Case conference Ratchan Jariengprasert

CASE

Patient profile : Thai elderly woman, 68 years old

Chief complaint : ถกู MC เฉ่ียว ล้มศีรษะกระแทกพื้น

8/11/59 11.00 น.

Primary survey A : patent airway, C-spine not tender, can mobile

B : normal breathing pattern, trachea in midline, normal breath sound, equal both, CCT negative

C : hemodynamic stable, BP 200/100 mmHg, PR 80 bpm

D : E4V5M6, pupil 3 mmRTLBE

E : LW 6 cm at left temporal area, no other external bleeding, PCT negative

secondary survey

A : none

M : Underlying disease DM, HT

P : ไมเ่คยเขา้นอน รพ. ไมเ่คยผ่าตัดอะไรมาก่อน

L : 17.00

E : ระหวา่งเดินจูงจกัรยานขา้มถนน รถMC เฉียว ล้มศีรษะ กระแทก สลบ จำาไมเ่หตกุารณ์ไมไ่ด้ อาเจยีนสองครัง้ มเีลือดออก จากหซูา้ย มแีผลท่ีศีรษะด้านซา้ย

physical examination

GA : elderly woman, good consciousness

HEENT : no pale conjunctiva, anicteric sclerahead : LW 2 cm deep to subcutaneous with hepatoma 5 cmear : bloody otorrhea Lt

CVS : normal s1s2 no murmur, full regular pulse

Lung : normal breath sound, equal both, no adventitious sound

Abdomen : soft, not tender, no guarding, no rebound

Extremity : no edema, no deformity, no external wound

Neuro : motor power grade V all ext.

Diagnosis + management

Severe head injury (high risk)

r/o base of skull fracture

Refer จากรพ. ด่านขุนทด

consult neuro surgery

CT brain non contrast

pelvis AP, Chest x-ray

CT brain NCLeft parieto-temporal bone fractureSAH along bilateral temporal sulci

Admitobserve neuro sign 2 day

refer กลับด่านขุนทด

CC : ปวดขา ปวดหลัง ลกุนัง่แล้วปวด ลงมาเดินไมไ่ด้

PI : ต่ืนดี ไมป่วดหวั ไมอ่่อนแรง ไมช่า ไมม่ปีวดรา้วลงขากลัน้ปัสสาวะอุจจาระได้

ล้อหน้าจกัรยานกระแทกขาขวา เจบ็ด้านขา้ง

thoracolumbar spine : midline back pain level L1L2

motor power grade V all, except Rt leg

DTR 2+ all extremities, intact PPS

PR : tight sphincter tone, perianal sensation intact

Ext. - tender Rt leg, can flex/extend knee

A - alignment : 4 line ant/post. vertebral body/lamina/spinousno subluxation, no stepping, loss of kyphosis/lordosisspondylolithisis,retrolithisis

B - bone : vertebral height, shape(square/wedge), density(osteolytic, osteoblastic lesion), homogenousend plate involve, subchondal sclerosis, marginal osteophyte

C - cartilage : disc narrowing, vacuum disc, facet joint

D - distance : interpedicular distance (เพิม่ขึ้นจากบน ลงล่าง ใหเ้ทียบกับอันล่าง ถ้ากวา้งกวา่แปลวา่+)

E - external soft tissue : paravertebral soft tissue, psoas muscle

Refer

R/o compression fracture L1

Close isolated fracture of Right proximal 1/3 fibular on short leg slab

AdmitBed rest

Pain controlCT TL spine

comminuted fracture of anterior and posterior vertebral body L1,

40% anterior height collapse of L1, burst fracture with fracture L1 spinous

process

no retropulsion of bone into spinal canal

the rest of spine no visualised fracture and spondylolisthesis

degenerative change of lumbar spine is seen

-??????-

“Burst fracture”

Dennis three column classification

▪ anterior column  ▪ anterior longitudinal ligament (ALL)▪ anterior 2/3 of  vertebral body and annulus

▪ middle column  ▪ posterior longitudinal ligament (PLL)▪ posterior 1/3 of vertebral body and annulus

▪ posterior column  ▪ pedicles▪ lamina▪ facets▪ spinous process▪ posterior ligament complex (PLC):

The PLC serves as a posterior "tension band" of the spinal column and plays an important role in the stability of the spine.

