Thoracic Spine Compression FX

Thoracic Spinal Cord Compression Fx's commonly occur in the lower t-spine since the upper t-spine is stabilized by the rib cage attachments. Spinal cord compression fx's occur when the vertebral body of spinal cord collapse resulting in acute back pain that causes a decrease mobility and general health.

The most common motion that causes the vertebral body to collapse is a forward bend with downward pressure on the spinal column. Osteoporosis can also be a contributing factor to pts with t-spine compression fx's The osteoporotic t-spine can cause a pt's spine to form an exaggerated kyphotic curve of upper t-spine related to the back pain causing the shoulders to slump forward. Traumatic injuries such as an MVA, fall, or a forceful landing from a jump can all also cause t-spine compression fx's. Metastatic disease can also cause a t-spine compression fx. The spread of cancer to the vertebral body causes a weakening in the bony structure allowing a compression fx to present.

AP and Lateral radiographs are the best form of identifying t-spine compression fx's. This form of radiography is the best why to completely visualize the entire aspect of the vertebral body. Next, a multislice axial CT scan with reformats in the frontal and sagittal plane of the t-spine are useful to examine any pathology that may be affecting the spinal canal. MRI is used only in spinal cord compression fx pt's that have any resulting neurologic deficiencies. Lastly, an Nuclear Medicine bone scan may also be ordered to determine the age and nature of the t-spine compression fx.

Most t-spine compression fx are treated with pain medication, physical therapy, decreasing activity, bracing, and/or a form of surgical fixation.

Some t-spine compression fx may require the use of a vertebroplasty or kyphoplasty intervention. This procedure is done either in a surgical suite or in an interventional radiography suite. In a vertebroplasty, a medical grade cement is injected in the vertebral body at the site of the fx to stabilize the vertebrae in relieve pain. In a kyphoplasty, a balloon is inserted in the fx site in order to reinstate the original shape of the vertebral body, and then inject the medical grade cement into the vertebrae. This is also in efforts to rebuild the vertebral body to its original form and relieve pain.

http://www.csmc.edu/9466.html

http://emedicine.medscape.com/article/397896-overview

http://www.umm.edu/spinecenter/education/thoracic_compression_fractures.htm

JEFFERSON'S FX

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A Jefferson's FX is a result of a burst fracture to the closed ring of C1 (atlas). A Jefferson's FX most commonly results in at least 2 fractures of C1 because of the anatomical structure being a ring. These FX's often occur as a result of an axial loading impact to the skull.

There are three impact injuries that are responsible for the majority of all Jefferson FX's.

1-Diving into shallow water and hitting on head

2 -Hitting on head of roof of motor vehicle during an MVA

3 - Falls that result in landing on head

Depending on the injury, and the amount of impact on the head other additional injuries can accompany a Jefferson's FX.

1 - C2 FX

2 - Vertebral artery damage

3 - Cranial nerve defects in V, IX, X, and XI

4 - atlantooccipital dislocation

5 - transverse ligament fracture

Pt's who have a Jefferson's FX will present with neck pain, as a result of an injury. It is common for most all neck pain pt's to present with these symptoms; however, it is vital to rule out a Jefferson's FX promptly before any neurologically damage occurs as a result of an untreated Jefferson's FX. If a pt presents, and is positive for a Jefferson's FX and does have substantial neurological deficits. They will need to have a tracheostomy place to assist with respiratory needs.

Once a Jefferson's FX has been confirmed, and the severity of the FX has been decided, a

decision on the treatment that needs to take place is the next vital step for these patients

Depending on the severity of any additional symptoms in patients with Jefferson's FX, treatment then varies accordingly.

The first steps of treatment occur at the site of the injury. Airway, breathing, and circulation must first be assessed prior to moving the patient. If the airway and breathing are not working sufficiently - intubation must be performed without movement of the C-spine. At this point, it is also important to remember that these patients may have suffered a concussion or may be in shock and unable to report any neck pain. To be safe, it is a must to treat all patients as if there might be a spinal cord injury of some sort.

