[MUSIC] [MUSIC] The spine is divided into the cervical spine, thoracic spine, lumbar spine and the sacrum. Injuries to the cervical spine are categorised according to classifications of their own. The AO classification is applied to the other sections of the spine. Due to the similarities they share, fractures to the thoracic spine and the lumbar spine are dealt with first in what follows. In order to be able to understand the nature of the injury, it is helpful first of all to recall the basic principles of anatomy. It is important while doing this to take into account the movement segment. This consists of the anterior and posterior longitudinal ligament, the supraspinal ligament, the interspinal ligament and the ligamentum flavum as well as the intervertebral disc. The most frequent fractures of the spine occur in the thoracolumbal transition from T10, T11, T12 to L1, L2. The injury mechanism most frequently encountered is to be found either in a high speed trauma, fall from a great height, direct impact trauma or due to osteoporotic fractures. The Three Columns Model according to Denis has been proven to be a sound method for assessing the stability of spinal injuries. This consists of the anterior column: the anterior two thirds of the vertebral body together with the anulus fibrosus and the anterior longitudinal ligament, the central column, consisting of the posterior third of the vertebral bodies, the pedicle of the vertebral arch and the posterior longitudinal ligament as well as the posterior column: the vertebral arch, the joints and the interarticular ligaments. If an injury has been incurred by at least two columns, then the injury is assessed as being unstable. Hello. My name is Dr. Huber-Wagner. I am the trauma surgeon on duty. Can you tell me what happened? I fell out of the apple tree. My neighbour’s cat climbed up into it. It is always chasing the birds and then finds it does not know how to get down again and mewls all day long up there. So I climbed up into the tree. I usually feel very safe up there, but today I slipped and fell. I just had the wrong type of shoes on. I fell onto my back and, my goodness, does it hurt, so something must be wrong there. >> OK, so something's not right. - Ok. Ähm. Do you feel pain anywhere else, apart from in your back? >> No. But that is bad enough on its own! Did you fall on your head at all...? >> No, onto my back. >> So you landed squarely on your buttocks? >> Yes, about there in the middle, onto the spine. Ok. What do you estimate was the height you fell from? >> About 2 1/2 meters. >> About 2 1/2 meters, OK. Ok. Ähm. Are you taking any form of medication, Mr. Vogel? >> No, no. How old are you? >> 59. >> 59. Ok. Can you feel anything in your legs? Yes, yes. >> Can you move your legs alright? >> Yes, but I have not done so yet. >> I would now like to examine you. Let's have a look at your legs and back. Then, we’ll take an x-ray image and we’ll take things further after that, step-by-step, OK? Knowledge of the previous medical history is crucial for treating spinal injuries. Clinical examination should be conducted by means of inspection and palpitation. Functional testing is only permitted if any fractures have previously been excluded by x-ray examination. A neurological examination of the peripheries is very important in establishing that no neurological damage has been triggered by the spinal fractures. The previous history of the patient is, on the one hand, very important for the clinical examination of spinal injuries. Typical clinical symptoms are pains, movement disturbances and potential neurological deficits. This slide shows a clinical examination of healthy spinal movement. The finger-ground distance and segmental range of movement are important factors. This can be quantified for the lumbar spines using Schober’s Test and for the thoracic spine using Ott's test. Normal spinal movement encompasses lateral flexion of 40/0/40, rotation of 30/0/30 and inclination-reclination of approx. 250. Clinical-neurological examination is of the greatest importance in all cases of spinal injuries. To begin with, this consists of testing sensibility according to neurological characteristic lines and as derived from testing strength. In this process, the degree of strength is established in quantative terms by employing a scale of 0 - standing for complete loss of function - up to 5 - movement against maximum resistance. Knowledge of the segment-indicating reflexes is required in order to conduct a clinical-neurological examination. It is the case that varying degrees of severity of the injury can cause various injuries not to occur. The clinical-neurological examination should record any potential deficits along the dermatones which typically occur. It is of the greatest important for any clinical-neurological examination that any vesicorectal disturbances are excluded. It is important to conduct an examination focusing on saddle block anaesthesia. If you could just.... can you stretch your legs out a bit? I’ll uncover them first. >> Yes, but I then feel pain in my back. >> Try it once. OK, that’s all right. Close your eyes, please. Can you feel anything if I touch this spot here? >> Yes. Ok. Here? >> Yes. >> Here? >> Yes. >> Here? Yes. >> Can you feel anything on your side? >> Yes. >> Spüren Sie? >> Yes. - Yes. >> Here? Ok. Now let’s check how well you can move. Pull your big toe up to meet your face. >> Yes. >> Here, that’s OK. Very good. On the other side. That is still intact. And now press your foot downwards, against the resistance from me. - That’s good. - Here as well. >> That hurts. >> Okay. Pull upwards - pull, pull, pull. Ok. That’s fine. Press downwards, push against me. We’ll soon be finished. Lift the knee towards the ceiling, please. - Ok, three and four times more. The same lying on your side. Good. You have probably not yet urinated since having suffered the accident, have you? No. >> Ok. Then we need to take a separate look at that. Can I now please examine your abdomen? Does this hurt in your abdomen at all? >> No, in my back. >> Your back hurts. Can I have another look here, at your chest? - So your