Orthopaedics

1. SPINE INJURIES

2. OUTLINE
▪ Quick revision ofanatomy
▪ How to read Xray, CT Scan and MRI
▪ Types for spinefracture
▪ AO Classification
▪ Brief idea onmanagement

3. ANATOMY • 33 Vertebrae
• 24 are movable
- 7Cervical
❖ Atypical :1st, 2nd and 7th
cervical vertebrae
❖ Typical :3rd, 4th,5th and
6th cervical vertebrae

4. VERTEBRAE
CERVICAL
TYPI CAL CERVICAL VERTEBR AE
❖ Body: small and broader from
side to side than before
backward
❖ Vertebral foramen:Larger than
body, triangular in shape
❖ Bifid spinous process

5. ATYPICAL CERVICALVERTEBRAE
C1- Atlas
□ No body and no Spinous Process
□ Consists of anterior and posterior arches
and 2 lateralmasses
□ SuperiorArticular Facets are kidney
shaped

6. C2- Axis
□ The strongest cervicalvertebra
□ Odontoid process = Dens
□ Has two large, flat surface superior
articular facets
□ Has a large Bifid spinous process that can
be felt deep in the nuchal groove
C7
□ Characterized by general structure of
vertebra but has long spinous process
and notbifid
□ Large transverse process

8. CERVICAL X-RAY INTERPRETATION
❖ 3 standard views: Lateral, AP and Odontoid peg view (open mouth view)

9. Systemic Approach:
1.Coverage : All cervical vertebrae are visible
from the skull base until T1
2. Alignment: 4 longitudinallines
❖ Anterior Vertebral Line: line of theanterior
longitudinal ligament
❖ Posterior Vertebral Line: line ofthe
posterior longitudinal ligament
❖ Spinolaminal Line: line formed by the
anterior edge of the spinous processes
❖ Spinous Process Line
3. Bones: vertebral body height
4.Spacing: Discs and spinous process
(should be approximately equal in height)

12. 1. Alignment: by tracing the
anterior and posterior
margins of the vertebraeand
of the spinous process,
normal lumbar lordosis
2. Bones: vertebral body height,
outline of the bone/fracture /
bony erosion (lytic or
sclerotic)
3. Spacing: Disc should be equal
in height
4. Pedicle:look for widening or
displacement of the pedicle
(which indicative of burst
fracture),
THORACOLUMBAR XRAY

13. Anterior Column:
- Anterior half of vertebralbody
- Anterior part ofintervertebral
disk
- Anterior longitudinal ligament
Middle Column:
- Posterior half of vertebralbody
- Posterior part ofintervertebral
disk
- Posterior longitudinal ligament
Posterior Column:
- Pedicle
- Facet joints
- Posterior body arches
- Interspinous ligament
- Supraspinous ligament
🡪 Important to establish whetherthe
injury is stable or unstable
THREE COLUMN CONCEPT

14. 1. COMPRESSION FRACTURE
◼ Mechanism of injury: due to severe spinal flexion
◼ Traumatic /Non-traumatic
◼ Example: Fall from height on the heels or buttock
◼ Commonlyno neurological deficit

15. X-RAY FEATURES
✔ Reduce height of the
anterior vertebral body
✔ Anterior superior
endplate fracture of
vertebral body
✔ Wedge shape
appearance
✔ Posterior cortex intact

16. 2. BURST FRACTURE
❑ Mechanism due to severe axial compression may ‘explode’ the vertebral body,
❑ shattering the posterior part of vertebral body and extruding fragments of bone into the spinal
canal
❑ Example: fall from height in erect position, landing on the feet
❑ Usually unstable
❑ In cervical spine: this fracture commonly cause neurological deficit
❑ In thoracolumbar spine: this force rarely neurological deficit (due to wide canal at this level)

17. X-RAY FEATURES
- Both anterior and
middle column are
disrupted
- A large vertebral body
fragment is displaced
anteriorly
- Retropulsion of bone into

18. ❖ Widening of
the
interpedicular
distance
❖ Seen in 80%
of burst
fracture

19. JEFFERSON FRACTURE
▪ burst fracture of the atlas C1
▪ described as a four-part fracture with
double fractures through the anterior
and posterior arches
▪ Mechanism injury : Axial loading along
the axis of the cervical spine (diving
headfirst into shallow water)
▪ Radiographs will show asymmetry in
the odontoid view
▪ treated conservatively (hard collar
immobilization)

20. HANGMAN FRACTURE
▪ known as a hyperextension injury causing bilateral
pedicular fracture of C2
▪ most common symptom : neck pain following a fall
or motor vehicle accident
▪ can be very unstable
▪ leading to increasing deformity that can result in
serious damage to the spinal cord or progressive
pain.
▪ Younger age group average
▪ Tx :immobilization and surgical intervention

21. CHANCE FRACTURE
❖ Also known as Flexion-Distraction
❖ Mechanism of injury: combined flexion and posterior distraction ( seen typically in severe
seat belt injuries)
❖ It is an unstable injury because posterior and middle columns fail under tension and
anterior column fails under compression
❖ Associated injury with GI injuries
❖ MRI to evaluate injury of posterior elements

24. HOWTO READASPINECT:
ABCS
- CT is often used to image fractures, ligament injuries
and dislocations
1. Adequacy of image and alignment
Assess spinal alignment on the scout and midsagittal
images. The normal lumbar spine has a smooth
lordosis. Relative lumbar kyphosis may be due to
degenerative disc disease or anterior vertebral collapse

25. Kyphosis due to vertebral collapse of L3

27. 2. Bone
-Review each vertebral body in the bone window,
scrolling down the vertebral column
- Look for changes in bone density.
-midsagittal views, ensure the vertebral body is square
and of similar height to the adjacent vertebrae
3. Cartilage
-ensure that there is no loss of disc height, as
compared with adjacent levels, and look for endplate
fractures or abnormalities
-Further MRI can be requested if there is any clinical
suspicion.

