Fracture of thoracic & lumbar spine. Diagnostics & Therapy
Treatment of injuries of the thoracic and lumbar spine.
Many of the torso spine injuries can be conservatively treated, that is, treated without surgery, so long as an instability and thus the risk of developing deformities and failures of the nerves can be excluded. More severe injuries, for example, with dislocation or destruction of individual vertebrae (such as, a fracture) must be treated surgically. The former and usual practice of treating such injuries with weeks or months of bed rest is now regarded as obsolete.
With the advances of modern spinal surgery the most severe injuries can be corrected and stabilised so that early mobilisation is possible without a corset. We use the strong vertebral arches and vertebral body described above to anchor screws inserted from the rear into the thoracic spine and lumbar spine. Here, it is also no longer necessary in all cases to expose large areas of the spine. The screws and links are inserted through small skin incisions and connected with each other under the skin and muscles. By moving the screws on the connecting rods and changing the angle of the screws the vertebral fracture can be straightened and then stabilised.
Diagnostics & treatment of middle & lower spinal fracures.
Diagnostics. Detection of spinal fractures
How are spinal injuries (such as a break) identified?
Conventional X-rays on two planes give an indication. Injury criteria are:
Difficult diagnosis by superposition of the thoracic spine.
As the upper thoracic spine is superimposed through the breast bone in the anteroposterior projection, that is, in the examination from front to back, and through the shoulders, ribs and the lung in a lateral projection, it is difficult to assess this section, especially in osteoporosis.
For further diagnosis, CT or MRI are added.
If the signs of injury listed here are present, then the suspicious section of the spine must be further clarified using computer tomography. Magnetic resonance imaging (MRI) is indicated for the diagnosis of a disc-instability as well as neurological failures without conventional detectable signs of injury of the spine.
Diagnostics of the transition from thoracic to lumbar spine.
The area of transition from the chest to the lumbar spine (thoracolumbar transition) is only marginally shown on conventional X-rays of the thoracic and lumbar spine. Over or underexposure as a result of the various tissue thicknesses of the breast and abdomen also make it difficult to assess. For a proper assessment, a focused picture of the lumbar-thoracic transition area is therefore essential. In addition to the known direct and indirect fracture signs, there is also an unclear structure here and a boundary line of the psoas edge as indirect signs of injury of the lumbar spine, which is due to a hemorrhage in the muscle.
The psoas muscle is a very powerful muscle that lies on both sides of the lumbar spine and goes down to the thigh bone: A strong hip flexor. As in the other sections of the spine, a detailed ultrasound scan/diagnostic is done by computer tomography. Other diagnostic measures such as MRI and bone scintigraphy, remain subject to particular questions.
Surgery. Operative treatment of spinal fractures
Restoring the ability to bear loads.
4/5 of the weight of the human body is carried by the front-lying vertebrae. If there is an injury causing one or more vertebrae to be destroyed, as is the case when a fracture occurs, then these need to be surgically rebuilt. Here, the injured parts of the vertebrae and the intervertebral disc are removed and replaced. According to conventional technique, the chest or the abdomen must be opened and extended, and not infrequently both body cavities, was required for this procedure. Accessing the spine has long been considered the most difficult and stressful intervention for the patients, which is also often associated with pain and functional impairment long after the operation. For this reason, it was necessary to develop and deploy an endoscopic procedure for the treatment of spinal injuries.
Use of plastic sleeves.
The principle is based on the use of four plastic sleeves, which are each inserted into the chest through a large 1.5 -2 cm incision between the ribs. A high resolution camera lens is introduced through one of the sleeves and with the help of this, the entire operation inside the body is transmitted to two monitors in the operating theatre. The other 3 sleeves are used the careful introduction of surgical instruments, such as an ultrasonic knife for example. To improve visibility in the chest cavity, the lung on the affected side is disconnected from the ventilator for the duration of the operation. The strong chest cavity serves as a naturally created surgical cave during the procedure, so that the operation can be performed in an low-pressure environment without the use of a gas.
Release of the spinal cord.
Pliers, high frequency fraises and punches, specially developed for this technique can then be used to remove the broken portions of the vertebral body and intervertebral discs. Not infrequently, the force of the accident mechanism, has also resulted in a partial or complete dislocation of the spinal canal with formation of paralysis and failure of nerves. It is now possible endoscopically to gently remove these bone fragments from the canal in order to relieve the spinal cord and thus creating the best possible conditions for the hoped reduction in paralysis and loss of sensation.
Using the titanium basket.
