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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