TVM-Trauma vertebral
dorsal y lumbar; manejo
diagnóstico y terapéutico
Riveros Ruiz, Jason Wilmer
Médico Residente de Neurocirugía
HNDAC
Caso clínico
• Pcte RCRF
• 78 años
• Ant: Portador de prótesis de cadera hace 6 años. HTA hace 2 años
• Historia de precipitación de segundo piso (2 m aprox) 1 mes antes
ingreso aproximadamente
• Clínica:
• Dolor en zona lumbar
• Paraparesia MMII derecho 1/5 izquierdo 3/5
Epidemiology
• % Thoracolumbar
• 65% of thoracolumbar fractures occur in motor vehicle accidents or in falls from a height
• 50 to 60% affected the T11–L2 region
• 25 to 40% affected the thoracic spine
• 10 to 14% involved the lower lumbar spine and sacrum
• Are commonly observed in men and the peak incidence is observed in adults between
20 and 40 years of age.
• 20-25% neurological deficits
• 47% Associated injuries:
• 26% head injuries
• 24%chest injuries
• 23% long-bone injuries
• Fulcrum
• Cifosis Lordosis
• Inmóvil Móvil
Morphology
• Diagnosis
• Classification
Injury to the
• Prognosis
posterior Injury
ligamentous mechanism • Assesment of
complex stability
• Traetment protocol
Neurologic
deficit
• Fracture
• Can not ruled out
TAC inestability or canal stenosis
• Can not adequaly seen the
interested region
MRI. Indications:
• Possibility of ligamentous trauma
It is recommended when • Disk injuries in the presence of
radiograph and CT scan osseous trauma
suggest: • Neurologic deficit does not match the
level of radiographic abnormality
• Spinal cord injury without
radiographic abnormality (SCIWORA)
TRANSLACIÓN/
DISLOCACIÓN
DISTRACCIÓN
COMPRESIÓN
Conceptos a aclarar…
• Complejo ligamentario posterior
• Columna posterior
• Ligamento longitudinal posterior
• Banda de tensión posterior
Francis Denis
Tensión band
Control
Stability subsystem:
SNC
Limitation of movement when subjecting the
column to forces
external to prevent spinal cord or root
damage
Passive Active
subsystem: subsystem:
Spine Muscles
White and Panjabi
A0
• not affecting the spinal stability
• isolated fracture of the spinous process, the
transverse process or the lamina.
A1
• Wedge compression or impaction fracture
• one or both endplates involved but the
fractures do not connect with one another
• Gap or pain
• AB
A2
• split- or pincer-type fractures
• both endplates involved CONECTION with
one another
A3
• burst injuries are fractures of a single
endplate
• There may be a vertical fracture of the
lamina
• The posterior tension band is maintained.
A4
• Type A4 burst injuries are fractures of both
endplates.
• A vertical fracture of the lamina, does not
imply posterior tension band rupture.
B1
• monosegmental bony posterior tension band
injury.
• There is complete osseous failure of the
posterior tension band
• "Chance" fractures (named after George
Quentin Chance, a British radiologist who
first described it in 1948).
B2
• This injury may be associated with any A-
type fracture (vertebral body).
• the injury should be classified based on that
segment (i.e., T11-T12) and not as a single
vertebral level
B3
• is characterized by a tension injury of the disc
or vertebral body or both, resulting in a
hyperextended position of the vertebral
column.
• This injury may be associated with any A-
type fracture (vertebral body).
C
• displacement injuries
• This Furthermore, complete disruption of the
soft tissue, even in the absence of
translation, is also considered a type C
displacement injury.
Neurologic Status
Head injury, intoxication,
polytrauma, or intubation/
sedation
TREATMENT
¡SOLO DESPIERTAME SI ES
ALGO PARA OPERAR!
INSECTO
Need or not surgery?
When the patient needs surgery
with any doubt:
Open spinal injuries. These may be caused by external forces
(gunshot, incisions) and/or major dislocations.
Neurological deficits with relevant narrowing of the spinal canal.70 A
spinal shock can mask the true neurological status during the first 48
hours after injury. The same applies to a patient with unknown
neurological status, for example, sedated patient with relevant
traumatic spinal canal stenosis.
