body mass index, pallor, icterus, cyanosis and clubbing were done. Blood pressure and pulse of the patient was measured and recorded. Local examination of spine were inspected for swelling, any scar, sinus and palpated for tenderness. Results: Commonly fractured vertebra is L1(30%) and then L2 and L3 jointly (23.33%). Least fractured vertebra is L4 Conclusion: The most common mode of injury in these patients with thoracolumbar vertebral fractures was fall from height (80%) followed by road traffic accidents (RTA)
(ii) Thoracolumbar spinal fractures: review of anatomy, biomechanics, classification and treatment
Orthopaedics and Trauma, 2014
The management of thoracolumbar spine fractures remains a controversial issue. There is disagreement both as to how to describe these injuries and how to manage them. No ideal classification system, accepted by the world of spinal surgery, exists and such systems are under on-going development. While the majority of these injuries can be managed conservatively, new surgical techniques have been developed alongside the evolution of diagnostic tools classification systems.
Thoracolumbar Spine Trauma: Pearls and Pitfalls of the Newer Classification Systems
Neurographics, 2018
The American Society of Neuroradiology (ASNR) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASNR designates this enduring material for a maximum of one AMA PRA Category one credit TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To obtain credit for this activity, an online quiz must be successfully completed and submitted.
Indications and principles of surgical treatment in injuries affecting the thoracolumbar spine
Orthopaedics and Trauma, 2020
Vertebral fractures are very common and primarily affect the thoracolumbar spine as the result of an isolated injury or in polytrauma patients. The majority of these fractures can be treated nonoperatively. Surgical stabilization of thoracolumbar fractures may be indicated after high-energy trauma or in the multiply injured patient. Surgery aims to provide a stable spinal column to allow early mobilization and optimize neurological outcome. This article considers the principles of clinical assessment and decision-making in the surgical management of thoracolumbar fractures. The AO spine thoracolumbar classification system can be used to guide treatment because the choice of surgical strategy depends on the biomechanics of the injury. Most injuries can be stabilized through a posterior approach but anterior column reconstruction can be performed, either as a stand-alone procedure or in order to support a posterior stabilization. The use of minimally invasive techniques is discussed. Interventional spinal technologies for osteoporotic vertebral compression fractures are also considered.
Introduction to Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations
Neurospine, 2021
World Federation of Neurosurgical Societies (WFNS) Spine Committee is focused on giving a new horizon in light of research and available recent past data. With the increasing advances and day to day variations in surgical approaches, it has become extremely important to develop new guidelines and recommendations. After developing and publishing guidelines about cervical trauma, 1 spinal cord injury, 2 lumbar spinal stenosis, 3 and cervical spondylotic myelopathy, 4 the WFNS Spine Committee has developed recommendations regarding thoracolumbar (TL) spine trauma. This was achieved after a gross literature search between 2010 and 2020 and then holding a consensus meeting. It is an honour for me to be part of this work done during the chairmanship of Prof Zileli, Prof Fornari, and myself. Up-to-date information was reviewed to reach an agreement in the World Federation of Neurosurgical Societies (WFNS) Spine Committee meeting. The first meeting was conducted live in Peshawar in December 2019, and the second meeting was a virtual meeting on June 12, 2020. Both meetings aimed to analyze a preformulated questionnaire through preliminary literature review statements based on the current evidence levels to generate recommendations through a comprehensive voting session. Delphi method was utilized to administer the questionnaire to preserve a high degree of validity. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined, with evidence strength, recommendation grade, and consensus level provided. The 6 papers you will find in the following pages are guidelines for almost all aspects of the TL fracture. The annual incidence of TL fractures is about 30/100,000 inhabitants, including osteoporotic fractures. There is a trend towards increasing fractures in developed countries, especially due to low velocity falls in the elderly population. The mortality rate after the spinal injury decreases in developed countries due to improvements in motor vehicle safety and traffic regulations. 5 The TL spine is the most frequently injured spinal region in blunt trauma. The potential risk of concomitant injury to the spinal cord, chronic pain, and lifelong disability presents a significant burden on patients and the health service. Due to the range of injury classification systems and varied treatment efficacy, literature on the indications for nonoperative treatment of TL fractures is conflicting. The WFNS Spine Committee was able to formulate numerous key recommendations to guide clinical practice. Although compression-type fractures and stable burst fractures can
Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations
Neurospine, 2021
This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The inci...