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Treatment of Common Geriatric Fractures: Spine and Pelvis

[Music]

the topic today as we're continuing this

series on aging bones is on pelvic

fractures which I'll be talking about

and also spine fractures which are some

of the more complex injuries that we

treat as orthopedic trauma surgeons and

trig with his expertise in both spine

and trauma surgery is uniquely qualified

to talk about that but I'm gonna kick

things off and start off talking about

pelvic fractures so we'll start off this

is just kind of a quick overview well

we'll go through a little bit of the

anatomy of the pelvis it's one of the

more complex areas that we deal with in

our specialty we'll talk a little bit

about different types of injuries just

in sort of broad categories that we

typically see and how that varies as we

get older in terms of what types of

injury patterns we see as well as injury

mechanism we see and then we'll talk a

little bit just in broad strokes about

kind of how we approach treatment of the

diverse types of injuries that can

happen to the pelvis so when we talk

about the pelvis what what do we mean

specifically

so the pelvis in the most basic terms

from from a biomechanics standpoint is

what connects your spine to your hips

and your legs so it transmits a

tremendous amount of force from your

from your legs up through your hip

joints and into the pelvis and up to

your spine and the front of the pelvis

is made up of on each side we call it

the innominate bone it has three parts

but they're really kind of fused

together into one part but they're

called the ilium the pubis and the

ischium those three make up this

innominate bone which is kind of each

half of your pelvis is one innominate

bone and they meet in the back at an

area called the sacrum and the sacrum is

actually trig we'll get into to some

degree I think as part of your it's

actually part of your spine it's the

lowest part of your spine but we also

consider it part of your pelvis and it

forms this ring of stability

that transmits load from the spine in

the back up to your hips in the front

it's joined in the front by a lot of

ligaments and I'll talk a little bit

about that because that's a really kind

of critical part of the anatomy so this

innominate bone and the sacrum they

don't just just bite if they're not like

this perfect ball and socket joint that

naturally stays together because of the

way they're shaped they stay together

because there are big strong stout

ligaments that hold the bones together

the joint in the back that connects the

sacrum to the rest of the pelvis is

called the sacroiliac joint so you may

have heard people talk about sacroiliac

joint problems but it's in the very back

of your pelvis again where the spine

needs the pelvis and it's covered by

these extremely thick ligaments that are

like ropes that hold the back of the

pelvis together and this is really

important when we start getting into

pelvic injuries because these play an

important role in providing stability in

determining what a stable injury is from

an unstable one in the front of the

pelvis you have these two halves of the

pelvis the two halves of the ring coming

around to the front and they meet at an

area called your pubic symphysis and you

can feel this kind of right in the front

of your pelvis that's the prominence in

that area and there's a thick

fibrocartilage attachment right in that

area that's very dense and strong as

well this is the area that in in

pregnant women who are going to give

birth it actually loosens up a little

bit and allows that pelvis to open up to

allow a delivery to occur but it's a

very important ligament it's normally

very very stout very rigidly held

together and so that's important as we

think about what the different types of

injuries are so again just to recap the

pubic symphysis is in the front we have

the sacroiliac ligaments Sacro for

sacrum iliac being meaning the iliac

bone was that first part of the

innominate bone so the sacroiliac

ligaments and they have there's a front

part of those ligaments and then a back

part of those ligaments that make up so

those are really the three

major groups of ligaments that hold

these pelvic bones together and play a

role in pelvic injuries

you can't talk about pelvic fractures

without talking about some of the major

important structures that go by it so

kind of go through each of these and a

little bit of sequence so the blood

vessels are obviously very important

that your de comes down and it branches

into your iliac vessels the iliac

vessels are the are the are the two big

branches of area order that provide

blood supply to your leg they have a

have one branch that goes inside the

pelvis and supplies blood to all your

organs that sit within your pelvis and

then another branch that goes down into

your legs and supplies blood supply down

to your feet that has two important

implications one is that when you break

your pelvis there's a can be an awful

lot of bleeding and so there these are

in orthopedics we don't have a lot of we

consider ourselves saving limbs a lot of

the time but these are injuries where

sometimes it's very life-saving because

there can be so much bleeding that there

can be life-threatening injuries in many

cases it also means that if you disrupt

one of these then you could lose blood

flow to some of these organs or two to

your limb and so these are higher risk

injuries than many of the other ones

that we we commonly talk about the

nerves are also major nerve so all the

all these major nerves that emerge from

the lower part of your spine pass

through the pelvis the biggest ones your

sciatic nerve which I think most people

