Thoracic Lumbar Fracture 1st Ph Lecture Final PDF

TRAUMATIC CONDITIONS OF THE SPINE By Fatma Abdel Fattah Shewail  Importance of the spine The spine is critical for It helps to integrate protection for our efficient movement of movements between spinal cord and nervous...

TRAUMATIC CONDITIONS OF THE SPINE By Fatma Abdel Fattah Shewail  Importance of the spine The spine is critical for It helps to integrate protection for our efficient movement of movements between spinal cord and nervous the body the torso, pelvis, and system. shoulder girdle  VERTEBRAL COLUMN ▪ The spine consists of 33 vertebrae divided structurally into five regions , there are: ▪ 7 cervical vertebrae ▪ 12 thoracic vertebrae, ▪ 5 lumbar vertebrae, ▪ 5 fused sacral vertebrae, and ▪ 4 small fused coccygeal vertebrae. Each region has a specific structure designed for its function, and each region has a curve unto itself. These natural curvatures contribute to “ideal” spinal posture while one is standing. ▪ The spine seems to be straight and symmetrical from frontal view and it has a curved nature from lateral view ▪ There are four normal curves of the spine : ▪ two curves are convex posterior at thoracic and sacral regions. ▪ The other two curves are convex anterior at cervical and lumbar regions.  FUNCTIONS OF SPINAL CURVATURE 1. Define the anatomic (or neutral) position of the different regions of the spine. 2. Allow the spine to withstand& distribute stress and absorb forces that occur from everyday activities such as walking or from more intense activities such as running and jumping. 3. provides shock absorption function & increase elasticity and flexibility of spine and movement  SPINAL MOTION SEGMENT : Motion segment of the spine is the functional unit of the spine each motion segment consists of : ▪ two vertebral bodies (above and below) ▪ inter vertebral disc in between ▪ Ligaments and structures It allow six degrees of freedom in three planes they are: ▪ Flexion , extension ,right lateral bending &left lateral bending& rotation to right and left.  Postural Stability in the Spine Postural Stability in the Spine is described in terms of three subsystems: passive (inert structures/bones and ligaments) Active (muscles) neural control. The three subsystems are interrelated and can be thought of as a three-legged stool. if any one of the legs is not it affects the stability of the whole providing support structure Instability of a spinal segment is often a combination of insufficient muscular strength inert tissue damage, or endurance poor neuromuscular control.  Ligaments of the spine The most have ahigh collagen content, which limits ligamentous their extensibility during spine motion structures surrounding Anterior& posterior longitudinal ligaments the spine contribute the its intrinsic Interspinous& supraspinous ligaments stability. Ligamentum flavum Inter transvers ligaments  FACTORS WHICH INFLUENCE THE STABILITY AND MOBILITY OF THE SPINAL COLUMN articulation of the ribs with direction and the vertebrae obliquity of relative thickness articular facets and shape of the &spinous process anteroposterior intervertebral curves. disks & ligaments  Fractures of the spine ▪Disease, trauma, overuse, and normal aging can cause a host of neuromuscular and musculoskeletal problems involving the axial skeleton. ▪ spinal fractures are one of the traumatic injuries which affect the spine which divided into cervical, thoracic and thoracolumbar fractures.  Thoracolumbar fractures ▪ the T10-L2 thoracolumbar region is the most common area of injury to the spine from trauma due to the specific biomechanics of this segment of the spine. ▪ Specifically, this is a transition area from the rigid and less mobile thoracic spine (due to the presence of the ribs which attach to the spine bilaterally) to a more flexible lumbar spine. ▪ Injury to this area can result in a permanent neurological deficit from compression or direct injury to the nerve roots of the cauda equina or the conus medullaris and warrants immediate attention and assessment.  PATHOPHYSIOLOGY ▪ The thoracolumbar region is a fulcrum between the more rigid thoracic segment with facets that are coronally oriented to prevent flexion-extension, translation, and rotation and the lumbar segment whose facets are oriented sagittally to allow flexion-extension movement. ▪ Transitional zones of the spine have a characteristic higher degree of flexibility and degrees of motion; however, this can make these segments more prone to injury. ▪ This anatomical setup makes the T10-L2 segment the most mobile and vulnerable portion of the spine. At the thoracolumbar junction, the stiff kyphotic thoracic spine meets the caudal lordotic lumbar spine. The kinetic energy conveyed to this region can make it vulnerable to degenerative disease pathologies and traumatic injuries in higher energy mechanisms. Energy transferred from an impact at any anatomical level of the spine can accumulate and produce stress in the thoracolumbar junction.  