Download Free Medical Thoracic Spine Trauma PowerPoint Presentation

Thoracic Spine Trauma PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical presentation on Radiology and Imaging, which is titled "Thoracic Spine Trauma", to know about Thoracic Spine Trauma.

Tags : Radiology, Imaging, Thoracic Spine Trauma

Published on : Jul 28, 2021 | Views : 2196 | Downloads : 14

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Thoracic Spine Trauma Sunil Jeph MBBS, MD
Slide 2-

Biomechanics
Slide 3-

Stabilizing anatomy of thoracolumbar spine
Slide 4-

ppt slide no 4 content not found
Slide 5-

Mechanism of injury
Slide 6-

Intervertebral disks in load bearing and force distribution during axial compression.
Slide 7-

Normal anatomic configuration of the PLC (Posterior ligament complex)
Slide 8-

Anteriorly displaced center of gravity that creates a compressive force (dotted arrow) on the spinal vertebrae similar to the force on the crane lifting arm. The resulting baseline flexion force (solid arrow) on the PLC is similar to the tension on the crane’s lifting cable
Slide 9-

Critical factor for treatment decision making Mechanical stability Integrity of bone and ligamentous components. Objective of treatment: Prevent the development of neurologic injury Prevent the development of progressive deformity in response to physiologic loading and a normal range of movement.
Slide 10-

Thoracolumbar spine classification for clinical and surgical treatment.
Slide 11-

Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
Slide 12-

Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
Slide 13-

Based on Anatomic structures or proposed injury mechanism. Denis three-column classification system: This model is used to predict the soft tissue injury from bone injury Denis three-column classification system
Slide 14-

Denis three-column classification system: Emphasis on the fracture involvement of the “middle column,” (posterior half of the vertebral body and intervertebral disk and the posterior longitudinal ligament)
Slide 15-

Denis three-column classification system: Spinal stability is dependent on at least two intact columns. When two of the three columns are disrupted, it will allow abnormal segmental motion, i.e. instability. So a simple anterior wedge fracture or just sprain of the posterior ligaments is a stable injury. A wedge fracture with rupture of the interspinous ligaments is unstable, because the anterior and the posterior column are disrupted. A burst fracture is always unstable because at least the anterior and middle column are disrupted.
Slide 16-

Criteria to predict soft-tissue injury from bony injury are: Angulation greater than 20 degrees. Translation of 3.5 mm or more.
Slide 17-

Major injuries Compression fracture Burst fracture Seat belt injury Fracture-dislocation Minor injuries: Transverse process fracture articular process fracture pars interarticularis fracture spinous process fracture Denis three-column classification system Injury to the middle column renders the spine mechanically unstable
Slide 18-

Modifications of the Denis classification: Intact posterior ligamentous complex (PLC), two-column unstable injuries can be successfully treated nonsurgically - Unstable Stable. All based on the premise that a fracture caused by forward flexion should be treated by undoing the flexion by positioning the patient in an extension brace, or by surgical intervention correcting the spinal column in extension. Some of the injuries thought to be due to extension mechanisms, however, turn out to be due to flexion and vice versa. These descriptions may thus be misleading.
Slide 19-

Denis classification, Cons: Does not provide prognostic information or consider the patient’s neurologic status, and therefore it cannot adequately guide surgical intervention. Since it uses the terms stable and unstable. In many cases, however, there is no good correlation with the necessity for surgery
Slide 20-

Stability Ambiguous and may refer to: Direct osseous stability Neurological stability Long-term (ligamentous) stability.
Slide 21-

Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
Slide 22-

Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Types (9 subtypes in each) Group A: vertebral body compression Group B: anterior and posterior element injuries with distraction. Transverse disruption either anteriorly or posteriorly. Group C: anterior and posterior element injuries with rotation. axial torque.
Slide 23-

Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Pros: Highly detailed subclassifications, the AO system has shown limited inter-observer variability. Cons: Difficult to use. Does not incorporate the patient’s neurologic status.
Slide 24-

Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
Slide 25-

Thoracolumbar Injury Classification and Severity Score (TLICS) is a scoring and classification system developed by the Spine Trauma Study Group . Scoring and classification system. Decide surgery vs no surgery Based on 3 components: Injury morphology (not mechanism). Integrity of the posterior ligamentous complex. Neurologic status of the patient.
Slide 26-

ppt slide no 26 content not found
Slide 27-

Injury Morphology If more than one injury morphology exists, the single injury with the largest score is used. If multiple levels of injury are involved, each injury is assessed independently
Slide 28-

PLC Integrity SIGNS OF PLC DISRUPTION: Widening of the interspinous space. Avulsion fracture of the superior or inferior aspects of contiguous spinous processes, Facet joints: widening, empty (“naked”), perched or dislocated. Vertebral body translation or rotation.
Slide 29-

Normal PLC anatomy MR imaging is the standard of reference for detecting PLC injury.
Slide 30-

Except, vertebral body translation or interspinous widening, osseous findings such as a loss of vertebral body height and kyphosis have been found to be unreliable in assessing PLC integrity because of the inverse relationship between osseous destruction and ligamentous injury. Patients with severe osseous destruction may have less risk for PLC injury because the vertebral injury dissipates energy, thereby sparing adjacent soft tissues. Conversely, patients with a significant translation or rotation injury and less vertebral fragmentation may have a higher risk for PLC injury. PLC must be directly assessed at MR imaging regardless of the severity of vertebral body injury seen at CT
Slide 31-

PLC injury scenarios
Slide 32-

PLC injury scenario: 1
Slide 33-

Axial compression with mild flexion, which results in nearly asymmetric height loss of the anterior and middle columns and minimizes the risk of distraction injury to the PLC
Slide 34-

ppt slide no 34 content not found
Slide 35-

PLC injury scenario: 2
Slide 36-

ppt slide no 36 content not found
Slide 37-

Flexion-distraction mechanism and PLC injury should also be suspected if a superior or inferior posterior endplate fracture is seen because this likely reflects an avulsion fracture from the comparatively strong annulus fibrosus of the intervertebral disk. PLC injuries can occur in this setting with minimal kyphosis or vertebral body height loss, a fact that further underscores the importance of MR imaging in
Slide 38-

PLC injury scenario: 3
Slide 39-

Posterior endplate fracture with flexion-distraction mechanism and PLC injury.
Slide 40-

ppt slide no 40 content not found
Slide 41-

ppt slide no 41 content not found
Slide 42-

Neurologic Status Although clinical neurologic status cannot be directly determined at imaging, a cord or nerve root injury identified on MR images should be included in the imaging report with the percentage of spinal canal narrowing .
Slide 43-

Axial compression with significant burst fracture of the vertebral body, bone retropulsion into the spinal canal, and resultant risk of neurologic injury.
Slide 44-

Anterior vertebral body compression percentage: percentage of anterior vertebral body compression with respect to the average height of the anterior vertebral bodies immediately cephalad and caudad to the injury level . Retropulsion: distance of a line drawn between the posterior margins of the adjacent vertebral bodies and the most posterior margin of the bone fragment. Sagittal canal diameter: distance between the posterior canal border and the anterior canal border. Posterior canal border: convergence of the superior margins of the left and right laminae at the midline of the spinous process. Anterior canal border: posterior extent of the retropulsed midvertebral body.
Slide 45-

Treatment TLICS addresses three different categories of spine stability: Immediate mechanical stability, suggested by injury morphology Long-term stability, indicated by PLC status Neurologic stability, indicated by the presence or absence of a neurologic deficit
Slide 46-

Burst fracture, in the absence of a neurologic deficit is controversial Osseous retropulsion alone does not imply neurologic injury or indicate a need for surgical decompression. Thoracic spine injury with retropulsion may cause significant neurologic injury because the spinal canal in the thoracic area is narrow and blood supply to the cord is sparse. Lumbar spine fracture may result in marked displacement of the cauda equina but no neurologic deficit because of the wider canal and cord termination near L1 Highly comminuted vertebral body fracture is more likely to deform under physiologic loading and may require short-segment posterior fixation and anterior fusion or long-segment posterior fixation. In the absence of a neurologic deficit, PLC integrity should be confirmed at MR imaging, especially if conservative management of burst fracture is planned
Slide 47-

