DISLOCATION AND MANAGEMENT OF DISLOCATION OF VERTEBRAL COLUMN,

TUMORS OF VERTEBRAL COLUMN, TUMORS OF SPINAL CORD

Dislocation and management of vertebral column: The unique anatomy of

the thoracolumbar junction predisposes this level of the spinal column
to dislocation fractures. As the thoracic spine loses its structural rigidity
with floating ribs at T11 and T12, the orientation of the facet joints also
changes from a more frontal projection to oblique and then sagittal in
the upper lumbar spine. These spinal dislocation fractures result from
violent traumatic injuries and are associated with a very high incidence
of neurologic deficit resulting from the translation of the spine.

Approximately 90% of dislocations above T10 result in complete

paraplegia, and 60% of dislocations below T10 result in complete
neurologic deficit. The spinal cord ends at the L1-2 level in most adults;
the cauda equina represents the terminal nerve roots of the lumbosacral
spine present below this site. The prognosis for a pure nerve-root injury
is much better than for an actual spinal-cord injury. In some of these
injuries, spinal-cord injury and nerve-root damage are combined.

Of the injuries affecting the thoracolumbar spine, dislocation fractures

are the most unstable. Involvement of all three spinal columns generally
necessitates operative intervention to stabilize the spine and optimize
neurologic recovery and patient rehabilitation.

Causes: The most frequent causes of spinal-column injuries are motor

vehicle accidents, falls from heights, sports-related injuries, and acts of
violence.

Surgical Management: Fracture dislocations are associated with the

highest incidence of neurologic injury. In individuals with incomplete or
normal neurologic examination findings, the spinal injury has still
resulted in significant instability. To allow early mobilization and afford
the chance for neurologic improvement, surgical management is almost
always indicated. Closed reduction of these injuries is quite difficult.
Dislocation fractures can be managed via an entirely posterior approach.
Reduction of the misalignment results in spinal-canal clearance in most
individuals. Significant residual compression can be addressed through
an anterior approach either in a staged manner or on the same day,
depending on the circumstances. In transpedicular bone grafting
approach the defect created by the reduction is filled with autologous
bone.

Indications of surgery: The usual indications for surgical reconstruction

include loss of mechanical stability and neurologic compromise.

Long term monitoring: The sutures generally can be removed after

approximately 10 days, and rehabilitation can be initiated as soon as the
general medical condition of the patient allows. Arthrodesis progresses
over a 3- to 6-month period, and serial radiographs should be obtained
to assess the alignment and progressive union of the bone grafting.
Bracing (artificial external device serving to support the spine or to
prevent or assist relative movement) usually involving a removable
thoracolumbosacral orthosis (TLSO) is employed for 3-6 months.

Medical management: Pain killers such as NSAIDS, Opiates (used with

precaution, may precipitate urinary retention), Systemic Corticosteroids
in compressive neurological comprise due to dislocation of vertebra to
prevent early disabilities or minimize disabilities, Symptomatic care in
paralysis or paresis e.g. Anticholinergic for urinary retention and
constipation, & intermittent urinary catheterization are some aspects of
medical management. In individuals who are paraplegic, close attention
must be paid to skin pressure and potential breakdown
(decubitus ulcers). Physiotherapy and occupational therapy programs
must be started.

Tumors of spinal cord: Spinal tumors are neoplasms located in the spinal
cord. Extradural tumors are more common than intradural neoplasms.
Depending on their location, the spinal cord tumors can be: Extradural -
outside the Dura mater lining (most common), Intradural - part of the
Dura, Intramedullary - inside the spinal cord, Extra medullary- inside
the Dura, but outside the spinal cord.

Symptoms: Pain is the most common symptom at presentation.[1] The

symptoms seen are due to spinal nerve compression and weakening of
the vertebral structure. Incontinence and decreased sensitivity in the
saddle area (buttocks) are generally considered warning signs of spinal
cord compression by the tumor. Other symptoms of spinal cord
compression include lower extremity weakness, sensory loss, numbness
in hands and legs and rapid onset paralysis.

Diagnosis: MRI and bone scanning are used for diagnostic purposes.

Classification: Extradural tumors are mostly metastases from primary

cancers elsewhere (commonly breast, prostate and lung cancer).
Intradural tumors can be classified as intramedullary (within the spinal
parenchyma) or extra medullary (within the Dura, but outside the spinal
parenchyma). Extra medullary tumors are more common than
Intramedullary tumors. Common extra medullary tumors include
meningiomas, schwannomas, extra medullary ependymomas,
haemangioblastomas, while intramedullary tumors include
astrocytomas and intramedullary ependymomas.

Treatment: Steroids (e.g. corticosteroids may be administered if there is

evidence of spinal cord compression. Radiotherapy may be administered
to patients with malignant tumors. Surgery is sometimes possible. Extra
medullary tumors are more amenable to resection than intramedullary
tumors. The combination of minimally invasive surgery and radiation or
chemotherapy is a new technique for treating spinal tumors. Some
suggest that direct decompressive surgery combined with postoperative
radiotherapy; provide better outcomes than treatment with
radiotherapy alone for patients with spinal cord compression due to
metastatic cancer.

Tumors of vertebral column: A vertebral tumor is a type of spinal tumor

affecting the bones or vertebrae of the spine. Whether cancerous or not,
a vertebral tumor can be life-threatening and cause permanent
disability. Vertebral tumors are also known as extradural tumors
because they occur outside the spinal cord itself.

Symptoms: A vertebral tumor can affect neurological function by pushing

on the spinal cord or nerve roots nearby. As these tumors grow within
the bone, they may also cause pain, vertebral fractures or spinal
instability. Although the original (primary) cancer is usually diagnosed
before back problems develop, back pain may be the first symptom of
disease in people with metastatic vertebral tumors.

Classification: Vertebral Column Tumors include Primary tumors: These

tumors occur in the vertebral column, and grow either from the bone or
disc elements of the spine such as chordoma, chondrosarcoma,
osteosarcoma, plasmacytoma and Ewing's sarcoma. Tumors that begin
in the bones of the spine (primary tumors) are far less common .They
typically occurring in younger adults. Osteogenic sarcoma
(osteosarcoma) is the most common malignant bone tumor. Vertebral
column tumors also include secondary tumors that have often spread
(metastasized) from cancers in other parts of the body e.g. prostate,
breast, lung or kidney. Multiple myeloma is a type of cancer that often
metastasizes to the spine.
Treatment: There are many treatment options for vertebral tumors,
including surgery, radiation therapy, chemotherapy, medications or
sometimes just monitoring the tumor.