ETIOLOGY The majority of thoracolumbar junction fractures result from: ▪ High impact trauma, including motor vehicle accidents and falls from height. ▪ Recreational accidents, and occupational injuries. ▪ Also low energy trauma can cause fracture of the spine specially if coupled with osteoporosis, which weakens the structural integrity of individual vertebrae  CLASSIFICATION A number of systems have been used to classify thoracolumbar spinal fractures based on the mechanism of injury. The Denis classification, which is widely used, is based on a three-column biomechanical model of the spine. The anterior column consists of the anterior longitudinal ligament and the anterior portion of the vertebral body. The middle column consists of the posterior portion of the vertebral body and the posterior longitudinal ligament. The posterior column consists of the posterior elements.  Denis classified thoracic and lumbar fractures into minor and major injuries The major injuries are categorized as: 1. compression fractures, 2. burst fractures, 3. flexion/distraction injuries, 4. and fracture/dislocations The Minor injuries : involves only apart of a column and do not lead to acute instability and Not accompanied by major injuries consisted of: 1. Pars interarticularis 2. spinous process, Articular process 3. transverse process fractures and facet fractures.  TYPES OF FRACTURES Compression fractures Burst fractures Flexion-distraction injuries Fracture dislocations  TYPES OF FRACTURES ▪ Compression fractures : are the most common injuries and are usually stable injuries with intact posterior elements. ▪ Burst fractures: have the anterior column and the posterior column involved and typically have retropulsed bone into the canal. ▪ Flexion-distraction injuries: usually are one or two-level hyperflexion injuries through the soft-tissue ligaments or the bony structures. These involve the anterior and posterior columns and the posterior ligaments, including the ligamentum flavum, and represent an unstable injury as the fracture typically extends through the ligament and the anterior and posterior columns. ▪ Fracture dislocations: are unstable and should be stabilized at the earliest possible opportunity  Mechanism of Injury Compression fractures 1-Caused by forward or Burst lateral flexion, caused primarily fractures 2- resulting in loss of by axial loading, height of the anterior such as in a fall column. 3-The middle column is from a height. not involved When compression exceeds 50% of the vertebral height or 20 anterior and middle degrees of angulation, a column posterior ligamentous involvement with injury may be present variable degrees of This is due to failure of the bony retropulsion posterior column in tension In this case, there is potential into the canal for instability. Compression fracture Burst fracture  Fracture/dislocations: By definition, three-column involvement occurs. caused by a high-energy mechanism with a combination of forces, including rotation, distraction, compression, and shear. These are highly unstable fractures. Up to 75 percent of patients with these injuries have a complete neurologic deficit. EVALUATION  Evaluation Before initiating treatment the therapist should perform a thorough examination to assess the patient’s status and help to create an individualized program. ▪ The examination should include: ▪ neurologic examination and search for associated injuries. ▪ relevant tests and measures, such as (posture, gait, (ROM), strength, balance, body mechanics, and specific functional tasks) while making sure not to overload the lumbar spine. signs on the physical exam: widened spaces between spinous processes or displacement of spinous processes from the midline, which can be seen in the patient's physical exam on palpation and inspection when the patient is rolled over in the primary trauma survey. The therapist and patient can then begin to collaborate on and establish goals for treatment ▪Weight Bearing ▪ The patient may stand and bear weight if the fracture pattern is stable. ▪ If the fracture pattern is unstable, the patient may begin ambulation as soon as it has been stabilized by a cast or brace or by internal fixation. ▪ The patient may be more comfortable standing, because the intradiscal pressure is less than in a sitting position. Pressure in the disc spaces usually doubles with sitting. However, the patient may sit with the back supported as soon as this feels comfortable.  ▪ GAIT During gait, the limb is functionally lengthened or shortened by anterior & posterior pelvic tilt. In fractures of the lumbar spine, tilt is reduced because of pain and stiffness. The pelvis rotates medially (anteriorly) at the end of the swing phase, lengthening the limb as it prepares to accept weight. The opposite rotation (lateral or posterior) occurs at the end of the stance phase, with functional shortening by lateral rotation decreasing the height needed to clear the swing-phase limb.  GAIT: Fractures of the hip or lumbar spine impair or prevent normal pelvic rotation & pelvic tilt during gait. ▪ Reciprocating or alternating spinal motion during gait is affected with rigid paraspinal muscles until the fracture has healed. ▪ Spinal rotation is limited; this reduces pelvic advancement, which in turn reduces stride length. ▪ The double-stance phase may be increased with both feet on the ground to provide more stability. ▪ Cadence is reduced, and step length is usually decreased. Upper arm swing likewise is reduced. ▪ In lumbar fractures, the anterior located iliopsoas muscle may be weakened, further reducing pelvic advancement.  Radiological evaluation of the spine Spine x-ray films usually do not provide the X-rays amount of detail to characterize the type of fracture and are not routinely used. CT scan will give an adequate assessment of bony Ct scan structures, including the vertebral bodies, pedicles, laminae, facets, and transverse and spinous processes. MRI will provide a better assessment of the MRI ligamentous and the neural structures, including the spinal cord, cauda equina, conus medullaris, and spinal nerve roots.  TREATMENT Nonoperative& operative Treatment  TREATMENT GOALS Restore functional Maintain Allow for Develop and pain- Restore spinal functional spinal free ROM in strength of alignment movements as flexibility for all planes the and pain-free sitting, functional without paraspinal independence reduction of standing, and creating muscles walking,. the fracture neurologic deficits  NONOPERATIVE TREATMENT ▪ nonoperative treatment of vertebral fractures involves the use of an appropriate brace or cast with early mobilization of the patient as tolerated. ▪ stable fractures without neurologic deficits can be effectively treated nonoperatively. Orthosis/Body Cast ▪ The Jewett brace is effective in hyperextending and limiting the flexion of the spine The thoracolumbar-sacral orthosis (TLSO) offers the most support in all planes. The thoracolumbar-sacral orthosis Jewett brace, a hyperextension brace (TLSO) is a rigid body jacket and that immobilizes flexion of the thoracolumbar spine. controls spinal motion in all planes.  operative Treatment Instrumentation/Arthrodesis ▪Surgical treatment of spinal fractures consists of various anterior and posterior arthrodesis procedures. ▪Short segment fixation and arthrodesis of one segment above and one below the injured vertebrae is favored over a long arthrodesis to preserve motion segments.  Indications In compression fractures: posterior instrumentation and arthrodesis is usually indicated for ▪ patients with greater than 50% loss of anterior vertebral height or more than 25 degrees of angulation. ▪ In a young patient with a high-energy injury in which posterior ligamentous disruption is suspected, surgery may be beneficial. ▪ Osteoporotic compression fractures are usually treated without surgery. For burst fractures: posterior distraction instrumentation and arthrodesis is indicated if ▪ there is 40% (or more) canal compromise and 25 degrees of kyphosis.  PROGRAM OF REHABILITATION POST OPERATIVE Phase 1(day1-4 week)  Phase 1(day1-4 week) Phase 1(day1-4 week) - 1- Avoid flexion of the trunk-sit up-spinal rotation 4-functional -Log rolling precaution To avoid breathing problems- activities -Lying: may be side lying or supine &avoid lying prone to avoid hyper extension ( Pursed lip breathing and diaphragmatic breathing) -Initially done cloths from sitting Avoid flexion of spine specially during wearing foot wear 2-ROM Active ROM of U.L & L.L 5-transfer -supine to sit No ROM of the spine transfer to a chair using assistive devices (Walker/Cane). 