Highly unstable fractures (type C).
In multiple injured patients with highly unstable spine injuries on the
basis of damage control surgery.
Patients with vertebral body fractures and preexisting preponderance
to instability such as in patients with ankylosing spondylitis.
INDIVIDUALIZED
bone quality
age
perioperative risk factors
activity level accompanied injuries
compliance
individual demands
CONSERVATIVE treatment
• Bed rest 1 week max
• Pain control
• Orthosis 8-12 weeks
• Mantains spinal aligment
• Inmobilizaes spine during healing
• Control pain by restricting movment
• Clinical and radiological follow up
What abaout pain ?
The most commonly used measure of pain — the 10-point visual analogue
scale (VAS) — is inadequate to capture the complexity of SCI pain. In order
to obtain a comprehensive evaluation of SCI pain, the following
dimensions should be evaluated: Site, Frequency, Intensity, Duration, Pain
quality/characteristics, Timing, and Interference with function.
Importan concepts:
• zones of partial preservation (ZPP)
• Psychological factors:
• chronic pain could contribute to psychological stress and even trigger
psychoreactive disorders (e.g. adaptive disorder or anxiety disorder)
Bracing or not? isolated
AO-A3 burst fracture between T10
and L3 with kyphotic
deformity lower than 35
Bracing or not?
T8 and L4 Thoracolumbar sacral orthosis (TLSO)
Thoracolumbar junction T10-L2 TLSO hyperextension brace (Jewett)
T1 and T7
TLSO with cervical extension
L5 and the first sacral vertebral TLSO with leg extension
• A fracture that is deemed to be stable may be treated with brace
Bracing or not? immobilization or no brace immobilization.
• Early mobilization is instituted once a patient is upright.
• The purpose of a brace is to prevent ranges of motion outside of
limits deemed unfavorable for fracture healing.
• A brace is also commonly used following surgical stabilization to
temper patient activity.
• Bracing is often unsuccessful for ligamentous disruption in the adult
patient.
• AP lateral plain x-rays are obtained to make sure there is no
significant fracture displacement requiring surgery.
• In four studies, only A3 fractures (or equivalent burst
fractures) were included.
• The other one
included patients with A1, A2, and A3 fractures, but
comparison between brace and control was only
per-
formed for A1/A2 group
Physiotherapy and manual
therapy
Physiotherapy is
good for ASCI
patients recovery
Frequency and
Specific types?
Some intersting results:
• osteoporotic vertebral fractures the
complication rate is significantly lower if
adjunctive physiotherapy is started early
• early functional treatment significantly
reduced the length of inpatient stay
without negative effects on alignment
• isometric training appears to result in
an increase in muscle size comparable
to that achieved with flexion exercises,
SURGERY ROOM !!!
When the patient needs surgery
with any doubt:
Open spinal injuries. These may be caused by external forces
(gunshot, incisions) and/or major dislocations.
Neurological deficits with relevant narrowing of the spinal canal.70 A
spinal shock can mask the true neurological status during the first 48
hours after injury. The same applies to a patient with unknown
neurological status, for example, sedated patient with relevant
traumatic spinal canal stenosis.
Highly unstable fractures (type C).
In multiple injured patients with highly unstable spine injuries on the
basis of damage control surgery.
Patients with vertebral body fractures and preexisting preponderance
to instability such as in patients with ankylosing spondylitis.
pain and enables early mobilization and rehabilitation
The severity of neurological injury is
neurological recovery and long term functional outcomes. determined by the extent of neuronal
injury incurred at the time of primary
injury.
Morphological Criteria
MM 1: Disorder in the Physiological Alignment of the
VertebralColumn
Whenever possible, EPA should be
• End plate Angle (EPA) 15 – 20°
measured on posterior-anterior
• Scoliotic angle 10°
standing radiographs
MM 2: Comminution of the Vertebral Body.
McCormack Load Sharing Fragment displacement at the upperor lower endplate is usually
Classification associated with adjacent intervertebral disc lesion.