back is what hurts, is it? I would now like to feel your pulse. Blood pressure was OK. The nurses have just measured that. We’ll create an access site so that you can be given some pain relief. We then need to take an x-ray and conduct an ultrasound examination and we’ll then discuss how things will progress from there, if that is OK? Can you now please sit up for me? I would like to examine your back briefly from behind. I’ll help you a bit. Yes, upwards - great. - To begin with, if you could show me with your finger: where does it hurt most? OK, there at the back. >> About here. Everything understood. - Good. I’m now going to feel the pelvis briefly. That is level L4. - If I press here? - How about here? Is that where it hurts most? >> Yes. It hurts less there? Yes indeed. This is where it hurts most, therefore. I need to tap a little here. - Does that hurt at all? - >> [INAUDIBLE] >> Not so much, Ok. You can now slowly turn back. We’ll now conduct the ultrasound. If you could turn onto your side, first this way and then that way, and raise your legs. Right, Mr. Vogel, we’ll now make an ultrasonic examination of your abdomen. Everything is OK there, no cardiac tamponade. To repeat, everything fine so far. Let's now take a look at the liver, down here. Ok. That’s fine. Now let’s move towards the spleen. Could you please take a deep breath and [MUSIC] hold it in? The spleen is always a bit more difficult to view. OK. It can now be seen really well. I’ll now check for fluid, save the results and we’ll then take a look down here. As the bladder is full, you will feel this now, but there is no free fluid here either. Okay. Well, at least no abdominal injury has been incurred. Right, so we’ll now take the x-ray and then we’ll see where we go from there. Is that OK with you? I’ll see you again soon. Okay. >> Classification according to Magerl has been shown to provide the best way to identify the optimal form of treatment. This takes account of the primary injury mechanism. Within this, Type A injuries are compression injuries. Type B injuries involve compression-distraction forces, while Type C injuries involve additional rotation movements. Type A injuries are distinguished by axial forces with intact dorsal ligamentary structures. A1 fractures do not involve any posterior edges. A2 fractures are fissured fractures in the sagittal or frontal plane and A3 ones are bursting fractures with comminution of the vertebral body. These are often unstable with accompanying neurological symptoms caused by spinal cord compression. These slides show Type A injuries; on the left side Type A1 with impaction, in the middle, Type A2 with gap formation and on the right, Type A3 with bursting of the vertebral body. Type B injuries are characterised by injuries of the anterior and posterior spinal elements. Under this, B1 designates a laceration of the intervertebral joints, B2 a laceration through the vertebral arch and B3 a ventral laceration of the intervertebral disc. The left side of this slide shows a B1 injury with dorsal ligamentary laceration, in the middle, a B2 injury with dorsal osseous laceration and the right side a B3 injury with laceration of the intervertebral disc. This magnetic resonance imaging shows a typical B injury to the spine with laceration of both the ventral and also dorsal structures. This computerised tomogram shows the involvement of the posterior edge. What is clear is that any injury is associated with a danger being posed to the spinal cord. This can be narrowed by the osseous structures. Type C injuries are characterised by injuries of the anterior and posterior spinal elements with additional rotation component. These injuries are usually unstable and are accompanied by a high rate of neurological complications. This slide shows a Type C1 injury on the left side. This is made up of a Type A fracture with additional rotation. A Type C2 injury can be recognised in the middle. This is made up of a Type B fracture with additional rotation. A C3 injury is shown on the right side. This designates an additional rotation and shear of the spine. What is clear is that these injuries have a high degree of instability. These computerised tomograms show, for example, the surgical treatment of unstable spinal injuries. Surgical treatment provides for both dorsal and ventral stabilisation in accordance with the Three Columns Model. [MUSIC] [MUSIC] OK, Mr. Vogel, so now you have undergone an x-ray and also a CT. I have printed off the most important images so that I can explain things better to you in terms of the kind of injury you have sustained. To be precise, you have broken your first lumbar vertebra. This has been a major injury and there is also a bit of a bend in it as well. This has to be operated on in the course of treatment, OK? The spinal cord, however, is not affected. That’s the silver lining inside the cloud. Can you see it there? >> Yes. >> You are now looking at the x-ray image of the lumbar vertebrae from the side. You can see here the 5th., 4th., 3rd., 2nd. lumbar vertebrae and the 1st. is broken here in the form of bursting and in the form of a reduction in height. You can see it is shaped in a wedge form here and no longer matches the adjoining vertebral bodies in height. >> Yes. >> They are of normal height and this one is simply not pressed in correctly. This is what we call a compression fracture, a Type A fracture. If someone falls and lands in this area, then that is a very typical injury mechanism. The same can be seen here. That is the same as the view from the front if you look at it square on. You can see here as well that, compared with those adjoining it, it has reduced elevation, as we call it. The CT scan confirms everything. You can see again very clearly in this how that is pressed in and I’ll now show you a cross-section view of the broken lumbar vertebra. You can see here how it has really burst, but the good news is: back here is your spinal cord canal and we can see here that it is free and there is adequate space. And that is the really good news. >> It is important to assess the stability of the injury in order to provide the optimal