3-strength -isometric abdominal training start as early as possible 6- -start with assistive device & with assistance -Gluteal &quadriceps sets and anterior tibial muscle & ambulation -stair climbing started firstly with one step then step – ankle isotonic exercise To provide help for early over –step (Step height from 7-8 inches) ambulation -At week 2-calf strengthening with heal raises from standing -Straight leg raises (SLR) Weight started by using tilting table to ring patient into erect Personal Start with elevated toilets seat To reduce flexion of trunk bearing: posture to avoid orthostatic hypotension) hygiene at lumbar spine 1-knee walking and four-point kneeling: Pre-weight- bearing activities 2-Partial weight-bearing or no weight-bearing as tolerated with assistive device ACTIVE ROM OF U.L&L.L GLUTEAL SET &QUAD SET EXERCISE  Isometric abdominal training Lay on your back, with knees bent and feet flat on floor. then contract abdominal muscles by pulling them down and (tuck your abdomen in ). Hold this position for 5 seconds making sure you continue to breathe  ▪ Abdominal draw-in maneuver Lay on your back, with knees bent and feet flat on floor. Place your fingers on the muscles just below your belly button then contract those muscles by pulling them down and away from your fingers. Keep your upper abdominal muscles, back muscles, and hip muscles relaxed. Hold this position for 5 seconds making sure you continue to breathe  calf strengthening with heal raises from standing starting from week 2 Stand facing a wall with only your toes on a rolled or folded towel (a). Use the wall for balance, perform a heel raise (b), then slowly lower yourself down to the starting position.  Ankle Exercise Ankle dorsiflexor strengthening with resistance band. Ankle Isotonic Exercise LOG ROLLING  TRANSFER FROM SUPINE TO SIT Instruct patient to come to one side and push up on the elbow and shoulder with assistance  Lying postures Fig. A, Supported supine lying. Fig. B, Supported side lying. Patients generally prefer to have the whole leg The patient needs enough pillows to support the supported rather than just the knees. Any UEs. A body pillow frequently works well. The unsupported area becomes uncomfortable and patient should pull the support directly into the causes the patient to shift and wake. upper thigh and chest and then roll slightly onto it; he or she should not lie on the same side all night. ADJUSTABLE TILTING TABLE& WALKING AIDS  PROGRAM OF REHABILITATION POST OPERATIVE Phase 2(4-8 week)  Phase 2(4-8week) Phase2 (4-8week) 1-precaution No passive ROM of the spine 4-functional -Log rolling -Avoid rotatory movement & flexion of the spine activities -Lying may be side lying or supine &avoid lying prone to avoid hyper extension 2-ROM 1)Active ROM of U.L & L.L& all planes. 5-transfer -supine to sit 2) Shoulder shrugs -from bed to chair then the opposite with assistive 3) Scapular sets device 4) Over 90 degrees, self-assisted heel slips. 5) active extension of spine for stable compression fracture 3-strength -Isotonic exercise of U.L &L.L 6-ambulation -start with assistive device & with assistance ( strength push up muscles) -stair climbing started firstly with one step then step – -active back extensor strengthening& avoid para spinal over –step (Step height from 7-8 inches) muscles strengthening 1-Self-resisted exercises for muscles of the hip and knee. 2) Exercises using isometrics to target the Medius and maximus muscles. 3) Utilizing weight cuff and TheraBand, resistance workouts for hip flexion, extension, and abduction.SLR with weight cuff in supine and side-lying. -In cases of stable fracture: brace is removed during Personal -Start with elevated toilets seat To reduce flexion of ROM ex then weared hygiene: trunk at lumbar spine -But in patient with internal fixation no ROM -taking shower from standing no tube bath  Shoulder girdle depressions using a Seated push-ups Swiss ball. Patient depresses the shoulders Patient sits next to Swiss ball and places while maintaining straight elbows, elbow on the ball. Patient maintains a 90° thereby lifting the torso. Patient bend in the elbow while depressing the then slowly lowers torso, Scapular sets attempting to avoid excessive scapula to push the elbow down into the ball. Tis exercise is good for those who superior translation of the humeral cannot or should not perform seated head. push-ups with a plus (e.g., older patients).  Resisted SLR with weight cuff Figure. (B): Resisted SLR exercises with weight cuff in Figure. (A): Resisted SLR exercises with side-lying provided in weeks 7 and 8. weight cuff in supine provided in weeks 7 and 8.  