Thoracic Spinal Thoracic Spinal InjuryInjury
operative treatmentoperative treatmentandand
related problemsrelated problemsGeorge SapkasGeorge Sapkas
Asc. ProfessorAsc. Professor--
11stst Orthopaedic Dpt Orthopaedic DptMedical School Medical School
Athens UniversityAthens UniversityMETROPOLITAN HOSPITALMETROPOLITAN HOSPITAL
Mi. – Ch.: Male 35Mi. – Ch.: Male 35constructor constructor History:History:
Fall from 6 -7 meters Fall from 6 -7 meters height on the height on the construction site at 9 construction site at 9 June 2011June 2011
Initial treatmentInitial treatmentTransportation to the Transportation to the First Aids Station First Aids Station of the remote islandof the remote island
Plain x-raysPlain x-rays(not available) (not available) demonstrated:demonstrated:
Injury at the Injury at the thoracic level of thoracic level of the spinethe spine
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Neurologic deficit was Neurologic deficit was detected at that time detected at that time affected mainly the affected mainly the right leg (extensors of right leg (extensors of the foot 3/5)the foot 3/5)
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Following the original Following the original management management he was transported to the he was transported to the main Cyclades’ island main Cyclades’ island where he was submitted where he was submitted in x-rays & CT in x-rays & CT examinationexamination(not available)(not available)
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
The The investigations investigations revealed revealed fractures of the fractures of the T4 – T5 – T6 T4 – T5 – T6 vertebrae and vertebrae and haemothorax haemothorax bilaterally bilaterally
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
The patient did The patient did not sustained not sustained any injury in any injury in other parts of other parts of his bodyhis bodyThe patient The patient transported to transported to “ATTIKON” “ATTIKON” University University Hospital Athens Hospital Athens
at the same dayat the same day
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
On admissionOn admissionClinical Clinical examinationexamination
Deterioration Deterioration of the of the neurologic neurologic deficit deficit
Right leg Right leg (2/5)(2/5)Left leg (4/5)Left leg (4/5)
Sphincteric Sphincteric function: function: unspecified unspecified
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Radiological Radiological investigationinvestigation
CT scanCT scan
MRIMRI
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
The CT The CT examination examination made clear that made clear that the spinal injury the spinal injury occurred at the occurred at the level of a level of a pre-existed right pre-existed right thoracic scoliosis thoracic scoliosis estimated estimated approximately approximately at 25 degrees.at 25 degrees.
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
CT scanCT scansaggital saggital
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Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
CT scanCT scancoronal coronal
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
CT scanCT scanaxial axial
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Total disruption Total disruption of the three of the three spinal columns spinal columns detected as well detected as well as vertebral – as vertebral – ribs ribs articulation, articulation, which made which made clear that gross clear that gross instability instability existed.existed.
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Type CType CCase 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Magerl et al. Eur. Spine J 1994
DESTRUCTIONDESTRUCTIONof theof the
33COLLUMNSCOLLUMNS
MAXIMUM INSTABILITYMAXIMUM INSTABILITY
ROTATIONAL ROTATIONAL INJURIESINJURIES
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Magerl et al. Eur. Spine J 1994
M.R.IM.R.Isaggitalsaggital
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
What do you What do you propose ?propose ?
Conservative Conservative treatment treatment
Bed restBed restThoracolumbar braceThoracolumbar braceMethylprednisoloneMethylprednisolone
Operative treatmentOperative treatment
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Operative Operative treatmenttreatment
Time of Time of operationoperation
Immediately Immediately or or
As soon as the As soon as the patient condition patient condition permitspermits
ProcedureProcedureAnteriorAnterior
PosteriorPosterior
Combined Combined
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Posterior Posterior procedureprocedure
LaminectomyLaminectomy
VertebrectomyVertebrectomy
Laminectomy & Laminectomy & VertebrectomyVertebrectomy
Stabilization Stabilization In situIn situ
Correction of the Correction of the scoliotic scoliotic deformity deformity and stabilizationand stabilization
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Due to various reasons related Due to various reasons related to the cardio-respiratory to the cardio-respiratory function the operative function the operative treatment postponed until the treatment postponed until the patient’s condition improvedpatient’s condition improvedIn the meantime neurological In the meantime neurological function of the lower limbs function of the lower limbs deteriorated mainly deteriorated mainly of the right oneof the right oneFinally the patient underwent Finally the patient underwent the operation on the operation on 1212thth August 2011 (3 days later) August 2011 (3 days later)
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
It is clear the It is clear the total disruption total disruption of the posterior of the posterior spinal elements spinal elements and the lateral and the lateral displacement of displacement of the spinous the spinous process of the process of the vertebra above vertebra above related to the related to the next below next below
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Posterior Posterior procedureprocedure
Neuro monitoring Neuro monitoring
Extensive Extensive laminectomies of the laminectomies of the 55thth and 6 and 6thth vertebra vertebra
Partial Partial vertebrectomies vertebrectomies of the 5of the 5thth and 6 and 6thth vertebravertebra
Pre-bended rods Pre-bended rods according to the according to the scoliotic curve scoliotic curve appliedapplied
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
During the During the procedureprocedure
Disturbance of the Disturbance of the neurological function neurological function on both legs whileon both legs whilethe secure screw the secure screw applied on the 8applied on the 8thth right right vertebral screw vertebral screw causing interruption causing interruption of the motor of the motor potentialspotentials
Implants removed Implants removed immediately and the immediately and the motor potentials motor potentials recurrentrecurrent
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
Ten minutes later a Ten minutes later a similar effort was similar effort was made and similar made and similar neurologic neurologic disturbance occurred disturbance occurred
Implants removed Implants removed immediately and the immediately and the motor potential motor potential recurrent againrecurrent again
Finally the pre-Finally the pre-bended rods applied bended rods applied over the vertebral over the vertebral screws.screws.The secure screw of The secure screw of the 8the 8thth right vertebral right vertebral screw was not appliedscrew was not appliedNo disturbance of the No disturbance of the neurological function neurological function was notedwas noted
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
The post operative The post operative course of the patient was course of the patient was initially normal with initially normal with improvement of his improvement of his neurologic deficitneurologic deficit
On the 9On the 9thth post operative post operative day neurologic day neurologic deterioration appeared deterioration appeared on both legson both legs
The MRI examination The MRI examination revealed an extensive revealed an extensive heamatoma (± CSF)heamatoma (± CSF)
Evacuation of Evacuation of heamatoma (twice)heamatoma (twice)
Thereafter it appeared Thereafter it appeared steady progress of his steady progress of his neurological conditionneurological condition
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
He discharged two He discharged two months later being months later being in a very in a very satisfactory satisfactory neurological neurological condition and at 9 condition and at 9 months time he was months time he was back to his work in back to his work in lighter dutieslighter duties
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
What is the cause What is the cause of the intra of the intra operative operative deterioration ?deterioration ?
Pressure of the Pressure of the spinal cordspinal cord
Ischemia – occlusion Ischemia – occlusion
of the Adamkiewiczof the Adamkiewicz arteryartery
Both of the above Both of the above due to regional due to regional instability instability
Something elseSomething else
Case 01Case 01
Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas
““ATTIKON” UNIVERSITY ATTIKON” UNIVERSITY HOPSITALHOPSITAL