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Thoracolumbar Trauma

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381. Cardiovascular Concerns in Spinal Cord Injury (Diagnosis)

bradycardia, 68% are hypotensive, 35% require pressors, and 16% have primary cardiac arrest. [ , ] The prevalence rate of symptomatic CHD in SCI is 30-50%, in comparison to 5-10% in the general able-bodied population. Autonomic dysreflexia is 3 times more prevalent in complete tetraplegia than with incomplete injury. Of persons with motor incomplete cervical injuries (ASIA grades C and D), 35-71% develop bradycardia, but few have hypotension or require pressors. Among patients with thoracolumbar injuries (...) with tetraplegia commonly develop pulmonary edema if given too much volume. The etiology of this phenomenon is not clear, but it may be related to decreased pulmonary vascular resistance and/or a lack of sympathetic innervation to the lungs. Therefore, following resuscitation with about 2 L, start pressors to maintain blood pressure after hypovolemia due to other trauma has been ruled out. Conditions to consider in the differential diagnosis of cardiovascular disease in patients with spinal cord injury include

2014 eMedicine.com

382. Autonomic Dysreflexia in Spinal Cord Injury (Diagnosis)

sensory input travels up the spinal cord and evokes a massive reflex sympathetic surge from the thoracolumbar sympathetic nerves, causing widespread vasoconstriction, most significantly in the subdiaphragmatic (or splanchnic) vasculature. Thus, peripheral arterial hypertension occurs. (C) The brain detects this hypertensive crisis through intact baroreceptors in the neck delivered to the brain through cranial nerves IX and X. (D) The brain attempts two maneuvers to halt the progression (...) or conditions all can cause episodes of autonomic dysreflexia: Bladder distention Urinary tract infection Calculus Cystoscopy/instrumentation Urodynamic study [ , ] Epididymitis or scrotal compression Bowel distention Fecal impaction Bowel instrumentation/colonoscopy Reflux or gastritis Gallstones Gastric ulcers Invasive testing Hemorrhoids Gastrocolic irritation Appendicitis or other intra-abdominal pathology/trauma Anal fissure Menstruation Pregnancy - Especially labor and delivery Vaginitis Sexual

2014 eMedicine.com

383. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Diagnosis)

develop clinical manifestations of spondyloarthropathy. [ , ] Patients with AS may experience exacerbations after trauma. However, no scientific studies support trauma as a cause of AS. Previous Next: Epidemiology AS is the most common of the classic spondyloarthropathies. Prevalence varies with the prevalence of the HLA-B27 gene in a given population, which increases with distance from the equator. In general, AS is more common in whites than in nonwhites. It occurs in 0.1-1% of the general (...) abnormalities. J Rheumatol . 2010 Oct. 37(10):2110-7. . Vinson EN, Major NM. MR imaging of ankylosing spondylitis. Semin Musculoskelet Radiol . 2003 Jun. 7(2):103-13. . Geijer M, Gothlin GG, Gothlin JH. The clinical utility of computed tomography compared to conventional radiography in diagnosing sacroiliitis. A retrospective study on 910 patients and literature review. J Rheumatol . 2007 Jul. 34(7):1561-5. . Van Royen BJ, De Gast A. Lumbar osteotomy for correction of thoracolumbar kyphotic deformity

2014 eMedicine.com

384. Ankylosing Spondylitis (Diagnosis)

develop clinical manifestations of spondyloarthropathy. [ , ] Patients with AS may experience exacerbations after trauma. However, no scientific studies support trauma as a cause of AS. Previous Next: Epidemiology AS is the most common of the classic spondyloarthropathies. Prevalence varies with the prevalence of the HLA-B27 gene in a given population, which increases with distance from the equator. In general, AS is more common in whites than in nonwhites. It occurs in 0.1-1% of the general (...) abnormalities. J Rheumatol . 2010 Oct. 37(10):2110-7. . Vinson EN, Major NM. MR imaging of ankylosing spondylitis. Semin Musculoskelet Radiol . 2003 Jun. 7(2):103-13. . Geijer M, Gothlin GG, Gothlin JH. The clinical utility of computed tomography compared to conventional radiography in diagnosing sacroiliitis. A retrospective study on 910 patients and literature review. J Rheumatol . 2007 Jul. 34(7):1561-5. . Van Royen BJ, De Gast A. Lumbar osteotomy for correction of thoracolumbar kyphotic deformity

