distinguish between compression of a vertebra d/t OP & that d/t acute trauma
acute trauma
evidence of cortical disruption
increase in density beneath the endplate of an involved vertebra indicate impaction of bone due to acute fracture
osteoporotic compression
the deformed vertebral body similar in density to adjacent vertebrae
frequently show evidence of osteophytic spurs
radioisotopic bone scan of little use
CT scan may be useful
Pathologic Fracture of the Spine
metastatic disease
radiographic feature
bony destruction - pedicle erosion
any component of the vertebra
the fractures are multiple, discontiguous, or both
surrounding soft tissue mass
history
trivial trauma
fracture of osteoporosis or with metastatic disease
CT or MRI examination helps
Burst Fractures
axial load
failure of the anterior & middle columns
neurological deficit
Radiographic Characteristics
lateral film
failure of the middle column
fracture of the posterior wall cortex
loss of posterior height
retropulsion of a fragment of bone into the canal
AP film
increase of the interpediculate distance
vertical laminar fracture
splaying of the posterior joints
CT Scan
break of the posterior wall of the vertebral body
retropulsion of bone into the canal
five different types of burst fractures
Type A - E
Seat-Belt-Type Injuries
failure of both the posterior and middle columns
tension forces by flexion and distraction
anterior column acts as a hinge
Radiographic Characteristics
increase of interspinous distance
horizontal split of the transverse processes, pedicles
pars interarticularis fractures
increased height of the posterior vertebral body & posterior opening of the disc space
CT Scan
not much information
may totally miss the fracture - lateral tomograms
subtypes
one-level lesions
Chance fracture
ligamentous disruption
two-level lesions
Fracture Dislocations
failure of all columns under compression, tension, rotation or shear
this leads to subluxation or dislocation
may present in a reduced position - high index of suspicion
subtle signs (multiple rib #, multiple transverse process #, horizontal laminar or spinous process #s)
Types and Subtypes
type A - flexion rotation
type B - shear type
type C - fracture dislocation
Correlation of the classification with neurological deficits
close link between mechanism of injury, type of # & neurological deficit
Isolated transverse process fractures
T1 and T2 ---> brachial plexus injuries
L4 and LS ---> pelvic fractures with lumbosacral plexus injuries
Isolated spinous process fractures
temporary conus contusions
Isolated facet and pars interarticularis fractures
Compression fractures
Seat-Belt Type Injuries
no neurological injury
Burst fractures
50% were neurologically intact at first examination
Hx leg numbness, tingling and/or weakness
impact to conus or cauda equina
50% with neurological deficits
high proportion of incomplete paraplegia (96.45%)
Fracture dislocations
Flexion rotation type
neurologically intact in 25%
when neurologically injured, 50% of them were complete
Shear type
all cases were complete paraplegics on admission (Frankel A)
Flexion-distraction type
were incomplete paraplegics in 75% cases
intact in one case 25%
Correlation of the classification with instability and basic rationale for treatment
Stable injury
minimal & moderate compression #s w/ an intact posterior column
Rx
early ambulation w/ or w/out external immobilisation
degree of compression
kyphosis & the age of the patient
Instability of the first degree (mechanical instability)
clinical instability
"the loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage no subsequent irritation to the spinal cord or nerve roots and, in addition, no development of deformity with excessive pain"( Panjabi )
severe compression fractures and seat-belt-type injuries
disruption of the posterior ligamentous
flexion allows buckling around the hinge of the anterior column
does not acutely threaten the neural elements
Rx
bedrest in hyperextension
brace
ORIF
Instability of the second degree (neurological instability)
burst fractures
middle column ruptured under axial load
continued compression by the fragment of the middle column against the neural elements
early ambulation leads to axial load
may develop neurology if treated conservatively
Rx
controversial
non-operative
neurologically intact
angle of kyphosis < 15°
angle of scoliosis < 15°
displacement in any direction < 5 mm
surgical
if > any of above
pt. should be informed of the neurological risk
posterolateral instrumentation & fusion
anterior or posterior decompression
Instability of 3rd degree (mechanical & neurologic)
fracture-dislocation & severe burst fracture w/ neurological deficit
2°displacements & progression of neurological deficit may occur