As a replacement for a broken vertebra and disc, a titanium cage, filled with bone substance from the patients own body or a bone graft is used in the defective area of the spine. A titanium plate, specially developed for this process, is anchored into the spine with screws to improve stability further.
Advantages of endoscopy: Fast recovery after surgery.
Ongoing investigations have not only proven a significantly lower blood loss during surgery, but above all, a positive influence on the intensity of pain after surgery. These effects were reflected in a rapid recovery of patients with the possibility of early mobilisation. So patients can and should be able to get up on the first day after surgery without experiencing injury-related paralysis. A pleasant side effect for patients is that the scars are small and after a few weeks barely visible.
The use of navigation systems.
If operations depend on the utmost precision, all procedures shown above can now be carried out using a navigation system. Image data of the injured spine acquired preoperatively, i.e. before surgery, can be compared with data recorded during the operation, either by radiography or manual sensing of the prominent structures. The spine is then depicted to the surgeon as a three-dimensional model, in which they can control, for example, the direction of drilling, as well as the length and direction of screws in all planes and correct them if necessary.
Rehabilitation after injuries to the spine.
Thanks to the advances in spinal surgery and modern rehabilitation processes, a spinal injury represents a fateful turning point in the lives of only a portion of the injured, namely, for those who have suffered paralysis or other serious loss of function. Depending on the extent of dislocation of the spinal canal, this results in paralysis due to the compression of the spinal cord or nerve bundle.
If we are successful in freeing the cord from the pressure in the shortest possible time, a recovery of nerve function is possible. In the follow-up treatment, for both groups of patients - with and without neurological deficit - we can build on the fact that in the area of injury after conservative or surgical therapy, stable conditions exist that allow functional physiotherapy and occupational therapy to take place very early. In most cases, rehabilitation can begin as early as the 1st day after surgery.
Reintegration into the work force.
In patients without neurological deficit, reintegration into the original active life stands very much in the foreground. This is dependent, in varying degrees, on the original work carried out. A carpenter, who, as a result of a fall from the roof, experiences a comminuted fracture of the 1st lumbar, even today, despite the use of advanced minimally invasive procedures to stabilise and reconstruct the spine, is hardly in a position to carry out his profession - connected with severe physical stress – competitively over a long period of time, and will - if he is young enough - have to retrain.
In professions involving mild or moderate physical stress, it is far cheaper, we when look across the board of occupations, to take into account a rehabilitation rate of about 80% after spinal injury. In the German speaking area, we expect the average duration of 8 to 12 weeks until a return to work. In North America, it is only days or up to a few weeks.
Restoration of independence after a paralysis.
Depending on the level of paralysis, the primary objective of rehabilitation of an injured person with paralysis is the restoration of independence. Day-to-day activities must be relearned and adjusted for the new conditions. These include, learning to use a wheelchair and moving from bed to wheelchair. The catheters of the urinary bladder and the emptying of the intestines are new requirements that arise from the paralysis of the bladder and rectum.
Even in Germany and Switzerland, whose treatment centres are also international world leaders, many months can pass from being discharged from rehabilitation to being taken back home. The average paraplegic needs life-long post-care, in order to detect typical complications such as urinary tract infections and bed ulcers early. In comparison to 100 years ago where 80-90% of the average paraplegics died early after their injury due to complications that were directly connected to these issues, paralysed patients today can count on a nearly normal life expectancy. Depending on the paralysis picture, the reintegration into working life should always be sought in order to also stabilise the patient's social environment.
Outlook and summary.
Significant advances in the treatment of vertebral lesions can be expected from materials that act as substitutes for bone and disc tissue are introduced into the injured area to replace the body's own tissue and promote the healing of fractures. Here quite a few things can be expected, from the use of bone growth hormones and factors as well as by the use of so-called bio-absorbable or bioactive substances. Most current methods still lead to a stiffening of individual sections of the spine with the aim of restoring the capacity. Perhaps here, the real future lies in a vertebral body replacement where the damping function of the intervertebral discs can be integrated. The further development of navigation systems will make it easier to manage and improve the accuracy of spine surgery and thus guarantee safety. New pharmacological approaches in the treatment of paraplegia after spinal cord injury also gives us some hope. Some studies show a positive effect on the recovery of nerve functions by applying scar inhibiting techniques or factors stimulating nerve growth and stem cells.
Thoracic & lumbar spine fracture
Most of the about six thousand serious injuries of the spine each year in Germany affect the thoracic and lumbar sections of the spine.
Here you can find our specialized clinics for fractures of the thoracic and lumbar spine and the treatment of back pain. We're glad to help you!