A torn PLC has a tendency not to heal and can lead to progressive kyphosis and collapse.

TL spine injury

compression Fx

stable/unstable burst Fx

chance Fx (seat belt injury) flexion-distraction(ant, post)

fracture dislocation

Burst fracture

define : vertebral fx with compromise ant. + middle column

mechanism : axial loading + flexion

TL junction most vulnerable to traumatic injury

maximum neural compression at moment of impact

Radiographs◦ recommended views

▪ obtain radiographs of entire spine (concomitant spine fractures in 20%)

◦ AP shows▪ widening of pedicles (>1 mm difference between the vertebrae above and below)▪ coronal deformity

◦ lateral shows▪ retropulsion of bone into canal

▪ loss of ant+post vertebral height▪ kyphotic deformity

-the injury level interpedicular distance is more than average of the level above/below

-suggest disruption of middle column and presence of burst Fx

Dennis classification burst fx 5 subtypes

◦ Type A: Fracture of both end-plates.

◦ Type B: Fracture of the superior end-plate. -common

◦ Type C: Fracture of the inferior end-plate. -rare

◦ Type D: Burst rotation. This fracture could be misdiagnosed as a fracture-dislocation. The he mechanism of this injury is a combination of axial load and rotation.

◦ Type E: Burst lateral flexion. This type of fracture differs from the lateral compression fracture in that it presents an increase of the interpediculate distance on anteroposterior roentgenogram

Thoracolumbar injury classification and severity score(TLICS)

score < 4 : non surgical treatment

score = 4/10 : non surgical treatment or surgical management

score > 4 : surgical management

*translation/rotation/distraction of post.side always involve PLC

CT features of PLC pathology are:• Widening of the interspinous space.• Avulsion fractures or transverse fractures of spinous processes or articular facets.• Widening or dislocation of facet joints.• Vertebral body translation or rotation.

When the PLC is definitely injured on CT, it can already be scored as 3.

TLICS = 4-5compression fracture + burst

no neurodeficit+- PCL indeterminate/injury

Surgical treatment

◦ surgical decompression & spinal stabilization▪ indications

▪ neurologic deficits with radiographic evidence of cord/thecal sac compression

▪ both complete and incomplete spinal cord injuries require decompression and stabilization to facilitate rehabilitation

▪ TLICS score = 5 or higher▪ unstable fracture pattern as defined by

▪ injury to the Posterior Ligament Complex (PLC) ▪ progressive kyphosis▪ > 30°kyphosis (controversial)▪ > 50% loss of vertebral body height (controversial)▪ > 50% canal compromise (controversial)

Nonsurgical treatment◦ ambulation as tolerated with or without a thoracolumbosacral orthosis      

▪ indications▪ patients that are neurologically intact and mechanically stable

▪ posterior ligament complex preserved▪ kyphosis < 30° (controversial)▪ vertebral body has lost < 50% of body height (controversial)

▪ TLICS score = 3 or lower

▪ thoracolumbar orthosis▪ recent evidence shows no clear advantage of TLSO on outcomes

▪ if it provides symptomatic relief, may be beneficial for patient

▪ outcomes▪ retropulsed fragments resorb over time and usually do not cause neurologic deterioration

Comparison

comparison between operative and non operative for thoracolumbar burst fracture with no neurological deficit :

There is no difference in kyphosis, residual back pain, cost of hospitalization and return to work between operative and non-operative approaches, but increased disability and complications with operative treatment.

Spine orthosisJewett brace - prevent flex > extend

Taylor brace - prevent extend > flex

Jewett brace

symptomatic relief of compression fracture

immobilisation after surgical stabilisation of TL fx

limit flexion T6-L1

contraindication : instability type compression fx above T6 compression fx cause by osteoporosis

Bed rest 6 weeks

TLSO until fracture union (3 months)

prevent pressure sore

breathing exercise

exercise upper and lower extremities

Reference

http://www.orthobullets.com/spine/2022/thoracolumbar-burst-fractures#5630

http://www.radiologyassistant.nl/en/p54885e620ee46/spine-injury-tlics-classification.html

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