TREATMENT OF SPINAL TRAUMA Department of Othopeadic Surgery at Faculty of Medicine, Masaryk University and University Hospital Brno Head : prof. MUDr. Martin Repko, Ph.D. MUDr. D. Matejička, MUDr. J. Sklenský, MUDr. M. Prýmek I. Revision of Anatomy II. Biomechanics of spine Mechanisms of trauma, III. AO classification IV. Spinal cord injury + examination V. Treatment -----→ VI. Instrumentation of the spine - trauma vs. degenerative goals & treatment CONTENT: A. CONSERVATIVE B. SURGICAL I. Revision of Anatomy - SPINE - count of vertebrae (variability!) - spine curvatures - neuro-vascular structures! Facet joints angle -Synarthrosis „joints“ (conection by cartilage/ligament/bone) -Diarthrosis (synovial) joints (articular surfaces, joint capsule, cavity, synovial fliud …) II. Biomechanics - Functional Spinal Unit (FSU) = smallest mobile segment of the spine - Composed of: 2 adjacent vertebrae, intervertebral disc, ligamnets 2 facet joints and capsules, surrounding soft tissues II. Incidence of spinal trauma • 3-6 % of all injuries • 70 % thoracic and lumbar • 30 % cervical • 20 % presence of neurological deficit Leucht et al. 2009 Etiology of spinal trauma oHigh energy trauma – youth oLow energy trauma – over 60 yo (osteoporotic fx.) oFalls oTraffic accidents - whiplash injury oSport oCombinations Leucht et al. 2009 Spinal trauma- mechanisms Hematomyelia=bleeding Myelopathy=pressure Types of injuries ➢Axial load forces ➢Flexion-Extention forces ➢Rotation formces ➢Combination 2 column theory (Holdsworth) vs. 3 column theory (Denis) III. SPINE TRAUMA CLASSIFICATION TLICS Classification - Thoraco-Lumbar Injury Classification and Severity score komprese distrakce AO classification (Magerl 1994) COMPRESSION FLECTION+ DISTRACTION EXTENSION ROTATION/ TRANSLATION - numerous definitions… (Louis, Roy-Camille, White and Panjabi, Frymoer and Krag) SPINE IS INTOLERANT OF PHYSIOLOGICAL LOADING… Spine INSTABILITY Spine INSTABILITY BONY HEALING FUSION ACUTE LIGAMENTOUS CHRONIC INSTABILITY LIGAMENTOUS INSTABILITY • conservative treatment cannot lead to healing • result is chronic progressive instability • pseudoathrosis or kyphotic deformity may occur • can only be repaired by fusion of affected segment Instability of C-spine Neurological deficit Immediate (A) onset caused mechanically in case of injury (fragment in the spinal canal, dislocations of the joint, kyphotization, translation, etc.). Gradual (B) onset caused by edema or ischemia. IV. Spinal Cord Injuries (SCI) Spinal cord impairment causing temporary or permanent changes in motor, sensory, or autonomous spinal cord functions. 1) type : A) primary B) secondary 2) degree: A) complete B) incomplete 1A) Primary SCI It is caused directly during the injury process. Therefore it CAN NOT BE influenced!  Spinal cord compression by bone fragments, hematoma, herniated intervertebral disc. Torsion, distraction, (shear forces = unfavorable prognosis) Ischemia Penetrating injury Nucleus Medical Media (2020). Cervical spinal cord trauma and cervical disc herniation [Digital image]. Retrieved from https://ebsco.smartimagebase.com/cervical-spinal-cord-trauma-and-cervical-disc-herniation/view-item?ItemID=77457 •Vascular changes : - reduced flow - thrombosis - vasospasm - hemorrhagia •electrolyte changes •free O2 radicals •Inflammatory reaction => the result is neuronal necrosis !! 1B) Secondary SCI 1B) Secondary SCI It occurs as a result of primary impairment. COULD BE partially influenced, and that is the goal of treatment. Possibilities of its influence : - oxygenation, optimal BP - pharmacotherapy (anti-oedematous treatment -corticoids ?) - surgical treatment (decompression of neural structures + insturmentation of the spine for its stabilization) www.medicalexpo.com/prod/rti-surgical/product-103597-820814.html 2) Degrees of SCI complete lesion /according to the height of the injury/ cervical quadriplegia thoracic paraplegia incomplete lesion /specific syndromes/ anterior cord sy. central cord sy. posterior cord sy. Brown-Sequard