According to authors, using this point system, fractures
with mild comminution totaling 6 points or less can be
successfully repaired from the posterior approach with
pedicle screw implants. Severely comminuted fractures
scoring 7 points or more must be repaired by an
anterior approach with vertebrectomy
MM 3: Stenosis of the Spinal Canal.
Percentage loss of spinal canal area at the level of the most
narrowed spinal canal on axial CT compared with the
physiological size at the adjacent levels
(Canal occuped / normal
canal) x100
MM 4: Intervertebral Disc Lesion.
disk rupture with
edema intradiskal bleeding infraction
SURGERY APPROACH
Treatment of choice is
A0
earlymobilization, adequate
analgesia, and physiotherapy
δEPA < 5° to 20° conservative
A1 MM1 therapy.
At least monosegmental
instrumentation.
δEPA >15° to 20° operative
treatment,
MM2 Wide fragment separation An anterior bisegmental
and/or relevant lesion of the reconstruction with or
A2 without posterior
intervertebral disc can be an
indication for surgery instrumentation.
MM4
SURGERY APPROACH
At least monosegmental
δEPA >15° to 20° and/or scoliosis posterior
MM1
>10° operative treatment. instrumentation has to
A3
be considered
< 1/3 anterior reconstruction is
optional
MM2
monosegmental
=> 1/3 anterior reconstruction is
recommended
MM3
MM4
SURGERY APPROACH
At least bisegmental
δEPA >15° to 20° and/or scoliosis posterior
MM1
>10° operative treatment. instrumentation has to
A4
be considered
< 1/3 anterior reconstruction is
optional
MM2
bisegmental
=> 1/3 anterior reconstruction is
recommended
MM3
MM4
recovery of neurological function and
return to work
POSTERIOR
APPROACH
operative time, blood loss and cost.
SURGERY APPROACH
reduction and bisegmental
B1 posterior instrumentation is
indicated
MM1
MM2 At least posterior instrumentation
B2 should be performed. Additional
anterior reconstruction may be
MM3 indicated depending on the severity of
the corresponding ventral column
defect
MM4
MM1 SURGERY APPROACH
MM2 • Fracture reduction and posterior
instrumentation is recommended.
B3 • Additional monosegmental anterior
MM3 reconstruction might be necessary
depending on the severity of the
anterior column defect.
MM4
MM1
• Fracture reduction and posterior
instrumentation is indicated.
MM2 • A cross-connector should be used in
severe rotational instable fractures
C and short segmental procedures.
MM3 • In case of posterior tension band
disruption a posterior spondylodesis
MM4 has to be considered
Who?
by the recommendations of 483
worldwide spine surgeons.
Surgery
Time?
decompressive surgery prior to
24 hours after SCI was
performed safely and was
associated with improved
neurologic outcome defined as
at least a 2 grade AIS
improvement at 6 months
follow-up.
Patients with normal neurology and those with complete
neurological deficit are optimized for surgery which can be
performed at the earliest safe situation for the patient.
What happenned whith Osteoporotic
patients? Since about 50% of the patients were uncertain if they have
had any trauma, the group decided to develop one
classification for both traumatic and nontraumatic
(insufficiency) fractures.
The osteoporotic fracture classification (OF classification)
• No vertebral deformation (vertebral body
edema in MRI-STIR only).
Conservative treatment.
• Deformation with no or only minor
involvement of the posterior wall (<1/5).
• This type of fracture affects one endplate
only (impression fracture).
• Deformation with distinct involvement of
the posterior wall (>1/5).
Conservative or surgical
• This type of fracture affects one endplate
treatment.
only, but shows distinct involvement of the
anterior and posterior wall (incomplete
burst fracture).
• Loss of integrity of the vertebral frame
structure, or vertebral body collapse, or
pincer-type fracture.
• A vertebral body collapse is typically seen
as a final consequence of a failed
conservative treatment and can impose as
a plain vertebral body.
surgical treatment.
• Injuries with distraction or rotation.
• The injury includes not only the anterior
column but also the posterior bony and
ligamentous complex.
Gracias