form of treatment. It is recommended in this regard that the injury be classified according to the categorisation of Magerl. Type A fractures tend to be stable, while B and C fractures instead tend rather to be unstable. In principle, stable injuries can be treated non-operatively. An injury not involving the posterior edge, for example, is to be categorised as stable. Treatment then provides for mobilisation adapted according to the pain felt by the patient. A corset can be prescribed as an option. Potentially unstable injuries should be stabilised surgically. Dorsal stabilisation by means of fixateur interne is available to this end. If additional ventral instability is present, then this can be treated by means of plate, cage or span. A laminectomy should also be conducted in the case of compression of the spinal cord. Osteoporotic fractures can be treated by means of vertebro- or kyphoplasty. Dorsal stabilisation by means of fixateur interne provides for the straightening and stabilisation of the section affected. The indication is given for correspondingly unstable fractures of the spine. This photograph shows a typical dorsal stabilisation with pedicle screws joined by rods. Ventral stabilisation consists in the anterior column being reconstructed. This can be undertaken either by means of a bone chip, a rigid cage or nowadays by means of cages which can be expanded. The indication is given by the destruction of the ventral column. These x-ray images show the typical treatment of a spinal structure following dorsal stabilisation and supplementary ventral stabilisation by means of a cage. In the event of the spinal canal being narrowed by osseous fragments, a laminectomy should be conducted. This slide shows where the bone chips are removed on the anterior arch. Vertebroplasty involves the inserting of cement into the vertebral body under radiological supervision. Kyphoplasty means that the cement is inserted into a cavity created in advance. In practice, these days only kyphoplasty is still used. The indication is given by a painful osteoporotic fracture after non-operative treatment has proven to be non-effective. Let me summarise: Type A injuries can either be treated non-operatively or by means of dorsal stabilisation. Type B injuries frequently require dorsal and dorsoventral stabilisation and Type C injuries always require dorsoventral combination treatment. >> I now want to show you what kind of operation we would recommend for you. Care must be taken to ensure that this fracture does not heal in this wedge position, but rather that it is straightened again and heals at the right height and from behind here, that is to say from the rear direction. A special rod system can be applied, what we call a fixateur interne, which is used to straighten the fracture again well and which can retain it in this position. >> And will that then fully heal? >> After eight, nine, ten months, it all depends, that can be removed again and the segment can be released again. That is the procedure we would recommend. We’ll schedule everything for tomorrow and I’ll call in again afterwards. Okay, Mr. Vogel? then we'll see you again soon? Until then. Goodbye. >> Thank you. Goodbye. >> Cervical spine injuries. This slide repeats the basic anatomical principles of the upper cervical spine. In the top left corner, the first cervical vertebra, the atlas, can be recognised and in the lower left, the second cervical vertebra, the axis. The transverse ligament is important as this stabilises the dens axis in a backward position and so retains it in position. The typical accident mechanism is an impact injury of the skull, such as can occur, for example, with diving into shallow water. High speed automobile accidents can also result in acceleration injuries. [NOISE] In the case of injuries to the upper cervical spinal column, a distinction is made between atlanto-occiptal and atlanto-axial dissociations. Further distinctions are also made between atlas and dens fractures and traumatic spondylolisthesis. Unstable atlas fractures are combined injuries of the anterior and posterior ring structure with rupture of the transverse ligament. The mechanism is typically formed by axial compression. The way atlas fractures are treated depends on the degree of instability. If the injury is stable, it can be treated non-operatively. All unstable injuries should be treated surgically. The most frequent fracture of the upper cervical spine is a fracture of C2. This is then divided into a dens fracture and a vertebral arch fracture. Categorisation as dens fracture is undertaken according to Anderson and D’Alonzo. Type I fractures are fractures of the tips, Type II are fractures of the neck of the dens and Type III are dens corpus fractures. This computerised tomogram shows a Type III injury of the second vertebral body. Surgical stabilisation is shown on the right side. This computerised tomogram shows a Type II dens fracture. The lower images show surgical treatment by means of ventral plate and screw osteosynthesis. Type I and Type II stable injuries can in principle be treated non-operatively. Type II and unstable Type III injuries must be stabilised surgically. A Hang Man’s Fracture is a special form of C2/C3 injury. This is categorised according to Effendi and designates the degree of dislocation. Type I involves traumatic spondylolisthesis without dislocation, Type II covers dislocation without clear detachment and Type III is a clear dislocation with detachment of the posterior fragment. The left side of this x-ray image shows a typical form of treatment of a Hang Man's Fracture by means of plate osteosynthesis. Typical examples of the positioning of plate and screw osteosyntheses are shown on the right side. In summary, it can be said that spinal injuries frequently occur. The important thing is to exclude whether any appearances of neurological deficits are present. The optimal form of treatment to be applied depends on establishing the degree of stability. Stable A injuries can be treated non-operatively, unstable B and C injuries surgically. Many thanks for having listened so attentively. [MUSIC]