sy. cauda equina sy. H.GrayAnatomy of th Human Body (1918) Evaluation of spinal cord injury 3 functions: - motoric - sensoric - spinal reflexes The purpose of the evaluation is to determine the height and type of lesion. Evaluation of spinal cord injury CLINICAL EXAMINATION ̶ Aspection (defiguration, hematoma …) ̶ Palpation (rate and spreading of pain) ̶ Basic neurological assessment (Frankel scale, ASIA score) EXAMINATION - imaging methods Anamnesis Clinical examination Neurological status X-ray CT MRI Ortopedická klinika LF MU a FNB X- ray Fracture of the body and preventrtebral hematoma ! !!! X- ray 3D CT MRI OBJECTIVES OF THERAPY PAINLESSNESS FUNCTIONALITY (movement) STABILITY V. THERAPY conservative orthoses, corsets bed rest surgical Decompression of spinal cord and nerve structures + stabilization of the fracture by specific instrumentation Dorsal procedure Ventral procedure Combined Nucleus Medical Media (2020). Posterior spinal fusion [Digital image]. Retrieved from https://ebsco.smartimagebase.com/posterior- spinal-fusion/view-item?ItemID=68987 A) B) FIRST AID 1)FIXATION OF THE CERVICAL SPINE 2)EXCLUDE MOVEMENT OF T & L SPINE DURING MANIPULATION 3)TRANSPORT TO SPINAL CARE DEPARTMENT 1) Fixation of C-spine 2) Imobilization of T & L spine during transport „in line position“ – minimalize patient handling ! Head fixation Body and limbs fixation Surface for transport - „back board“ risk of pressure ulcers - vacuum mattresses - suitable for longer transport 2)„Log-roll“ manuever 3) Transport THERAPY conservative vs. surgical ❖ TYPE of fracture ❖ grade of INSTABILITY ❖ NEUROLOGICAL find V.A) CONSERVATIVE TREATMENT INDICATIONS: ✓flection-compression fr. w/o instability (A0, A1, rarely A2) ✓no injuries to important ligaments or discs (stable ¨burst¨ fr. - A3, w/o kyfotisation) ✓only instability in the bone part (Chance's fr.- B1) ✓Others (contraindications of surgery) V.A) CONSERVATIVE TREATMENT ! unstable ¨burst¨ fr. (A3 + A4) ! flection-distraction fr. (B- group according to AO) ! translation injury (C- group according to AO) ! NEUROLOGICAL deficit (Surgery is necessary within 6 hours !!) CONTRAINDICATIONS: => SURGICAL TREATMENT !! Rest regime Collars - foam - Philladelphia V.A) CONSERVATIVE TREATMENT 100 % 40-45 % 30-35 % 5-10 % V.A) CONSERVATIVE TREATMENT CERVICAL spine • halo-cast, halo-vest • Minerva Nucleus Medical Media (2020). Cervical spine fracture with application of halo ring stabilization [Digital image]. Retrieved from https://ebsco.smartimagebase.co m/cervical-spine-fracture-with- application-of-halo-ring- stabilization/view- item?ItemID=73352 Fitting the HALO traction CONSERVATIVE TREATMENT THORACO – LUMBAR spine • Jewett (hyperextension) brace - featuring 3 support points: suprapubic, dorsolumbar and sternal - it consists of mass-produced parts, but MUST BE individually adapted to the patient's needs and dimensions! CONSERVATIVE TREATMENT Modifications of THORACO – LUMBAR fixation – according to the height of the injury : • From Th 6 ABOVE • Th6 – L3 • from L3 BELOW Jewett brace with cervical extension classic Jewett brace TLSO (Thoracic Lumbar Sacral Orthosis)- individual/ mass-produced Cotrelův stůl Böhler‘s method of corection in hyperextension Cotrel‘s EDF frame (Elongation, Derotatin, Flection) plaster corsets CONSERVATIVE TREATMENT – history: Indications of corsets (except taumatic): - m. Scheurmann - Scoliosis (infantile e.g.) Others: - incompliance of pts (luxation of THA e.g.) V.A) CONSERVATIVE TREATMENT – results: • CORRECTION OF DEFORMIY - restore sagital balance of segment • STABILIZATION - anatomical shape of vertebra - anterior support if it's necessary • INTERVERTEBRAL FUSION - if it's necessary • DECOMPRESSION OF NEURAL STRUCTURES - direct or indirect (ligamentotaxis) V.B) goals of SURGICAL TREATMENT : V. SURGICAL TREATMENT – posterior approach – principles of REPOSITION: 1) Dorsal (trans-pedicular) fixation (B) 2) Lordotisation (C) 3) Distraction (D) 4) Stabilization - tightening the heads of screws V. SURGICAL