2014 eMedicine.com

385. Erectile Dysfunction (Diagnosis)

it may offer some benefit to patients with a history of central nervous system problems, peripheral neuropathy, diabetes, or penile sensory deficit Imaging studies are not commonly warranted, except in situations where pelvic trauma has been sustained or surgery performed. Modalities that may be considered include the following: Ultrasonography of the penis (to assess vascular function within the penis) Ultrasonography of the testes (to help disclose abnormalities in the testes and epididymides (...) the dorsomedial hypothalamus through the dorsal and central gray matter, descends to the locus ceruleus, and projects ventrally in the mesencephalic reticular formation. Input from the brain is conveyed through the dorsal spinal columns to the thoracolumbar and sacral autonomic nuclei. The primary nerve fibers to the penis are from the dorsal nerve of the penis, a branch of the pudendal nerve. The cavernosal nerves are a part of the autonomic nervous system and incorporate both sympathetic and parasympathetic

2014 eMedicine.com

386. Epidural Steroid Injections (Diagnosis)

third of the spinal cord in the thoracolumbar region. (See below for more details.) Cervical ESIs carry similar risks, with the apparent caveat that any damage to the spinal cord at the level of the cervical spine often results in greater impairment than damage at the lumbar levels and may precipitate respiratory arrest at higher cervical levels. There is the risk of spinal cord trauma if the operator performs direct injection into the spinal cord via an interlaminar approach, a risk (...) that is essentially absent at the lower lumbar spine, since the spinal cord terminates at the level of L2. Cord trauma can also result from compression of the spinal cord from an epidural abscess or an epidural hematoma. Despite these risks, most agree that complications are minimal when ESIs are performed by a physician with the proper equipment, training, and technique. Safety of the transforaminal approach The complications of ESIs can probably be averted by using fluoroscopic guidance, contrast enhancement

2014 eMedicine.com

387. Mucopolysaccharidosis Type IV (Treatment)

vest support may be needed following surgery, and the acquisition of a postoperative critical care bed and neuromonitoring for possible spinal cord injury for all surgeries longer than 45 minutes are recommended. [ , , , ] Prophylactic treatment of atlantoaxial instability is not recommended, and a clinical and imaging evaluation is necessary to determine whether surgical stabilization of the occipital-cervical junction is required. [ , ] Gibbus deformity (thoracolumbar kyphosis) is corrected

2014 eMedicine Pediatrics

388. Mucopolysaccharidosis Type IV (Follow-up)

vest support may be needed following surgery, and the acquisition of a postoperative critical care bed and neuromonitoring for possible spinal cord injury for all surgeries longer than 45 minutes are recommended. [ , , , ] Prophylactic treatment of atlantoaxial instability is not recommended, and a clinical and imaging evaluation is necessary to determine whether surgical stabilization of the occipital-cervical junction is required. [ , ] Gibbus deformity (thoracolumbar kyphosis) is corrected

2014 eMedicine Pediatrics

389. Neurofibromatosis (Treatment)

divided into cervical, thoracic, lumbosacral, and spinal canal pathologies. Cervical spine changes and associated complications Features of the cervical spine in patients with NF1 have not received enough attention in the literature. Cervical abnormalities occur much more frequently when a scoliosis or kyphoscoliosis is present in the thoracolumbar region, in which case the examiner's attention is focused on the more obvious deformity. The manifestations of NF1 can be observed as dystrophic changes (...) Y, Ni J, Gu S, Zhu X. Successful use of posterior instrumented spinal fusion alone for scoliosis in 19 patients with neurofibromatosis type-1 followed up for at least 25 months. Arch Orthop Trauma Surg . 2009 Jul. 129 (7):915-21. . Helenius IJ, Sponseller PD, Mackenzie W, Odent T, Dormans JP, Asghar J, et al. Outcomes of Spinal Fusion for Cervical Kyphosis in Children with Neurofibromatosis. J Bone Joint Surg Am . 2016 Nov 2. 98 (21):e95. . Lin T, Shao W, Zhang K, Gao R, Zhou X. Comparison

