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Thoracolumbar Trauma

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401. Congenital Spinal Deformity (Treatment)

involving the thoracolumbar spine. Defects of formation may be classified as follows: Anterior formation failure - This results in kyphosis, which is sharply angulated Posterior formation failure - This is rare but can produce a lordotic curve Lateral formation failure - This occurs frequently and produces the classic hemivertebrae of congenital scoliosis The scoliosis that develops may occur with kyphosis or lordosis, depending on the precise location of the defects. Specific defects of segmentation (...) and thoracolumbar regions and usually is less severe in the cervicothoracic and lumbar regions. On the other hand, a mild cervicothoracic curve may produce an unsightly appearance because of the head and neck tilt and the elevation of the shoulder line. Lumbar curves do not cause much cosmetic deformity unless decompensation or pelvic obliquity occurs. Congenital scoliosis, like idiopathic scoliosis, tends to progress most rapidly during the preadolescent growth spurt, after age 10 years. Scoliosis presenting

2014 eMedicine Surgery

402. Chance Fracture (Treatment)

and associated abdominal trauma. J Trauma . 1990 Apr. 30 (4):436-44. . Triantafyllou SJ, Gertzbein SD. Flexion distraction injuries of the thoracolumbar spine: a review. Orthopedics . 1992 Mar. 15 (3):357-64. . Tyroch AH, McGuire EL, McLean SF, Kozar RA, Gates KA, Kaups KL, et al. The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review. Am Surg . 2005 May. 71 (5):434-8. . Mulpuri K, Reilly CW, Perdios A, Tredwell SJ, Blair GK. The spectrum of abdominal injuries (...) . 2010 Oct. 23 (7):e1-8. . Parizel PM, van der Zijden T, Gaudino S, Spaepen M, Voormolen MH, Venstermans C, et al. Trauma of the spine and spinal cord: imaging strategies. Eur Spine J . 2010 Mar. 19 Suppl 1:S8-17. . Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol . 2006 Oct. 187 (4):859-68. . Groves CJ, Cassar-Pullicino VN, Tins BJ, Tyrrell PN, McCall IW. Chance-type flexion-distraction injuries

2014 eMedicine Surgery

403. Cauda Equina Syndrome (Treatment)

decompression is necessary to minimize the chances of permanent neurologic injury. Next: Emergency Department Care No proven medical treatment exists, and therapy generally is directed at the underlying cause of cauda equina syndrome. For penetrating trauma, steroids have not shown significant benefit. Surgery is controversial. The timing of decompression is controversial, with immediate, early, and late surgical decompression showing varying results. [ , , ] For mechanical compression of the cauda due (...) principles. Neurosurg Focus . 2004 Jun 15. 16(6):e4. . Fisher RG. Sacral fracture with compression of cauda equina: surgical treatment. J Trauma . 1988 Dec. 28(12):1678-80. . Schizas C, Ballesteros C, Roy P. Cauda equina compression after trauma: an unusual presentation of spinal epidural lipoma. Spine (Phila Pa 1976) . 2003 Apr 15. 28(8):E148-51. . Thongtrangan I, Le H, Park J, Kim DH. Cauda equina syndrome in patients with low lumbar fractures. Neurosurg Focus . 2004 Jun 15. 16(6):e6. . Haldeman S

2014 eMedicine Surgery

404. Thoracic Spine Fractures and Dislocations (Overview)

, Jupiter JB, Krettek C, Anderson PA, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction . 5th ed. Philadelphia: Elsevier Saunders; 2015. Vol 1: 911-80. Chapman MW, Szabo RM, Vince KG, et al, eds. Chapman's Orthopaedic Surgery . Philadelphia: Lippincott Williams & Wilkins; 2001. 3719-44. Frymoyer JW, Ducker TB, Hadler NM, Kostuik JP, eds. The Adult Spine: Principles and Practice . 2nd ed. Philadelphia: Lippincott-Raven; 1991. 1269-324. Aebi M. Classification of thoracolumbar fractures (...) and dislocations. Eur Spine J . 2010 Mar. 19 Suppl 1:S2-7. . . Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am . 1970 Dec. 52(8):1534-51. . Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) . 1983 Nov-Dec. 8 (8):817-31. . Browner BD, Jupiter JB, Krettek C. Thoracolumbar Fractures. Skeletal Trauma: Basic Science, Management, and Reconstruction . 5th ed. Philadelphia, PA