TREATMENT – posterior approach – principles of DECOMPRESSION of spinal canal: DIRECT = LAMINECTOMY (B) HEMI-LAMINECTOMY with (C) or without facetectomy (E) ANTERIOR DECOMPRESSION (D) INDIRECT = LIGAMENTOTAXIS E V. SURGICAL TREATMENT – posterior approach – principles of TRANSPEDICULAR fixation: → targeting the screwsoTranspedicular screws oRods oCross-link conector www.medicalexpo.com/prod/rti-surgical/product-103597-820814.html Inserting the TP screws TRANSPEDICULAR SCREWS: CT scan of correctly inserted screws in situ. V. SURGICAL TREATMENT – posterior approach – principles of TRANSPEDICULAR fixation: ̶ DIVERGENT instrumentation Ouellet JA, Richards C, Sardar ZM, Giannitsios D, Noiseux N, Strydom WS, Reindl R, Jarzem P, Arlet V, Steffen T. Finite Element Analysis and Biomechanical Comparison of Short Posterior Spinal Instrumentation with Divergent Bridge Construct versus Parallel Tension Band Construct for Thoracolumbar Spine Fractures. Global Spine J. 2013 Jun;3(2):85-94. Divergent instrumentation is up to 30% stronger than parallel ! Intersomatic fusion V. SURGICAL TREATMENT T-L SPINE – posterior approach – dorsal instrumentation + spongiolplasty: spongioplasty SPONGIO plasty (Daniaux technic) Kanno H, Aizawa T, Hashimoto K, Itoi E. Enhancing percutaneous pedicle screw fixation with hydroxyapatite granules: A biomechanical study using an osteoporotic bone model. PLoS One. 2019 Sep 26;14(9):e0223106. doi: 10.1371/journal.pone.0223106. eCollection 2019. PubMed PMID: 31557234 Milled bone- gaft V. SURGICAL TREATMENT T-L SPINE – combined approach – dorsal instrumentation + ventral spongiolplasty with bone strutgraft: Nucleus Medical Media (2020). Surgical decompression and stabilization of the spine [Digital image]. Retrieved from https://ebsco.smartimag ebase.com/surgical- decompression-and- stabilization-of-the- spine/view- item?ItemID=76291 V. SURGICAL TREATMENT T-L SPINE – anterior approach – ventral instrumentation + augmentation of ventral column (Harm's cage vs. Implant): Nucleus Medical Media (2020). Lumbar spine fracture with surgical repair [Digital image]. Retrieved from https://ebsco.smartimagebase.com/lumbar- spine-fracture-with-surgical-repair/view-item?ItemID=11652 V. SURGICAL TREATMENT T-L SPINE – anterior approach – ventral instrumentation + augmentation of ventral column (Harm's cage vs. Implant): V. SURGICAL TREATMENT T-L SPINE – combined approach – dorsal + ventral instrumentation + ventral column augmentation: Harm‘s cage ventral instrumentation dorsal instrumentation Synex - expandable implant CERVICAL SPINE INJURY oComminutive fr. of the body odiscoligamentous lesions disks and ligament oCombined - tear drop radiopaedia.org/cases/flexion-teardrop- fracture-illustration?lang=us INJURY OF THE UPPER C-SPINE ➢ fractures of condyles of occipital bone (C0) ➢ atlantooccipital dislocations (C0-C1) ➢ atlas fractures (C1) ➢ atlantoaxial dislocations (C1-C2) ➢ fractures of the epistropheum (C2) Synthes CerviFixKorean J Neurotrauma. 2019 Apr;15(1):55-60. https://doi.org/10.13004/kjnt.2019.15.e3 V. SURGICAL TREATMENT – UPPER C- SPINE – atlantooccipital dislocation : Dorsal O-C fusion V. SURGICAL TREATMENT UPPER C- SPINE: – atlas fractures (disruption of transvers ligamnet): atlantoaxial screw fixation and fusion (Magerl C1 and C2 transfacet screw technique) Gehweiler classification (1980) Schleicher P, Pingel A, Kandziora F. Safe management of acute cervical spine injuries. EFORT Open Rev. 2018 May 21;3(5):347-357. doi: 10.1302/2058- 5241.3.170076. eCollection 2018 May. PubMed PMID: Jefferson‘s fr. = type 3A (stable), 3B (unstable) !! Types 1,2,4,5 – non-operatively ODONTOID FRACTURES OF C2 https://boneandspine.com/dens-odontoid-fractures/ Anderson and D’Alonzo Classification of Odontoid Fractures Type II = NECESSITY OF SURGERY especially: - In pts age > 50 (high risk of non-union) - Fracture dispacement ≥ 5mm - Neurological deficit - Comminution Transoral (Sandberg) projection ODONTOID FRACTURES OF C2 V. SURGICAL TREATMENT UPPER C- SPINE – fractures of the epistropheum : dorsal / ventral appproach Harm‘s C1-C2 construct HANGMAN FRACTURE – traumatic olisthesis C2 V. SURGICAL TREATMENT UPPER C- SPINE – fractures of the epistropheum : dorsal / ventral appproach Jeong DH, You NK, Lee CK, Cho KH, Kim SH. Posterior C2-C3 Fixation for Unstable Hangman's Fracture. Korean J Spine. 