28. 4. Soft tissue and spinal canal
- Look in the spinal canal, particularly in the axial and
sagittal views, to detect any abnormalities such as
retropulsed bone fragments from burst fractures
Burst fracture with
retropulsion into the
spinal canal. Spinal cord
injury should be
suspected and further
imaging such as magnetic
resonance imaging may
be required.

29. HOW TO READ MRI SPINE
There are two basic types of MRI images which differ by the timing of the
radiofrequency pulses, named T1-weighted images and T2-weighted images. T1
images highlight FATty tissue.T2 images highlight FAT ANDWATER within tissues.

32. Left: MRI lumbarspine sagittal T1
image, Right:MRI lumbarspine
sagittalT2

33. 1. The Central Canal in the MRILumbar
Spine

34. 2. Vertebral
body

35. 3.
Alignment

36. 4. Intervertebral
Discs

38. Axial views

39. AO Classification
◼Spine thoracolumbar classification system consists of only three classes
of thoracolumbar injuries.

41. •A0: no or clinically insignificant fractures of the
spinous or transverse processes
•A1: also known as wedge compression injuries;
they involve a single anterior or middle endplate
of the vertebral body without the involvement of
the posterior aspect
Type A Compression
Injury

42. •A2: also known as split or pincer type injuries;
they involve both endplates without the
involvement of the posterior wall
•A3: also known as incomplete burst injuries;
they involve a single end plate along with the
posterior vertebral wall; a vertical laminar
fracture is usually also present (insufficient to
qualify as a tension band failure)
•A4: also known as complete burst injuries; they
involve both end plates along with the posterior
vertebral wall and are also often associated with
a laminar fracture (insufficient to qualify as a
tension band failure)

43. B type : Distraction
Injuries
•B1: also known as Chance fractures or pure
transosseous tension band disruption; they
disrupt the pedicles and spinous process in a
single vertebral level; a distracted horizontal
fracture through the vertebral body is often but not
necessarily present
•B2: also known as osseoligamentous posterior
tension band disruption; they involve an
intervertebral body level with disruption to the
posterior tension band ligaments with or without
involving the posterior bones; a type A fracture is
often present and should be specified separately

45. Type C injuries involve displacement in any
direction. No subtypes are present as there are
numerous possibilities of dislocating fractures.

46. Manageme
nt

47. • The TLICS consists of three independent parameters:
• The integrity of the posterior ligamentous complex plays an important role in the TLICS.

48. Management of spinal
injuries
• Objective:
– Preserve neurological function
– Relieve neural compression
– Restore the spine alignment
– Stabilize the spine
– Rehabiitate the patient
• Indication for urgent surgical stabilization
– Unstable fracture with neuro deficit
– Unstable fracture in patient with multiple
injuries

49. Burst
fracture
Non operative
- Ambulation as tolerated with or
without thoracolumbosacral orthosis
Indications
•patients that are neurologically intact
and mechanically stable
•posterior ligament complex preserved
•vertebral body has lost < 50% of body
height
•TLICS score = 3 or lower

50. Burst
fracture
Operative
Surgical decompression & spinal stabilization
Indications
• neurologic deficits with radiographic evidence of
cord/thecal sac compression
• unstable fracture pattern as defined by
– injury to the Posterior Ligament Complex (PLC)
– progressive kyphosis
• TLICS score = 5 or higher

51. Chance
fracture
• Non operative
– Immobilization in cast or TLSO
• Neurologically intact patient with
– Stable injury patterns with intact posterior elements
– Bony chance fracture
• Operative
– Surgical decompression and stabilization
• Pt with neurologic deficit
• Unstable spine with injury to the posterior ligament (soft tissue –
Chance fracture)

52. Compression
fracture
• Non operative
– Observation, bracing and medical
management
• PLL intact even if >30 degrees kyphosis or >50%
loss of vertebral body height

53. Compression
fracture
• Operative
– Vertebroplasty
– Kyphoplasty
• Patient continue to have severe pain symptoms after 6
weeks of non operative treatment
– Surgical decompression and stabilization
• Progressive neurologic deficit
• PLL injury and unstable spine

54. Take Home
Message
-Dont forget regarding line on spine Xray
-MRI T1 FATT2 FAT WATER
-Column concept
-TLICS score 4 and more surgical
intervention

55. Referenc
es
https://www.radiologymasterclass.co.uk/tutorials/m
ri
/t1_and_t2_images
https://aospine.aofoundation.org/clinical-library-
and-t ools/ao-spine-classification-systems

56. Thank
You