Single-leg steps Single-leg steps are a good way to evaluate neuromuscular control and body posture  PROGRAM OF REHABILITATION POST OPERATIVE Phase3 (8-12 week)  PHASE 3:(8-12) ▪ Remove orthosis in patient with solid arthrodesis or fracture healing is obtained ▪ So if you observe fracture healing and solid arthrodesis begin strengthening and flexibility ex ▪ Neurologic deficits may occur once ROM ex have been started in patient with un recognized ligamentous injuries and non operative treated so you should do radiological assessment after discontinued brace ▪ Dynamic lateral radiograph in flexion and extension to rule out-residual spinal instability in patient with ligamentous injuries once fracture healing ▪ If instability noted: arthrodesis should be considered specially if the fracture site is painful or there is neurologic sign and symptoms  Phase 3(8-12 week) Phase 3(8-12week) 1- No passive ROM of the spine 4- May be prone in bed at the end of week 12 & precaution functional Independent bed mobility activities 2-ROM Active flexion-extension-lateral bending and rotatory 5-transfer movement allowed to the spine independent from bed to sit to stand 3-strength -start strengthening of para spinal M.S and trunk 6- -Stretching exercise: are allowed of muscle of the spine ambulation normal without assistive device unless there is a pain -Swimming helps to regain flexibility and strength EXAMPLES: 1)Trunk strengthening and paraspinal strengthening exercises. 2) Plank in prone 3) Pelvic bridging (Figure 4. A and B) WEIGHT 1)full weight bearing. BEARING 2) Single-leg stand Personal tube bath and standing shower are encouraged 3) Staircase Climb (By the end of 12 weeks) hygiene: Plank EXERCISE Plank in prone  Pelvic bridging EXERCISE double Pelvic bridging Single leg bridging. This exercise teaches the patient to brace the spine first, then lift the trunk as a unit. The patient is moving in and out of a hip hinge and emphasis is on coordinating the trunk and hip muscles.  Fig(A)Single knee to chest. Fig(B)Prone press-ups. Begin in hook lying position. Hug one knee to chest Begin in prone position with hands placed under shoulders. allowing pelvis to posteriorly tilt. Opposite knee can While maintaining chin tuck, push-up, promoting lumbar stay fixed in early phase of healing and can be spine extension. This exercise can be progressed with elbow progressed to knee extension. extension, therefore increasing lumbar spine extension.  Transversus abdominis strengthening Fig(B), Transversus abdominis and hip Fig(A), Transversus abdominis strengthening. dissociation. In hook lying, isometrically contract the transversus Contract the transversus abdominis in hook abdominis by drawing in your belly button. Make sure to lying with a neutral spine. Lift one leg of the maintain a neutral spine and not posteriorly tilt the pelvis ground 1 to 2 inches. Alternate legs. causing lumbar flexion. Normal breathing should also be Transversus abdominis contraction should be maintained maintained throughout concentric and eccentric movement of both legs.  Multifidus strengthening. multifidus muscular Multifidus strengthening. activation -The multifidus activation test is performed with the patient prone using the command, “Gently swell out your Stand with your hands resting on a table. Perform the muscles under my fingers without using your spine or abdominal draw-in maneuver and kick one leg back pelvis. slightly, making sure not to arch your back or twist your - Hold the contraction while breathing normally” This test pelvis. Repeat on other leg, and continue alternating includes both side-to-side and multiple-level comparisons legs. to assess for segmental activation or inhibition of the lumbar multifidi.  Abdominal bracing and supine marching are good exercises to begin strengthening the trunk. Abdominal bracing with marching. The patient creates an abdominal brace by isometrically contract the (TA, multifidi, and pelvic floor). It is important to remember to move the abdominals without moving the spine. While maintaining the brace, the patient slowly takes the weight of one foot (removing only as much weight from the foot as possible without allowing the hips to rotate or the spine to extend). Eventually the patient should be able to lift the leg up to 90° of hip flexion with the knee bent. The patient then alternates feet.  