Next, cervical spine radiographs need to be performed in the ER. Usually this is a x-table lateral c-spine film to evaluate the alignment of the odontoid complex in relation to the remaining c-spine vertebra. This view is best to r/o any anterior dislocation. The odontoid view is also necessary to image to symmetry of the odontoid projection between the lateral masses of C2. If a lateral disruption overhangs the masses by more than 6.9mm a C1 FX is a established. Lastly, a CT may be used in addition to verify the Jefferson's FX with thin axial slices through the level of the base of the skull through C2. Angiography may also be needed to evaluate any vertebral vessel involvement.

The most common way to treat a Jefferson's FX is with a surgical fixation of a Halo collar and/or vest. This is the best way to provide for stable and reliable healing process. Depending on any other cervical spine resulting injuries, determines how/where the Halo/Vest will be fixated. The should be maintained safely in a structured stability collar until time of surgery. Traction is not recommended due to the risk of spinal cord damage. Once the patient is in the OR, it is vital to keep the neurological function of the patient monitored in order to verify that no additional injury has occurred. Post operatively, the patient will remain in the Halo for 8-12 weeks. They also should regularly be monitored with radiographs to verify the healing process.

http://emedicine.medscape.com/article/1263453-diagnosis

Vertebral Artery Dissection

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Vertebral Artery Disease(VAD) is the more common cause of strokes in patients under the age of 45. It is closely related to Coronary Artery disease, with the exception of the unique signs and symptoms. VAD is caused by an expanding hematoma in the vertebral artery vessel wall. It can arise spontaneously or as a secondary result of trauma.

In the United States, 20% of ischemic strokes in patients between 30-45 age years old are caused of VAD, and 10% of all VAD resulting in death. The common ratio of female to male is 3:1 with the presentation of VAD.

A typical presentation of a patient with VAD will present with:

Severe occipital heachache

Posterior nuchal pain

CNS dysfunction

Ipsilateral facial dysesthesia (pain and numbness) - Most common symptom
Dysarthria or hoarseness (cranial nerves [CN] IX and X)
Contralateral loss of pain and temperature sensation in the trunk and limbs
Ipsilateral loss of taste (nucleus and tractus solitarius)
Hiccups
Vertigo
Nausea and vomiting
Diplopia or oscillopsia (image movement experienced with head motion)
Dysphagia (CN IX and X)
Disequilibrium
Unilateral hearing loss

Contralateral weakness or paralysis (pyramidal tract)
Contralateral numbness (medial lemniscus)

Causes of VAD include either spontaneous or traumatic VAD. Causes of traumatic VAD include MVA, fall, or penetrating trauma. Several risk factors of Spontaneous VAD include:

Spinal manipulation
Yoga
Ceiling painting
Nose blowing
Minor neck trauma
Judo
Medical risk factors
Hypertension (48% in one series)
Oral contraceptive use
Chronic headache syndromes/migraines
Intrinsic vascular pathology
Fibromuscular dysplasia
Cystic medial necrosis
Female sex
Recent infection

Diagnosing VAD involves all of the following workup:

Lab work is done in anticipation of the need for anticoagulants. A PT, PTT, INR, and ESR are all blood levels that will need to be evaluated in order to safely administer any anticoagulants.

CT Scan, CTA, MRI, MRA, Ultrasound Vascular Duplex Scanning, Transcranial Dopler's, and LP's are all diagnostic imaging studies that vastly aid in the diagnosing and evaluation of possible VAD and the patients additional symptoms.

Once it is ruled that anticoagulants are safe to administer, it is the preferred method of treating VAD in the emergency room.. The anticoagulants are intended to prevent thrombogenic or embolic occlusion of the vertebrobasilar network and subsequent infarction of posterior CNS structures, brain stem, and cerebellum. All patient's first under go a CT scan of the head to rule out any subarachnoid hemorrhage. Additionally, once a VAD patient is deemed stable, a neurosurgery consult should be ordered.

http://emedicine.medscape.com/