2014 eMedicine Surgery

405. Fracture, Cervical Spine (Diagnosis)

, Izzo R, Muto M. The role of emergency radiology in spinal trauma. Br J Radiol . 2016. 89 (1061):20150833. . Winslow JE 3rd, Hensberry R, Bozeman WP, Hill KD, Miller PR. Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures. J Trauma . 2006 Sep. 61(3):686-7. . Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma . 2007 Jun. 62(6):1405-8 (...) in odontoid fractures and atlanto-occipital dislocation. [ , , , , , , ] Radiographic evaluation is indicated in the following [ , , , , , , ] : Patients who exhibit neurologic deficits consistent with a cord lesion Patients with an altered sensorium from head injury or intoxication Patients who complain about neck pain or tenderness Patients who do not complain about neck pain or tenderness but have significant distracting injuries A standard trauma series is composed of 5 views: cross-table lateral

2014 eMedicine Emergency Medicine

406. Cauda Equina Syndrome (Diagnosis)

, including disc herniation, intradural disc rupture, spinal stenosis secondary to other spinal conditions, traumatic injury, primary tumors such as ependymomas and schwannomas, metastatic tumors, infectious conditions, arteriovenous malformation or hemorrhage, and iatrogenic injury. [ , ] The most common causes of cauda equina and conus medullaris syndromes are the following: Lumbar stenosis (multilevel) Spinal trauma including fractures [ ] Herniated nucleus pulposus (cause of 2-6% of cases of cauda (...) of 66 consecutive cases of patients admitted to a neurosurgical unit with suspected cauda equina syndrome found that almost half had no evidence of structural pathology on MRI. [ ] These researchers suggested that the symptoms have a functional origin in such cases. Trauma Traumatic events leading to fracture or subluxation can lead to compression of the cauda equina. [ , , , , ] Penetrating trauma can cause damage or compression of the cauda equina. Spinal manipulation resulting in subluxation has

2014 eMedicine Emergency Medicine

407. Spinal Dislocations (Treatment)

Classic-XVII: Edwin Smith Surgical Papyrus. Cyber Museum of Neurosurgery. Available at . Accessed: January 23, 2019. NICOLL EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br . 1949 Aug. 31B (3):376-94. . Fellrath RF Jr, Hanley EN Jr. Multitrauma 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 (...) dislocations remains highly variable: a survey of members of the Spine Trauma Study Group. J Spinal Disord Tech . 2009 Apr. 22(2):96-9. . Bono CM, Rinaldi MD. Thoracolumbar trauma. Spivak J, Connolly PJ, eds. Orthopaedic Knowledge Update Spine 3 . 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006. 201-216/23. Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, et al. Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries

2014 eMedicine Surgery

408. Spinal Instability and Spinal Fusion Surgery (Treatment)

for fusion in cervical, thoracic, and lumbar spine trauma. Table 2. Treatment of Traumatic Instability of Cervical Spine Fracture/Dislocation (Mechanism) Type/Issue Treatment C1 Jefferson fracture (axial loading) 1. Isolated --> 2. With transverse ligament rupture --> 3. Widely diastatic --> 4. With odontoid fracture --> 1. Hard collar 2. Halo 3. Consider occiput-C2 fusion 4. Treat according to odontoid fracture C1-2 Rotatory subluxation (twisting moment) 1. Children, URI --> 2. Adults, tumor, trauma (...) and thoracolumbar fusions, the patient is positioned prone over a frame or table that permits the abdomen to hang free. Otherwise, the increased intra-abdominal pressure would interfere with venous return and would increase intraoperative bleeding. The Wilson frame fulfills this requirement and provides the fastest and least cumbersome means for positioning the patient. Certain other spine frames and tables (eg, the Andrews table) allow the patient to be positioned in a knee-to-chest position. The resultant

2014 eMedicine Surgery

409. Thoracic Spine Fractures and Dislocations (Treatment)

of an active infection. Guidelines on management of thoracolumbar burst fractures are available from the Congress of Neurological Surgeons, [ ] and guidelines on management of spinal cord injury (SCI) are available from AOSpine [ , , , , , ] (see ). Timing of surgical treatment The literature regarding the timing of surgical intervention for thoracic and lumbar fractures with an acute spinal cord injury (SCI) is scarce. However, several studies have looked at the timing of surgery in cervical spine trauma (...) in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) . 1983 Nov-Dec. 8 (8):817-31. . Browner BD, Jupiter JB, Krettek C. Thoracolumbar Fractures. Skeletal Trauma: Basic Science, Management, and Reconstruction . 5th ed. Philadelphia, PA: Elsevier; 2014 Dec 09. 803-812, 911-979. Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med . 2011 Nov. 34 (6