2013 Sep;10(3):165-9. doi: 10.14245/kjs.2013.10.3.165. Epub 2013 Sep 30. PubMed PMID: 24757480 Dorsal – TP fixation Ventral - ACDF Nucleus Medical Media (2020). Surgical decompression and stabilization of the spine [Digital image]. Retrieved from https://ebsco.smartimag ebase.com/surgical- decompression-and- stabilization-of-the- spine/view- item?ItemID=76291 ACDF = Anterior Cervical Decomresion and Fusion Ventral procedures - Plating - Discs / vertebral bodies replacement Dorsal procedures - TP stabilzations Combinations V. SURGICAL TREATMENT LOWER C- SPINE – ventral / dorsal appproach www.bbraun.com/content/dam/b- braun/global/website/products-and- therapies/degenerative-spinal- disorders/O85002_Aesculap_XP.pdf.bb- .95195616/O85002_Aesculap_XP.pdf CERVICAL PLATES - ventral stabilization CASPAR SYNTHES INTERSOMATIC FUSION C6/7 https://www.zimmerbiomet.com/content/dam/zi mmer-biomet/medical-professionals/spine/roi- c-cervical-cage/ROI- C%20Product%20Brochure.pdf TRABECULAR METAL Dorsal – TP fixation VERTEBROPLASTY MISS (Mini Invasive Spine Surgery) KYPHOPLASTY - pain reduction 70-90% - fracture stabilization - does NOT adjust vertebral height - HIGH pressure cement application ! - HIGH risk of leaking cement (65%) !! ̶ could be outpatient - pain reduction 90% - fracture stabilization - adjustment of vertebral height especially in acute fractures -creation of cavity reduces the risk of leakage (10%) - general anaesthesia Fourney DR, Schomer DF, Nader R, Chlan-Fourney J, Suki D, Ahrar K, Rhines LD, Gokaslan ZL. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg. 2003 Jan;98(1 Suppl):21-30. http://www.painmanagementexperts.com/ vertebroplasty-for-compression-fractures/ VERTEBROPLASTY – potential risks VERTEBROPLASTY KYPHOPLASTY PERCUTANE FIXATION & DECOMPRESSION MISS (Mini Invasive Spine Surgery) Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of early minimalinvasive spine fixation in acute thoracic and lumbar spine trauma. Indian J Orthop. 2007 Oct;41(4):374-80. doi: 10.4103/0019- 5413.37003. PERCUTANE FIXATION & DECOMPRESSION MISS (Mini Invasive Spine Surgery) Kim C, Siemionow K, Anderson D, Phillips F: The current state of minimally invasive spine surgery, in Egol K, Tornetta III P, eds: Instr Course Lect, 60. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2011, 353-370. Nucleus Medical Media (2020). Miniminally invasive disc removal [Digital image]. Retrieved from https://ebsco.smartimagebase.com/miniminally- invasive-disc-removal/view-item?ItemID=22128 prof. Kevin Foley Courtesy of prof. Kevin Foley Courtesy of prof. Kevin Foley TRAUMATIC VI. INSTRUMENTATION OF THE SPINE DEGENERATIVE & DEFORMITY ̶ Instrumentation should to restore physiological conditions (including mobility) ̶ Intervertebral fusion is NOT perfromed (or rarely) ̶ The instrumentarium is usually removed after fractures have healed ̶ The instrumentation helps to create new anatomical-biomechanical conditions (deformity correction, slip reduction, prevention of iatrogenic instability, etc.) ̶ Intervertebral fusion is the MAIN OBJECTIVE OF SURGERY (= immobilization of operated extent!) ̶ Instrumentarium stays in the body for rest of life Nucleus Medical Media (2020). Posterior spinal fusion [Digital image]. Retrieved from https://ebsco.smartimagebase.com/posterior- spinal-fusion/view-item?ItemID=69744 Complications of surgical treatment ➢Increased blood loss - epidural venous plexus, open cancellous bone ➢Wrong placement of transpedicular screws - medial (spinal canal) or caudal (intervertebral foramen) ➢Injury of the dural sac - risk of developing a CSF fistula ➢Infection - early, late www.pauljeffordsmd.c om/understanding-the- risks-of-spine-surgery