2014 eMedicine Surgery

390. Idiopathic Scoliosis (Treatment)

adolescent idiopathic scoliosis. This system, first published in 2001, includes the following three components [ ] : Curve type (1, 2, 3, 4, 5, or 6) Lumbar spine modifier (A, B, or C) Sagittal thoracic modifier (–, N, or +) On coronal and sagittal radiographs, the six types specified by Lenke et al have specific characteristics that distinguish structural and nonstructural curves in the proximal thoracic (PT), main thoracic (MT), thoracolumbar (TL), and lumbar (L) regions. [ ] Regional curves (...) of the thoracic curve is possible. When this is not the case, extensive fusion (at times down to the fourth lumbar segment) may become necessary. The Scoliosis Research Society has a reasonably specific definition of thoracolumbar scoliosis: a curve whose apex lies at the body of T-12 or L-1 or at the T12-L1 interspace. These curves are most commonly left-sided curves, and they present one of the most common scenarios in which anterior spinal fusion and instrumentation is utilized. Anterior approaches

2014 eMedicine Surgery

391. Lumbar Spine Fractures and Dislocations (Treatment)

Sports Med . 2008 Jan. 42(1):55-8. . Sieradzki JP, Sarwark JF. Thoracolumbar fracture-dislocation in child abuse: case report, closed reduction technique and review of the literature. Pediatr Neurosurg . 2008. 44 (3):253-7. . Schoenfeld AJ, Newcomb RL, Pallis MP, Cleveland AW 3rd, Serrano JA, Bader JO, et al. Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan: a study of 2,089 instances of spine trauma. J Trauma Acute Care Surg . 2013 Apr. 74(4 (...) ):1112-8. . Patten RM, Gunberg SR, Brandenburger DK. Frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal CT in patients with trauma. Radiology . 2000 Jun. 215(3):831-4. . Hsieh CT, Chen GJ, Wu CC, Su YH. Complete fracture-dislocation of the thoracolumbar spine without paraplegia. Am J Emerg Med . 2008 Jun. 26(5):633.e5-7. . Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine fractures. Spine J . 2014 Jan. 14 (1):145-64. . Levi AD

2014 eMedicine Surgery

392. Lower Cervical Spine Fractures and Dislocations (Treatment)

deterioration in the face of persistent compression from bone or disk fragments Although malalignment can be managed initially with cervical tong traction, definitive surgical stabilization, with or without decompression, generally is required. Anterior-column trauma may result from axial loading injuries in combination with flexion, extension, or rotational moments. Typically, the burst fracture or teardrop variant occurs with translation of bony fragments into the spinal canal. [ , , ] Direct trauma (...) herniation is identified before reduction, it can be removed anteriorly, and reduction then can be performed safely. This has been described in both unilateral and bilateral facet dislocations. Guidelines on treatment of subaxial cervical spine injuries are available from the American Association of Neurological Surgeons (AANS; see ). [ ] Next: Medical Therapy Medical management involves treating the multiple traumas and, more specifically, treating concomitant neurologic injury. The use of steroids