2014 eMedicine Surgery

410. Tumors of the Conus and Cauda Equina (Treatment)

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

411. Vertebral Fracture (Treatment)

for screening and management of stable fractures. J Trauma . 2010 Dec. 69(6):1491-5; discussion 1495-6. . Guarnieri G, Izzo R, Muto M. The role of emergency radiology in spinal trauma. Br J Radiol . 2015 Nov 27. 20150833. . Inaba K, Nosanov L, Menaker J, Bosarge P, Williams L, Turay D, et al. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. J Trauma Acute Care (...) . Operative treatment of progressive deformity in spinal tuberculosis. Int Orthop . 2001. 25(5):322-5. . Dimar JR, Fisher C, Vaccaro AR, et al. Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma . 2010 Dec. 69(6):1497-500. . Anderson DK, Hall ED, Braughler JM, et al. Effect of delayed administration of U74006F (tirilazad mesylate) on recovery of locomotor function after experimental spinal cord injury. J Neurotrauma . 1991 Fall. 8(3):187-92. . Baron BJ, Scalea

2014 eMedicine Surgery

412. Neurofibromatosis (Overview)

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

413. Lumbar Spine Fractures and Dislocations (Overview)

) . 2000 Nov 1. 25 (21):2847-8. . Dogan S, Safavi-Abbasi S, Theodore N, Chang SW, Horn EM, Mariwalla NR, et al. Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases. J Neurosurg . 2007 Jun. 106(6 Suppl):426-33. . El Assuity WI, El Masry MA, Chan D. Acute traumatic spondylolisthesis at the lumbosacral junction. J Trauma . 2007 Jun. 62(6):1514-6; discussion 1516-7. . Smith JA, Siegel JH, Siddiqi SQ. Spine and spinal cord injury in motor vehicle crashes: a function (...) , Benneker L, Zimmermann H, Siebenrock KA, Exadaktylos AK. Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland. Br J 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

2014 eMedicine Surgery

414. Kyphosis (Overview)

. 1981 Jul. 63 (6):891-9. . Schoenfeld AJ, Wood KB, Fisher CF, Fehlings M, Oner FC, Bouchard K, et al. Posttraumatic kyphosis: current state of diagnosis and treatment: results of a multinational survey of spine trauma surgeons. J Spinal Disord Tech . 2010 Oct. 23 (7):e1-8. . Macagno AE, O'Brien MF. Thoracic and thoracolumbar kyphosis in adults. Spine (Phila Pa 1976) . 2006 Sep 1. 31 (19 Suppl):S161-70. . Shelton YA. Scoliosis and kyphosis in adolescents: diagnosis and management. Adolesc Med State (...) of formation or failure of segmentation of the spinal elements, can cause a pathologic kyphosis. Autoimmune arthropathy, such as ankylosing spondylitis, can cause rigid kyphosis to develop as the spinal elements coalesce. Kyphosis can also develop as a result of trauma, a spinal tumor, or an infection. Iatrogenic causes of kyphosis include the effects of laminectomy and irradiation, which lead to incompetence of the anterior or posterior column. Finally, metabolic disorders and dwarfing conditions can lead

2014 eMedicine Surgery

415. Lower Cervical Spine Fractures and Dislocations (Overview)

cervical spine is important because of the association between these injuries and spinal cord and nerve root injury. Little room for malalignment exists in the lower cervical spine, and safe and expeditious realignment is of the utmost priority. The age distribution of patients presenting with lower cervical spine and spinal cord injuries is bimodal. Injuries in persons aged 15-24 years are usually the result of high-energy trauma, such as motor vehicle accidents, accidents resulting from sporting (...) activities, or acts of violence. [ ] Injuries in persons older than 55 years usually result from low-energy trauma, such as falls from the standing position. The age-associated narrows the spinal canal and predisposes the cervical cord to injury at this level. [ ] In patients presenting to an emergency facility with a history of a high-speed motor vehicle accident, significant head or facial trauma, a neurologic deficit, or neck pain, a cervical spine injury should be assumed to be present until proved

2014 eMedicine Surgery

416. Spinal Instability and Spinal Fusion Surgery (Follow-up)

for fusion in cervical, thoracic, and lumbar spine trauma. Table 2. Treatment of Traumatic Instability of Cervical Spine Fracture/Dislocation (Mechanism) Type/Issue Treatment C1 Jefferson fracture (axial loading) 1. Isolated --> 2. With transverse ligament rupture --> 3. Widely diastatic --> 4. With odontoid fracture --> 1. Hard collar 2. Halo 3. Consider occiput-C2 fusion 4. Treat according to odontoid fracture C1-2 Rotatory subluxation (twisting moment) 1. Children, URI --> 2. Adults, tumor, trauma (...) and thoracolumbar fusions, the patient is positioned prone over a frame or table that permits the abdomen to hang free. Otherwise, the increased intra-abdominal pressure would interfere with venous return and would increase intraoperative bleeding. The Wilson frame fulfills this requirement and provides the fastest and least cumbersome means for positioning the patient. Certain other spine frames and tables (eg, the Andrews table) allow the patient to be positioned in a knee-to-chest position. The resultant