Quadrupled abdominal drawing in Quadrupled abdominal drawing in with tactile cueing by the therapist. Note: This is an excellent teaching position, but the patient must progress to more functional positions such as standing and half kneeling (most difficult because it removes the lower extremity contribution to stabilization)  Quadruped alternating opposite arm and leg lift. Quadruped alternating opposite arm and leg lift. While in quadruped, the patient can draw in the deep abdominal muscles to perform an isometric contraction. Holding this contraction the patient will slowly extend the opposite arm and leg while maintaining good pelvic and lumbar spine alignment. Before this exercise the patient should be able to perform this activity first with just opposite arm movements and second with just leg movements.  Supine/hook lying activities laying vertical on a foam roll Supine activities on foam roll. Lying on a foam roll provides opportunity to challenge the trunk muscles and improve motor control. Adding marching with bracing or arm movements can challenge the trunk and lower extremity’s ability to maintain balance on the foam roll. Because of the sensitivity of the incision site or more focused pressure from the foam roll on the middle of the spine, some patients may not tolerate this position.  Balance activities sitting on an exercise ball. Trunk or hip perturbations standing Before starting sitting exercises on an exercise ball, the patient must demonstrate proper posture and be Resisted trunk motions in standing. comfortable in this position. Here the therapist is adding perturbations to the The therapist might want to start with postural exercises shoulders or hips while the patient meets the resistance, in this position while making sure to avoid excessive maintaining good standing posture and alignment. This lumbar spine lordosis or slumped sitting. Arm or leg helps to activate stabilizing muscles. movements, single-leg balance activities, or resisted Tera- These activities should begin with very light force until Band activities could provide an adequate challenge to the patient demonstrates the ability to tolerate more. improve balance and motor control. Balance/proprioception exercise with wobble board.  Flexibility exercises Lumbar flexion stretch Hip flexor stretch From an all-fours position, the patient can gradually The patient kneels on one leg with the other spread the knees and sit back on the heels, allowing the leg in front, braces the spine, and gradually spine to relax and stretch. begins to shift weight forward to the front foot. The patient should feel a stretch in the groin area of the kneeling leg. The spine should not be extended.  Hip rotator stretch. Latissimus dorsi stretch. It is important to maintain Latissimus mobility as short or While lying on the back, the patient crosses the tight Latissimus may pull the lumbar spine into excessive ankle of one leg over the knee of the other leg. The lordosis with overhead arm movements. patient performs the stretch by pulling the knee and In supine, the patient should be cued to use abdominal ankle toward the chest. The patient should feel a muscles to avoid lumbar spine extension while stretching stretch deep in the back of the hip. the arms overhead.  Lat pull downs. Strengthening muscles that attach to the thoracodorsal fascia can help with improving overall trunk stability. Before using weight machines at the gym, it would be beneficial to use Tera-Bands and have the patient leaning against a supportive surface where they can use the appropriate muscles to adequately stabilize the spine.  Program of rehabilitation post operative Phase 4(12 -16 week) Phase 4(12-16 week) Phase 4 (12- 16week) 1-precaution -NO contact sport until at least 6 4-functional activities Gradually return to sports months 2-ROM -Continue active ROM for trunk 5-transfer and spine independent from bed to sit to stand 3-strength -Trunk strengthening and 6-ambulation normal without assistive flexibility exercises should device unless there is a pain continue Personal hygiene: independent  LONG TERM CONSIDERATIONS OF THE FRACTURE ▪ Posttraumatic deformity, such as kyphosis and lateral list, and degenerative changes , intractable pain, or neurologic deficit occurs, surgical stabilization and decompression should be considered. ▪ Malalignment such as "flat back syndrome" may produce pain and fatigue below the level of the fusion and require additional corrective surgery ▪ The patient may have a permanent loss of range of motion. The extent of this loss depends on the number of segments arthrodesed and the levels of fracture involvement. ▪ Instrumentation may need to be removed if it is painful. ▪ If pseudoarthrosis occurs, re-instrumentation and fusion may be necessary.