Spinal Trauma,

Orthopaedic Management and

Its Impact to Biomechanic Spine

Dr . dr . A h m a d R a m d a n , S p O T ( K ) . , M . K M
 Introduction

 Annually, 10.000 spinal trauma in US

 150.000-160.000  # vertebra
 Spinal trauma  Decreased QOL
 Short term and long term complication
 Spinal deformity after trauma  one of the biggest
challenge in spinal surgery
 Introduction

 Post traumatic spinal deformity  coronal and

sagittal compensation
 Sagittal plane malalignment  cause pain and
disability
 Positif sagittal imbalance  decreased of HRQOL
 Deformity of correction significantly improved QOL
 Fixed sagittal malalignment needs complex
procedure
 Epidemiology

 Incidence 3.2-5.3/ 100.000 spinal trauma in US

 2.6% from multiple trauma
 43%-46% is complete lesion
 55% at level cervical, 30% at thoracal, 15 % at lumbar
 40% complete lesion, 40% incomplete lesion, 20%
no spinal cord injury
 Epidemiology

 Bimodal prevalence  peak at age 15-24 y.o and >

50 y.o
 Improvement in trauma management and spinal
surgery  decrease spinal cord injury incidence
 Increasing survivor  increasing longterm
complication  increasing spinal deformity with
global sagittal imbalance
 Now, it needs more attention
Basic Science

Local Kyphotic
Deformity
Basic Science

Dennis three
collum concept
of spine
Basic Science

Mc Afee classification for

Vertebra fracture
 Post traumatic Spinal deformity

 Most case  kyphotic deformity leading to Positive

Global sagittal alignment  severity depend on type of
injury
 Flexion compression injury cause lokal kyphotic at
level injury, less in progression
 Severe burst fracture/ flexion distraction injury
 severe kyphotic deformity, more in progression
 Severe burst fracture/ lateral compression 
combination sagittal and coronal deformity (rare case)
 Post traumatic Spinal deformity

Another cause of spinal deformity after trauma

 Related to previous management: pseudoarthrosis,
implant failure, posterior approach only, short fusion
segment, history previous laminectomy, mal practice
 Not related to management: osteoporosis, Kummell’s
disease, Charcot vertebra
 Post Traumatic Spinal Deformity

Clinical Finding:
 Chief complain: deformity at back region, increasing
pain, neurological deficit
 History: multiple trauma involved vertebral fracture with
post conservative treatment, no treatment, mild injury
related osteoporosis, ankylosing spondylitis
 Determine deformity  fixed or flexible
 Identify compensatory mechanism  cervical kyphosis,
hip or knee flexion
 Basic Science

- Sagittal Balance + Sagittal Balance

Global Sagittal
Alignment (GSA) Plumb line
 Basic Science

-400 to – 800 (-600)

+200 to +500 ( +350)

Kyphotic and Lordotic Concept

Basic Science

Pelvic Parameter

Spinopelvic Harmony
PI = LL +/- 90
PI = PT + SS

Normal range
PI = 520 +/- 100
PT = 150 +/-70
SS = 300 +/-90
 Basic Science

Pelvic parameter SVA (sacral vertebral axis)

Basic Science

Sagittal Balance

The Dubousset cone

Economic Concept
Pelvic Compensation Manouver

Retroversion pelvic

PT increase
But PI constant
 Fixed Sagittal Imbalance

Based on
ability to hyperextending
segment above or below the
deformity

Type I Type II
 Impact of fixed sagittal imbalance

 Difficulty in maintain horizontal gaze

 Flexion contracture on hip and knee
 Increasing risk for falling
 Loss of physiological endurance due to increasing
muscle energy output
 Cause of Fixed Sagittal Imbalance

 Post Harrington distraction Instrumentation for

scoliosis
 Degenerative sagittal imbalance
 Post traumatic sagittal imbalance
 Ankylosing Spondylitis
 Regional Deformity

 Cervical kyphosis (CK): Kyphosis between (C0) and (Th1)

 Thoracic kyphosis (TK): Kyphosis between (Th1) and (Th12)
 Thoracolumbar junction kyphosis (TLJK): Kyphosis between
(Th11) and (L2).
 Lumbar kyphosis (LK): Kyphosis between (L1) and (S1).
 Lower lumbar kyphosis (LLK): Kyphosis between (L4) and
(S1).
 Pelvic kyphosis (PK): Flexion at the hip joints
Cervical kyphosis

a. Clinical picture,
b. standing whole spine radiograph showing
compensatory lumbar hyperlordosis,
c. detail of the cervical spine,
d. detail of the pelvis standing: increased pelvic
tilt is present, suggesting that the deformity
involves the whole spine and pelvis
 Sagittal Compensatory Mechanism

 Cervical hyperlordosis: Increased lordosis between the (C0) and

(Th1)
 Thoracic lordosis: Decreased kyphosis between (Th1) and (Th12)
 Lumbar hyperlordosis: Hyperlordosis between (L1) and (S1)
 Upper lumbar hyperlordosis (L1–L3): Hyperlordosis (L1) and (L4)
 Lower lumbar hyperlordosis (L4–S1): Hyperlordosis between (L4)
and (S1)
 Pelvic retroversion: Posterior rotation of the pelvis through
extension of the hips; can be identified by increased pelvic tilt
 Knee flexion: Flexion at the knees. Knee flexion can be identified by
femoral shaft inclination over 50 in the sagittal plane.
Pelvic kyphosis