2014 eMedicine Surgery

417. Spinal Dislocations (Follow-up)

Classic-XVII: Edwin Smith Surgical Papyrus. Cyber Museum of Neurosurgery. Available at . Accessed: January 23, 2019. NICOLL EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br . 1949 Aug. 31B (3):376-94. . Fellrath RF Jr, Hanley EN Jr. Multitrauma 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 (...) dislocations remains highly variable: a survey of members of the Spine Trauma Study Group. J Spinal Disord Tech . 2009 Apr. 22(2):96-9. . Bono CM, Rinaldi MD. Thoracolumbar trauma. Spivak J, Connolly PJ, eds. Orthopaedic Knowledge Update Spine 3 . 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006. 201-216/23. Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, et al. Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries

2014 eMedicine Surgery

418. Cauda Equina Syndrome (Follow-up)

decompression is necessary to minimize the chances of permanent neurologic injury. Next: Emergency Department Care No proven medical treatment exists, and therapy generally is directed at the underlying cause of cauda equina syndrome. For penetrating trauma, steroids have not shown significant benefit. Surgery is controversial. The timing of decompression is controversial, with immediate, early, and late surgical decompression showing varying results. [ , , ] For mechanical compression of the cauda due (...) principles. Neurosurg Focus . 2004 Jun 15. 16(6):e4. . Fisher RG. Sacral fracture with compression of cauda equina: surgical treatment. J Trauma . 1988 Dec. 28(12):1678-80. . Schizas C, Ballesteros C, Roy P. Cauda equina compression after trauma: an unusual presentation of spinal epidural lipoma. Spine (Phila Pa 1976) . 2003 Apr 15. 28(8):E148-51. . Thongtrangan I, Le H, Park J, Kim DH. Cauda equina syndrome in patients with low lumbar fractures. Neurosurg Focus . 2004 Jun 15. 16(6):e6. . Haldeman S

2014 eMedicine Surgery

419. Diffuse Idiopathic Skeletal Hyperostosis (Follow-up)

. [ , ] Posterior longitudinal ligament ossifications may impinge on the spinal cord on rare occasions. Reduced vertebral column flexibility predisposes to vertebral fracture. Vertebral fracture risk (cervical, 60%; thoracic, 34.5%; lumbar, 5.5%) is inherent with an ankylosed hyperostotic vertebral column from minor trauma, preoperative and postoperative positioning, or intraoperative maneuvers (eg, retroperitoneal or hip replacement surgery). [ , , ] Note that as well as with fully ankylosed spines, partially (...) and imaging findings. AJR Am J Roentgenol . 1994 Apr. 162(4):899-904. . Matejka J. [Hyperextension injuries of the thoracolumbar spine]. Zentralbl Chir . 2006 Feb. 131(1):75-9. . Media Gallery Radiograph of the thoracic spine (anteroposterior view) showing osteophytes on the right side only, a feature typical of diffuse idiopathic skeletal hyperostosis. of 1 Tables Contributor Information and Disclosures Author Bruce M Rothschild, MD Professor of Medicine, West Virginia University School of Medicine

2014 eMedicine Surgery

420. Congenital Spinal Deformity (Follow-up)

involving the thoracolumbar spine. Defects of formation may be classified as follows: Anterior formation failure - This results in kyphosis, which is sharply angulated Posterior formation failure - This is rare but can produce a lordotic curve Lateral formation failure - This occurs frequently and produces the classic hemivertebrae of congenital scoliosis The scoliosis that develops may occur with kyphosis or lordosis, depending on the precise location of the defects. Specific defects of segmentation (...) and thoracolumbar regions and usually is less severe in the cervicothoracic and lumbar regions. On the other hand, a mild cervicothoracic curve may produce an unsightly appearance because of the head and neck tilt and the elevation of the shoulder line. Lumbar curves do not cause much cosmetic deformity unless decompensation or pelvic obliquity occurs. Congenital scoliosis, like idiopathic scoliosis, tends to progress most rapidly during the preadolescent growth spurt, after age 10 years. Scoliosis presenting

2014 eMedicine Surgery

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