Lülisamba traumaatiline vigastus (TLICS) 5. veebr Erki Parri
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1 Lülisamba traumaatiline vigastus (TLICS) Erki Parri 5. veebr. 2014
2 ThoracolumbarInjuryClassification and SeverityScore( TLICS) Eelnevatel klassifikatsiooni süst. on piiratud prognostiline väärtus Kirurgilise ravi vajadus? TLICS puhul hinnatakse Vigastuse morfoloogiat Post. lig. kompleksi (PLK) vigastust Pt. neuroloogilist staatust Igale kategooriale antakse arvuline väärtus ning mida suurem on arv-väärtus, seda raskem vigastus
3 Denise klassifikatsioon 3 samba klassifikatsioon Vigastuse morf. ja mehhanism 2 samba või keskmise samba vigastus-> ebastabiilne Kahe samba vigastust intaktseplk korral saab ravida konservatiivselt- ebastabiilsus? Denise klassif. ei anna prognostilist infot ega arvesta pt. neuroloogilist staatust
4 AO klassifikatsioon Jaotab vigastused 3 gruppi A-kompressioon; B-distraktsioon; C-translatsioon/ rotatsioon Igal grupil kuni 9 alagruppi Murru lokalisatsioon, morfoloogia, luu-ligamentide haaratus ning nihe A -> C vigastus ja ebastabiilsus süvenevad Hinnatakse pehmete kudede haaratust! Detailne klassifikatsioon-hindajate vaheline varieeruvus on piiratud! Pt. neuroloogiline staatus?
5 AO klassifikatsioon
6 TLICS 3 vigastuse kategooriat Vigastuse morfoloogia PLK intaktsus Pt. neuroloogiline staatus Igal kategoorial on alagrupid, millel arvuline väärtus
7 Vigastuse morfoloogia Kompresioonfraktuur 1 punkt (p) Purustusfraktuur/ kompresioonfraktuur, millel koronaartasapinnal> 15 deformatsiooni 2p Translatsioon/ rotatsioon murrud ( proc. spinosuste rotatsioon, fassettide fraktuurdislokatsioon, lülikeha subluksatsioon) 3 p Distraktsioonfraktuur 4p Mitu vigastuse morf. -> suurima skooriga vigastus Iga vigastust hinnatakse igal kõrgusel eraldi
8 Vigastuse morfoloogia
9 PLK intaktsus PLK takistab liigset flektsiooni, rotatsiooni, translatsiooni ning distraktsiooni TLICS rõhutab PLK intaktsust PLK vigastus vajab tavaliselt op.-i Opereerimata küfoos võib süveneda, millele võib järgneda lülikeha madaldumine PLK intaktus Intakne 0p Ei ole hinnatav(määramatu) 2p Vigastatud 3p
10 PLK intaktsus Viited rö-grammil ja KT-uuringul Proc. spinosuste vahelise kauguse suurenemine Proc. spinosuste avulsioonfraktuurid Fassett- liigesvahemike laienemine Nn. empty facet joint Fassett- liigese dislokatsioon lülikeha translatsioon või rotatsioon
11 Viited PLK vigastusele Empty facet sign
12 PLK intaktsus MRT on standard PLK hindamiseks Lig. flavumja lig.supraspinatust1-s ja T2-s madala signaaliga ( hinnata sagitaaltasapinnas) Lig. interspinosustehindamiseks STIR või T2-FAT SAT ( samuti sagitaaltasapinnas) AksiaalsedT2 FAT SAT fassett-kapsli turse/vedeliku hindamiseks Turset sidemete katkemiseta loetakse mittehinnatavaks ja annab 2p
13 PLK intaktsus Varasemalt täheldati PLK vigastuse ülehindamist MRT-s võrreldes op. leiuga VaccaroAR, Lee Jy, SchweitzerKM jr et al; SpineJ 2006 Väljendunud lülikeha vigastusega võib esineda vähene risk PLK vigastusele ning vastupidi MRT PLK hindamiseks sens. 91%, spets. 100% ning täpsus 100% Pizones J, Sanchez- Mariscal F; Spine 2012 Olenemata lülikeha vigastuse raskusastmest ning kui plaanitakse konservatiivset ravi (neurol. leiu puudumisel) on PLK intaktsust vaja hinnata MRTs RadcliffK, Kepler CK, RubinTA, et al; J NeurosurgSpine 2012
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15 Neuroloogiline staatus Jaotatakse grupidessearvestades neurol. leiu raskust ja pt.taastumise potentsiaali Neuroloogilise leiuta 0p Närvijuure vigastus või täielik seljaaju vigastus 2p Cauda equina s.,mittetäielik seljaaju vigastus 3p Kõige suurem potentsiaalne kasu kirurgilisest dekompressioonist
16 Lülikehade madaldumine ning spinaalkanali kitsenemine peaks olema väljendatud %-des a= (1-x/y)*100 a= spinaalkanali kitsenemine % x= spinaalkanali sagitaalne laius vigastuse kohal Y= spinaalkanalikeskmine laius lülikeha võrra kõrgemal ja madalamal
17 TLICS ja ravikäsitlus Mehhaniline stabiilsus- vigastuse morfoloogia Pikaajaline stabiilsus- PLK intaktsus Neuroloogiline stabiilsus- neurol. leid +/- TLICS skoor aitab hinnata vigastuse raskust ning abistab raviotsuste langetamisel
18 Radioloogi vastus Murru morfoloogia Lülikeha madaldumine %, nihe, spinaalkanali ahenemine % PLK vigastus (viited sellele) Epiduraalsed hematoomid, diskide vigastus jm Üldjuhul radioloogi vastus ei sisalda TLICS skoori kuna puudub info pt. neuroloogilise staatuse kohta
19 KT kontrollnimekiri
20 MRT kontrollnimekiri
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24 Kasutatud kirjandus Problem Solving in Neuroradiology; Elsevier 2011 Traumatic Thoracolumbar Spine Injuries: What the SpineSurgeonWantstoKnow; Radiographics2013, A Review of Thoracolumbar Spine Fracture Classifications; JournalofOrthopaedicsand Trauma; 2011 Does the load-sharing classification predict ligamentousinjury, neurologicalinjuryand theneed for surgery in patients with thoracolumar burst fractures; Journal of Neurosurgery: Spine; 2012
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