2014 eMedicine Surgery

393. Kyphosis (Treatment)

. Pseudarthrosis can occur, especially with long fusions, inadequate support of the anterior column, and fusions at the thoracolumbar junction. [ ] Other risk factors in long fusions to treat scoliosis include age greater than 55 years, [ ] thoracolumbar kyphosis greater than 20°, and fusion of more than 12 levels. [ ] Implant failure can lead to loss of correction, especially at the proximal portion of the instrumentation. Patients with osteoporosis are at somewhat increased risk of implant failure or even (...) angle in the measurement of vertebral, local and segmental kyphosis of traumatic lumbar spine fractures in the lateral X-ray. Arch Orthop Trauma Surg . 2010 Dec. 130 (12):1533-8. . Perriman DM, Scarvell JM, Hughes AR, Ashman B, Lueck CJ, Smith PN. Validation of the flexible electrogoniometer for measuring thoracic kyphosis. Spine (Phila Pa 1976) . 2010 Jun 15. 35 (14):E633-40. . Bautmans I, Van Arken J, Van Mackelenberg M, Mets T. Rehabilitation using manual mobilization for thoracic kyphosis

2014 eMedicine Surgery

394. Ankylosing Spondylitis (Treatment)

Royen BJ, De Gast A. Lumbar osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. A structured review of three methods of treatment. Ann Rheum Dis . 1999 Jul. 58(7):399-406. . . Shih LY, Chen TH, Lo WH, Yang DJ. Total hip arthroplasty in patients with ankylosing spondylitis: longterm followup. J Rheumatol . 1995 Sep. 22(9):1704-9. . Cawley MI, Chalmers TM, Ball J. Destructive lesions of vertebral bodies in ankylosing spondylitis. Ann Rheum Dis . 1971 Sep. 30(5):539 (...) of spondylarthropathies]. Rev Rhum Mal Osteoartic . 1990 Feb. 57(2):85-9. . Rasker JJ, Prevo RL, Lanting PJ. Spondylodiscitis in ankylosing spondylitis, inflammation or trauma? A description of six cases. Scand J Rheumatol . 1996. 25(1):52-7. . Dihlmann W, Delling G. Discovertebral destructive lesions (so called Andersson lesions) associated with ankylosing spondylitis. Skel Radiol . 1978. 3:10-6. Agarwal AK, Reidbord HE, Kraus DR, Eisenbeis CH Jr. Variable histopathology of discovertebral lesion (spondylodiscitis

2014 eMedicine Surgery

395. Vertebral Fracture (Overview)

the use of screws to achieve stability and promote fusion Posterior rods - Effective in stabilizing multiple fractures or unstable fractures Z-plate anterior thoracolumbar plating system - Has been used for the treatment of burst fractures Cage See for more detail. Next: Background Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomical and functional (...) . [ ] Given the shortage of neurosurgeons at many trauma centers in the United States, Baldwin et al designed a treatment protocol that used radiologic criteria to screen for potentially stable fractures and to guide treatment without spinal consultation. Using both prospective and retrospective evaluation, the study determined that use of a treatment protocol for stable thoracolumbar fractures appeared safe and could help conserve resources. Surgery for patients with complete neurologic deficit

2014 eMedicine Surgery

396. Tumors of the Conus and Cauda Equina (Overview)

with the following: Pain radiating to the lower extremity Motor weakness in a specific distribution Sensory loss or paresthesia in a specific dermatomal pattern Diminished reflexes Spinal stenosis can be the result of a congenitally shallow canal, with the following: Arthropathy of the facet Hypertrophied ligamentum flavum A bulging annulus or herniated disc With neurogenic claudication (compared with vascular claudication), the pain is dermatomal and worsens with ambulation. In the setting of major trauma (...) , fractures are likely nonpathologic. The bony fragments can compress the neural elements. Vascular Epidural spinal hematoma may be posttraumatic; in anticoagulated patients, minor trauma presumably may be the cause. Alternatively, it may result from a dural vascular malformation. may cause a hemorrhage that affects the conus medullaris but is less likely to affect individual roots. Infarction may result from disruption of the radicular vessels as a result of atherosclerotic disease of the aorta

