Lumbosacral Spine Acute Bony Injuries Treatment & Management
- Author: Federico C Vinas, MD; Chief Editor: Sherwin SW Ho, MD more...
Once the spine in a lumbar spine injury is stabilized, physical therapy is initiated with the goals of early mobilization, patient and family education (ie, therapeutic exercises, proper body mechanics, precautions), and neuromuscular reeducation.
A physical therapist evaluates range of motion, strength, sensation, bed mobility, balance in sitting and standing, transfers, and ambulation. The goal of physical therapy is to promote independent and safety in ambulation and functional mobility. If a patient reaches the above goals, discharge home with further therapy is recommended. Appropriate equipment is issued once the patient is safe and independent with the necessary equipment such as a cane, walker, or crutches.
Occupational therapy is initiated once the spine is stabilized. The purpose of occupational therapy at this early stage is similar to that of physical therapy.
An occupational therapist evaluates range of motion, strength, sensation, coordination, dexterity, functional muscle use, balance, transfers, and level of independence in activities of daily living. The goal of occupational therapy is to promote maximum independence and safety with activities of daily living, including basic self-care and daily activities such as dressing, bathing, home management, and functional mobility. Further therapy or durable medical equipment such as a bedside commode, assistive devices, and shower chair are recommended if the patient is to be discharged home. Physical and occupational therapy are likely to work in conjunction to promote maximum functional independence.
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Many potential complications can occur in patients with lumbar spine fractures. Often, these patients have experienced multiple traumas, and undetected injuries to intracavitary viscera can precipitate a sudden clinical deterioration. Neurologic deterioration can occur from neural traction, compression, or interruption of the vascular supply to the neural elements.
The stress resulting from a traumatic injury, a complicated surgery, and mechanical ventilation can predispose a patient to gastric ulcers. However, the widespread use of prophylaxis measures, such as H2 blockers, sucralfate, and proton pump inhibitors, has reduced the incidence of severe bleeding from stress ulcers.
In patients with spinal cord injury, another frequent source of acute morbidity is sepsis that is related to urinary tract infections.
Adynamic ileus is common in patients with a complete spinal cord injury. Preventive measures for both conditions include minimizing bed rest, returning to ambulation as early as possible, and limiting the use of narcotics. Early recognition and treatment of these conditions are essential to reduce morbidity and mortality. Initial treatment includes cessation of oral intake, nasogastric suction, insertion of rectal tubes, and cessation of narcotics.
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Surgical intervention is often necessary for patients with an unstable fracture or with neurological deficits related to compression of the neural structures by bony elements or hematomas, partial cord, or cauda equina injuries. The effect of the timing of decompressive surgery on the rate of neurologic recovery has remained unclear. Improved neurologic function has been reported with early and late decompression.
A variety of operative techniques are used in the treatment of spinal trauma.[39, 40, 41, 42, 43, 44, 45, 46, 47] The surgical approach used is determined by the level of the injury, characteristics of the fracture, and the location of the neural compression. Modern surgical techniques allow for effective decompression of the neural structures, usually by microsurgical approaches. In patients with unstable fractures, the use of segmental instrumental fixation is often necessary in conjunction with a fusion of the spine, either by an anterior or posterior surgical approach to the spine. This allows for the reduction and stabilization of the injured segments. See the image below.
In contrast with patients with spinal cord injuries at the cervical and thoracic spine, patients with nerve root compression at the lumbosacral region often achieve better outcomes following surgical decompression.
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All patients with compromise of multiple systems or pulmonary or cardiac contusions must be evaluated by a trauma surgeon. The presence of neurologic deficits prompts an evaluation by a neurosurgeon or orthopedic spine surgeon. An orthopedic surgeon is consulted to treat limb fractures. Consultations with other specialists depend on the condition of the patient and the system affected (ie, ophthalmologist; ear, nose, and throat specialist; cardiologist). Treating patients with a multidisciplinary team, including early consultation with a physical therapist, occupational therapist, and rehabilitation specialist, is important.
If, upon discharge from the acute care setting, the patient is not safe and independent with activities of daily living, functional mobility, and/or ambulation, an inpatient rehabilitation stay may be necessary. Inpatient rehabilitation is a continuation of comprehensive therapies in a more intense manner. The physical therapist works on bed mobility, transfers, strengthening, and ambulation, if applicable. The goal is to assist the patient in becoming independent with the above skills in a safe manner so that the individual may return home. Family instruction is provided so family members can assist patients at home with mobility and ambulation upon discharge.
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The occupational therapist works on activities of daily living retraining (eg, home safety and management, functional mobility, and basic self-care tasks) and activity tolerance and energy conservation/work simplification techniques. The goal is to assist the patient and family members to achieve the maximum level of independence with activities of daily living and functional mobility. The occupational therapist conducts a home evaluation to assess potential modification needs secondary to environmental barriers, if necessary.
Deep venous thrombosis (DVT) is a significant potential complication in patients with spinal fractures. Thromboembolism has been reported to occur in as many as 70% of patients with complete motor paralysis. Pulmonary embolism (PE) significantly affects the probability of survival following a spinal fracture.
Infections can occur following spine surgery, especially after a long surgical procedure for a complicated instrumentation placement. Superficial infections should be opened and debrided. The wound may be packed open or closed using retention sutures. Appropriate antibiotics should be employed, starting with coverage against gram-positive cocci and adjusting according to culture results.
Urinary complications continue to be significant sources of morbidity following spinal injuries. In patients with spinal cord injuries, distention of the bladder can lead to autonomic dysreflexia, impairment of bladder sensation, detrusor hyperreflexia, and sphincter dyssynergia, which can lead to renal damage from hydronephrosis or vesicourethral reflux.
Outpatient physical therapy may be necessary for further muscle strengthening and reconditioning of the spinal musculature once the patient is medically cleared by the physician. A physician's prescription is required for outpatient physical therapy and must include any precautions or contraindications that may still apply. The focus of this phase is an aggressive exercise program for both stretching and strengthening. Pain management modalities may be used to promote decreased pain in order to increase function and participation with therapy. Body mechanics training is also an important focus to reduce the risk of reinjury.
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If a spinal injury prevents a patient from returning to their job, a work-hardening program may be warranted. This program is designed to assist an injured person in returning to work. The work-hardening clinician, usually an occupational therapist, designs an individualized treatment plan for each patient. The goals are to build strength, increase endurance, reduce the risk of reinjury, and improve overall function. Work-hardening incorporates physical conditioning, work simulation, and education to achieve the above goals. A doctor's prescription is necessary to begin a work-hardening program.
Pseudarthrosis is a cause of chronic pain as result of malunion of the fusion. It may lead to progressive deformity, neural compromise, and pain. Failure of the instrumentation, such as dislodgment or breakage, is usually related to a failed fusion.
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