Introduction - Numbers

Spinal Trauma

Johan Van Goethem, Jasmina Boban, Majda Thurnher,

Frank Ramon, Luc van den Hauwe, Paul Parizel

ECNR 16th Cycle, Module 3 - Trauma Online, November 7, 2021 Overview

• introduction

• cervical trauma

• when / how / where

• stable / unstable

• thoracolumbar trauma

• when / how / where

• no surgery / surgery

• conclusion • introduction • cervical • thoracolumbar • conclusion

Introduction - Numbers• 250.000 … 500.000 traumatic spinal fractures /year in Europe

• 2…3% of all trauma patients

• 10% of all major trauma patients

• 50% thoracolumbar junction (Th11-L2)

• 25% cervical

• 25.000 traumatic spinal cord injuries /year • introduction • cervical • thoracolumbar • conclusion

Introduction - Numbers• disability

• paralysis and spinal cord injury incidence 40/million/year

• most survive their injuries

• 520.000 osteoporotic vertebral fractures per year in Europe

Introduction - Cost

• fear of missing occult injuries and fear of litigation -> radiographs on all trauma patients

• >95% negative

• <> pressure to reduce health care costs

Cervical

• introduction • cervical • thoracolumbar • conclusion

Imaging Algorithmspinal

trauma? STOP

CCR

Harbor-view MDCT

plain film

• introduction • cervical

• when? • thoracolumbar • conclusion

When is imaging needed?• Canadian C-spine Rule (CCR)

• most accurate tool in the triage of cervical spinal trauma in alert and stable patients

• 8,924 patients

• detected 100% of the 151 clinically important injuries

• specificity of 42.5%

• only 58.2% of alert, stable patients underwent imaging

When is imaging needed?Canadian C-spine Rule (CCR): NO imaging when ALL apply:

No high-risk factor including:

• age ≥65 years

• dangerous mechanism:

• fall from elevation ≥3 feet / 5 stairs

• axial load to the head

• >100km/hr MVA, rollover or ejection MVA

• motorized recreational vehicles

• bicycle collision

• paresthesias in extremities

Low-risk factor present incl.:

• simple rear-end MVA, excl:

• into oncoming traffic

• hit by bus or large truck

• rollover

• hit by high speed vehicle

• sitting position in ED

• ambulatory at any time since injury

• delayed onset of neck pain

• no of midline tenderness

Able to actively rotate the neck 45 degrees to the left and right

What imaging is needed?• Harborview high-risk criteria - ANY of these warrants (MD)CT:

• High-energy mechanism including:

• high-speed MVA (>50km/hr)

• MVA with death at scene

• fall from >10 feet

• High-risk clinical parameter including:

• significant head injury:

• intracranial hemorrhage

• unconscious in ED

• neurologic signs or symptoms referable to the cervical spine

• pelvic or multiple extremity fracture

• introduction • cervical

• how? • thoracolumbar • conclusion

Where are the lesions?• cervical spine:

• C2 most common (25% of fractures)

• 1/3 … 1/2 of these odontoid fractures

• 40% of fractures occur at C6 - C7

• one third of all injuries clinically insignificant• introduction • cervical

• where? • thoracolumbar • conclusion

Where are the lesions?• elderly patients (>70 years of age):

• the rate of cervical spine injuries is twice as great as it is in nongeriatric patients (4.59% versus 2.19%)

• 70% upper cervical spine

• odontoid fractures are the most frequent lesions accounting for upto 50% of all cervical fractures

• children (<14 years of age):

• 60…70% upper cervical spine

Upper Cervical Spine• occipital condyle fractures - Anderson and Montesano

• Type 1: non-displaced, stable, and result from compression forces (15%)

• Type 2: stable, skull base fractures that extend uni- or bilaterally to the occypital condyles (50%)

• Type 3: displaced, unstable avulsion fractures of the occypital condyle, usually with a fragment inside the spinal canal, and result from avulsion by the alar ligament (35%) • introduction

• cervical • stable?

• thoracolumbar • conclusion

Upper Cervical Spine

Watts et al. Orthobullets 2017


• atlanto-occipital dislocation

• upto 10% of fatal MVA, 1/3 of deaths of cervical spine trauma

• children <12 years of age


• A/ Wackenheim’s line: tangential to the posterior tip of the odontoid process

• B/ <5mm in adults, <10mm in children

• C/ BC/OA < 1

Walsh et al. Evaluation and Management of Craniocervical Dissociation. Neurosurgery 2015


Asfaw et al. Atlanto-occipital dislocation: Case report and discussion RCR 2011

Upper Cervical Spine• atlas fractures - rare

• Type I: isolated fractures of the anterior or posterior arch. The transverse ligament is intact. (Gehweiler I + II)

• Type II: burst fractures, with bilateral anterior and posterior arch fractures (Jefferson fractures), usually not associated with severe neurologic deficit (since fragments move away from the spinal canal) (Gehweiler III)

• Type III: fracture involving the lateral mass (Gehweiler IV)

• type II and III are unstable if associated with tear of the transverse ligament


Kalani et al. Injury to the Cervical Spine - Barrow Neurological Institute


• ligamentous lesions

• whiplash injuries

Upper Cervical Spine• dens fractures - Anderson and D’Alonzo

• Type I: avulsion of the dens tip - stable

• Type II: most common - transverse fracture through the base of the dens - unstable

• Type III: fracture extending to the body of the C2 - stable (when healed)


D’Alonzo et al. University of Washington - Harborview 2018

72-year-old, fallen out of bed Upper Cervical Spine• hangman’s fractures - Levine/Edwards:

• Type I: <3mm anterolisthesis, no angulation. Axial load + hyperextension

• Type II >3mm anterolisthesis, angulation; disruption of posterior longitudinal ligament. Hyperextension-axial loading + severe flexion

• Type IIa: horizontal fracture line; severe angulation without anterolithesis. Flexion, distraction

• Type III: type I with bilateral facet joint dislocation. Flexion + compression

• Type I usually stable, type II depending, type IIa and III unstable

• atypical C2 fractures


Pneumaticos et al. Trauma and Orthopaedic Classifications 2014


Robinson et al. C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases. Biomed Res Int 2017

Watanabe et al. Upper cervical spine injuries: Age-specific clinical features. Journal of Orthopaedic Science 2010

Lower Cervical Spine• flexion

• most common

• anterior wedge, clay-shoveler, flexion teardrop, bilateral facet dislocation, …

• extension

• hangman, extension teardrop

• axial loading

• burst

30-year-old - MVA

• classification system based on injury mechanisms

• based on the premise that a fracture caused by forward flexion should be treated by positioning the patient in an extension brace (or by surgical intervention correcting the spinal column in extension)

• however, these descriptions may be misleading

• some of the injuries thought to be due to extension turn out to be due to flexion and vice versa.

Lower Cervical Spine

Thoracolumbar

• introduction • cervical • thoracolumbar • conclusion

Imaging algorithm• when to image a patient with a TL trauma (ACR

Appropriateness Criteria):

• local signs of TL injury (ie, pain, tenderness with palpation)

• abnormal neurologic signs, cervical spine fracture

• Glasgow Coma Scale score of <15, major distracting injury, alcohol or drug intoxication

• introduction • cervical • thoracolumbar

• when? • conclusion

Imaging algorithm• screening after blunt trauma with the following

mechanism:

• motor vehicle accident at >50 km/h

• falls of >5m

• automobile hitting the pedestrian with the pedestrian thrown >3m

• assaulted, with a depressed level of consciousness

• AS or DISH

Imaging algorithm

• plain radiographs can be considered in patients <14 years of age

• reduced radiation dose

• no distracting degenerative changes


• how? • conclusion

Where are the lesions?• falling accidents

• burst fractures most common (33%)

• 50% located at the thoracolumbar junction

• followed by compression fractures (25%)

• 39% located at the thoracolumbar junction

• and posterior column fractures (25%)

• 40% in the cervical spine

• multiple-level spine fractures in 30% of the injured patients

• of which 30% at noncontinuous levels• introduction • cervical • thoracolumbar

• where? • conclusion

Classification• simple

• Denis three-column model (1983)

• more complex based on injury mechanism, integrity of the PLC and neurologic status

• AO-classification: without MRI (2013 - 2017)

• Thoracolumbar Injury Classification and Severity Scale (TLICS) (2005): + posterior ligamentous integrity (MRI)


• surgery? • conclusion


• Denis three-column model

Denis 3 column

Moore et al. Spine Biomechanics 2019




• AO-classification

• Arbeitsgemeinschaft für Osteosynthesefragen Spine Thoracolumbar Spine injury Classification System

• no MRI

• aims to simplify and universalise the process of classifying spinal injuries and improve interobserver and intraobserver reliability

AOSpine

• TL AOSpine injury score (2016) is based on

• morphology

• neurologic injury

• modifiers

AOSpine

• morphology

• Type A: compression injuries

• Type B: tension band injury

• Type C: translation/displacement injury

AOSpine

• compression injuries

• wedge compression + intact posterior wall

• A1: single endplate / A2: both endplates

• burst + posterior wall involved

• A3: single endplate / A4: both endplates

Bonfante et al. Thoracolumbar Spine Trauma: Pearls

and Pitfalls of the Newer Classification

Systems Neurographics 2018

+1 +2 +3 +5

AOSpine

• distraction injuries

• B1: transosseous disruption and/or Chance fracture, no intervertebral involvement

• B2: bony and/or ligament posterior tension band disruption, always involves the intervertebral level

• B3: hyperextension Injury through the disk or vertebral body

+5 +6 +7

AOSpine

• translation and/or displacement injury

• C: displacement of the vertebral column, with disruption of anterior and posterior elements

Bonfante et al. Thoracolumbar Spine Trauma: Pearls and Pitfalls of the Newer Classification Systems Neurographics 2018

+8

AOSpine• neurologic status:

• N0: normal

• N1: transient neurologic deficit

• N2: radicular symptoms

• N3: incomplete spinal cord injury or cauda equina syndrome

• N4: complete spinal cord injury

• Nx: unknown (head injury, intoxication, sedation, …)

+1+2

+4

+4

+3

AOSpine• patient specific modifiers:

• M1: designates fractures with an indeterminate injury to the tension band

• M2: comorbidity, including ankylosing spondylitis, rheumatologic conditions, diffuse idiopathic skeletal hyperostosis, osteopenia or osteoporosis, or burns that affect the skin overlying the injured spine

• might argue either for or against surgery

+1




• AO-classification

• Thoracolumbar Injury Classification and Severity Scale (TLICS)

• reliable, ease-to-use tool

• clinical decision making

TLICS• three independent parameters - each scored 0-4

points

• morphology

• posterior ligamentous complex

• neurological state

• a score of >4 indicates surgery

• each level scored separately, the highest score countsThe radiology assistant

TLICS

• the PLC is always involved (even if not directly evaluated) in cases of:

• translation/rotation injury

• posterior distraction

Conclusion• detect

• when to image?

• how to image?

• where are the lesions?

• classify

• stable / unstable

• no surgery / surgery

Documents

Introduction - Numbers