2014 eMedicine Surgery

397. Spinal Dislocations (Overview)

. The prognosis for a pure nerve-root injury is much better than for an actual spinal-cord injury. In some of these injuries, spinal-cord injury and nerve-root damage are combined. Of the injuries affecting the thoracolumbar spine, dislocation fractures are the most unstable, secondary to the soft-tissue and bony disruption resulting from the high-energy mechanics of injury. This injury is associated with the highest incidence of neurologic deficits and chest and abdominal trauma. Involvement of all three (...) and thoracolumbar fractures. Semin Spine Surg . 1995. 7:103-108. Levine AM. Facet fractures and dislocations of the thoracolumbar spine. Spine Trauma . 1998. 415-427. Whitesides TE Jr. Traumatic kyphosis of the thoracolumbar spine. Clin Orthop Relat Res . 1977 Oct. (128):78-92. . Dunn RN, van der Spuy D. Rugby and cervical spine injuries - has anything changed? A 5-year review in the Western Cape. S Afr Med J . 2010 Mar 30. 100(4):235-8. . Kemp AM, Joshi AH, Mann M, Tempest V, Liu A, Holden S, et al. What

2014 eMedicine Surgery

398. Spinal Instability and Spinal Fusion Surgery (Overview)

and gradually acquire a more sagittal orientation throughout the thoracic and upper lumbar spine. They then become more coronally oriented as one descends the lumbar spine. The transverse orientation of the facet joints and the loose facet capsules in the cervical spine allow relatively free movement of the neck in all three planes and do not protect the cervical spine against flexion injuries. In the thoracolumbar junction, the sagittal orientation of the facet joints and the strong capsular ligaments (...) permit greater movement in the sagittal plane than in other directions. This facet orientation and the transitional location of the thoracolumbar spine between the ribcage-stabilized thoracic spine and the more robust lumbar spine make the thoracolumbar junction more susceptible to flexion injuries. The more coronal orientation of the L5-S1 facet joints as compared with the L4-5 facets accounts for the lower incidence of degenerative spondylolisthesis at L5-S1, in spite of the biomechanically

2014 eMedicine Surgery

399. Spinal Stenosis (Overview)

stenosis of the cervical spine may predispose an individual to myelopathy as a result of minor trauma or spondylosis. [ , , , , , , ] refers to age-related degenerative changes of the cervical spine. These changes, which include intervertebral disk degeneration, disk space narrowing, spur formation, and facet and ligamentum flavum hypertrophy, can lead to the narrowing of the cervical spinal canal. Cervical spondylotic myelopathy (CSM) refers to the clinical presentation resulting from (...) compression with subsequent radicular symptomology. Previous Next: Etiology Primary stenosis is uncommon, occurring in only 9% of cases. Congenital malformations include the following: Incomplete vertebral arch closure (spinal dysraphism) Segmentation failure Achondroplasia Osteopetrosis Developmental flaws include the following: Early vertebral arch ossification Shortened pedicles Thoracolumbar kyphosis Apical vertebral wedging Anterior vertebral beaking (Morquio syndrome) Osseous exostosis Secondary

2014 eMedicine Surgery

400. Spinal Stenosis (Overview)

stenosis of the cervical spine may predispose an individual to myelopathy as a result of minor trauma or spondylosis. [ , , , , , , ] refers to age-related degenerative changes of the cervical spine. These changes, which include intervertebral disk degeneration, disk space narrowing, spur formation, and facet and ligamentum flavum hypertrophy, can lead to the narrowing of the cervical spinal canal. Cervical spondylotic myelopathy (CSM) refers to the clinical presentation resulting from (...) compression with subsequent radicular symptomology. Previous Next: Etiology Primary stenosis is uncommon, occurring in only 9% of cases. Congenital malformations include the following: Incomplete vertebral arch closure (spinal dysraphism) Segmentation failure Achondroplasia Osteopetrosis Developmental flaws include the following: Early vertebral arch ossification Shortened pedicles Thoracolumbar kyphosis Apical vertebral wedging Anterior vertebral beaking (Morquio syndrome) Osseous exostosis Secondary

2014 eMedicine Surgery

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