TLICS can help guide the surgical approach
Slide 48-

ppt slide no 48 content not found
Slide 49-

Case 1
Slide 50-

31 years old man: Trauma
Slide 51-

Jumper's fracture
Slide 52-

Case 2
Slide 53-

21-year-old female who presented after sustaining a seatbelt type injury. She had an exploratory laparotomy for repair of a ruptured duodenum. There was no neurologic deficit.
Slide 54-

Chance fracture
Slide 55-

ppt slide no 55 content not found
Slide 56-

ppt slide no 56 content not found
Slide 57-

Mechanism of chance fracture
Slide 58-

first described by G. Q. Chance in 1948 most common site: thoracolumbar junction (T12-L2) "seat belt injury" due to sudden forward flexion in a head-on automobile collision while being restrained by a lap belt. advent of both lap and shoulder belts in the 1980s, Chance fractures have become less common
Slide 59-

Chance variant
Slide 60-

Case 3
Slide 61-

31 year old male. He was working on a roof, fell approximately 5 meters landing on his feet. He complained of pain in left lower extremity and lower back.
Slide 62-

ppt slide no 62 content not found
Slide 63-

ppt slide no 63 content not found
Slide 64-

ppt slide no 64 content not found
Slide 65-

ppt slide no 65 content not found
Slide 66-

Case 4
Slide 67-

21-year-old woman presented with back pain after a motor vehicle collision in which she was an unrestrained passenger in the middle seat. CT and MR imaging findings are shown.
Slide 68-

Injury morphology (burst) = 2 PLC integrity (indeterminate) = 2 Neurologic status (normal) = 0 TOTAL=4 (Burst fracture PLC integrity indeterminate)
Slide 69-

Injury morphology (burst) = 2 PLC integrity (indeterminate) = 2 Neurologic status (normal) = 0 TOTAL=4 (Burst fracture PLC integrity indeterminate)
Slide 70-

Case 5
Slide 71-

21-year-old man presented with multiple injuries and lower extremity paralysis after a high-speed motor vehicle collision in which he was an unrestrained driver.
Slide 72-

Injury morphology (translation) = 3 PLC (disrupted) = 3, and Neurologic status (cord injury) = 3 TOTAL = 9
Slide 73-

Injury morphology (translation) = 3 PLC (disrupted) = 3, and Neurologic status (cord injury) = 3 TOTAL = 9
Slide 74-

Case 6
Slide 75-

29-year-old man presented with complete paralysis after he collided with a telephone pole while driving a motorcycle.
Slide 76-

Injury morphology (distraction) = 4 PLC (disrupted) = 3 Neurologic status (paralysis) = 2 Total = 9
Slide 77-

Injury morphology (distraction) = 4 PLC (disrupted) = 3 Neurologic status (paralysis) = 2 Total = 9
Slide 78-

Case 7
Slide 79-

17-year-old girl presented with right-sided radiculopathy after a motor vehicle collision in which she was an unrestrained backseat passenger.
Slide 80-

Injury morphology (translation) = 3 PLC (disrupted) = 3 Neurologic status (nerve root injury) = 2. TOTAL = 8
Slide 81-

Injury morphology (translation) = 3 PLC (disrupted) = 3 Neurologic status (nerve root injury) = 2. TOTAL = 8
Slide 82-

Checklist for Reporting Spine Injury: CT Indirect findings
Slide 83-

Checklist for Reporting Spine Injury: MR
Slide 84-

Radiology report may include the TLICS total score if there is clear imaging evidence of neurologic injury. Generally the report will not include the total score if the patient’s clinical neurologic status is unknown.
Slide 85-

References: Khurana B, Sheehan SE, Sodickson A, Bono CM, Harris MB. Traumatic thoracolumbar spine injuries: what the spine surgeon wants to know. Radiographics. 2013 Nov-Dec. Radiology assistant A Magerl F1, Aebi M, Gertzbein SD, Harms J, Nazarian S. comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994; Google images