• Insufficient lumbar lordosis (230) respect to

pelvic incidence (550) alters sagittal balance.
• Increased pelvic tilt that would be expected is
not present as a compensatory
mechanism (expected pelvic tilt is 140;
measured pelvic tilt is 100),
• resulting in abnormal translation of C7
plumbline (19 cm) without active
compensation.
• a Parkinson’s disease patient with resistance to
L-dopa and camptocormia (non traumatic
patient)
Lumbar khyposis

a. Clinical picture knee flexion as a compensatory

mechanism,
b. whole spine standing film shows all the
compensatory mechanisms: thoracic
lordosis, pelvic retroversion (showing as
increased pelvic tilt) and knee flexion
(presenting as femoral inclination).
Stage of Sagittal Imbalance
 Non operative treatment for Spinal Deformity

If asymptomatic:
 Physical therapy
 OAINS
 Lifestyle modification
 Operative treatment

Indication:
 Significant or progressive spinal deformity
 Increasing pain at back or lower extremity
 Spinal problem at level or lower of the deformity
 Pseudoarthrosis or malunion
 Neurological deficit
Objective for Correction Deformity
 Operative treatment

 Local kyphotic deformity ≥ 300  increasing risk of

local pain at area of deformity
 Flexible deformity  proper positioning, fusion
instrumentation
 Fixed deformity  proper positioning, osteotomy
Classification of Osteotomy for Spinal Deformity
Smith-Petersen Osteotomy
Pedicle Subtraction Osteotomy
 Operative Management

Post traumatic spinal deformity type I

 local kyphotic < 300, normal GSA  SPO

Post traumatic spinal deformity type II

 Local kyphotic < 300, SVA 2.5 – 5 cm  SPO
 Local kyphotic < 300, SVA > 5 cm  multiple SPO
 Local kyphotic > 300, SVA 2.5 -5 cm  SPO or PSO if at
thoracal, PSO if at lumbar
 Local kyphotic >300, SVA > 5 cm  PSO at any level
 Operative treatment

 SPO  correction -100

 PSO  correction -35-400
 Correction 30-35 0 Plumbline translate posteriorly
12-15 mm
 VCR  indication for combined deformity (coronal
and sagittal)
 VCR  correction 40-600
Algoritm based on character of deformity
Algoritm based of flexibility of spine
Comprehensive Management Sagittal Imbalance
 Complication

 High complication rate  37%

 Neurological deficit  17%
 Revision operation rate  35%
 Revision PSO rate  19%
 Incidence PJK  41%
 Outcome

Preoperative assessment
 40% collaps of body vertebra  bad outcome
 Operation time < 12 months  good outcome

Postoperative assessment
 78 % pain decreased significantly
Outcome

• 43-year-old
• Sustained multiple
proximal thoracic
compression #
• presented with thoracic
hyperkyphosis and pain
• treated with posterior
spinal fusion from T2 to
T11 using thoracic
pedicle screws
Outcome

• 14-year-old girl
• history a motor vehicle accident 1 year prior to
presentation and sustained an L2 Chance
fracture.
• previously treated with a TLSO for 6 months
• presented lately with significant segmental
kyphosis with compensatory hyperlordosis below
the level of injury.
• treated with posterior spinal fusion from L1 to L3
with a L2 pedicle subtraction osteotomy with
approximately 550 of correction and restoration
of normal sagittal contours
Outcome

• 23-year-old girl
• sustained a three-column compression/flexion-
distraction injury.
• treated previously with a combined anterior/posterior
spinal fusion from L1 to L3.
• postoperatively, she developed progressive spinal
deformity
• presented 18 years after her surgery with approximately
1050 lumbar kyphosis
• treated with a posterior spinal fusion from T10 to sacrum
with L2 pedicle subtraction osteotomy and a staged
anterior spinal fusion from T10 to sacrum with correction
of her deformity and restoration of normal sagittal
balance
Outcome

• the activity of the thoracic

extensor muscles and is key to
identify patients that can be
treated excluding of the fusion
area the mid- and high-thoracic
spine
• after selective fusion in the
lumbar spine
• achieves excellent balance with
reversal of compensatory
mechanisms
 Outcome

patient with L2 # causing thoracolumbar junction

kyphosis.
a. detail of the segmental deformity,
b. whole spine standing film, showing increased
lower lumbar lordosis and increased pelvic tilt as
compensatory mechanisms,
c. after correction of the regional deformity, lower
lumbar lordosis and pelvic tilt are normalized, C7
plumbline translates posteriorly, demonstrating
the global effect of the deformity
 Conclusion

 Spinal trauma related to QOL

 Short term and long term complication
 Spinal deformity  one of the biggest challenge in
Spine Surgery
 Post traumatic deformity with sagittal imbalance 
need advanced spinal surgery
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