have heard of their sciatic so your

sciatic nerve comes and passes through

the back of your pelvis and goes down

the back of your leg it supplies most of

the muscles in your in your the back of

your thigh and lower leg and also the

femoral nerve is the other major nerve

that passes through and the femoral

nerve goes and it supplies your

quadriceps muscle and so anytime you

have an injury to the pelvis there's

this risk that you might have a nerve

injury that could lead to potentially

like a foot drop it would be something

that we would commonly seek because of

the static nerve being injured

you can also there are nerves that go to

supply all the all the organs within the

pelvis so people can have problems with

bowel or

function because of the nerves that

supply those areas so this is another

major consideration in talking about

pelvic fractures and lastly what are

they what are the sort of pelvic

contents that we're talking about what

are the public contents that were

worried about in a pelvic fracture well

almost all of your lower abdominal

contents your intestines and everything

are sitting kind of adjacent to your

pelvis the ones that are mainly within

within the pelvic ring would be the

bladder the uterus and women and the

lower part of the GI tract so any of

these can be injury to injured in

association with a bad pelvic fracture

so this is always something that we're

thinking about this isn't just a broken

bone all these other structures are also

at risk and can cause significant

long-term problems for people so just to

summarize the anatomy part Before we

jump into the injury so there's a really

complex anatomy surrounding the pelvis

the bony injuries can be associated with

major ligament injuries and

instabilities vascular injuries nerve

injuries and bowel and bladder injuries

and not only is that complicated for the

injury it also complicates our surgical

treatment because exposing the pelvis is

not just a little skin incision it

usually involves quite a complex

exposure that has to take into account

all of these different anatomic

structures and that has relevance as we

talked about treatment a little bit

later so what are the injury patterns

that we typically would see for the

pelvis so I'm gonna split it into two

kind of big broad buckets that we we

would typically see the first is a

pelvic ring injury so a pelvic ring

injury we always use the analogy of a

pretzel it's literally it you can't

really break a pretzel in one place you

know it almost always breaks in two and

the pelvis is the same way and that ring

that goes from the pubic symphysis in

the front all the way to the sacrum in

the back can break and if it breaks in

two places we consider that a pelvic

ring injury

and what's relevant about that is we've

then disrupted the relationship the

stable relationship between your hip and

your spine that's the bad news but the

good news is the hip joint itself

there's not a there's not really a joint

injury per se at least not a hip joint

injury so arthritis and things like that

are less of a worry for a pelvic ring

injury the other big category of injury

so pelvic ring injuries on the one hand

and the other one is an acetabular

fracture the acetabulum is a fancy term

for your hip socket so the hip joint is

a ball-and-socket and you can break the

socket and that's called an acetabular

fracture and these are just some

pictures on the right side you see what

we would consider a pelvic ring injury

this is what we would call an open

open-book pelvis injury it's one we'll

go through this in more detail but where

this ligaments in the very front of the

pelvis disrupt then it get opens up

literally as it sounds like a book and

these can be quite severe injuries but

the good news is that they don't involve

the joint and so they don't tend to have

long term consequences for any joints in

contrast to the injury on the bottom

where the the ball of the ball and

socket the femoral head has been driven

up into the socket and it's it's kind of

shattered on that left side and that is

a much more is a complex injury to treat

and can have really a lot of long-term

consequences for the function of the hip

joint so well delve into a little bit

more detail on pelvic ring injuries so

what are the different elements of the

pelvic ring so I talked about the fact

that it's like pretzel it typically

breaks into places that break can take

on sort of one of two broad flavors that

can either be a ligament injury or it

can be a fracture a bony injury of some

kind and it can occur usually occurs in

the front and in the back so whenever we

see an injury in the front on an x-ray

we immediately start looking for where

the injury in the back might be the

front injuries most commonly would be

the pubic symphysis injury like I talked

about in that open

book injury or they could be a fracture

of the RAM I which is one of them one of

the main bones at the front of the

pelvis that's what's shown see if I have

a pointer here you see that so this

would be in this this drawing this would

be the ramus fracture and then this is

the fracture in the back of the iliac

bone but again it's it's fracture occurs

in both the front and the back of the

pelvis in the back of the pelvis it's

usually it's very commonly an ligament

injury of the SI joint the sacroiliac

joint or it can be a fracture again of

the sacrum or the or the iliac bone this

picture on the bottom is showing a tear

of those ligaments of the sacroiliac

ligaments in the back and then a tear of

the pubic symphysis in the front so

again this would be another example of

that open book type of injury so how do

these happen what would it what does it

take to break your pelvis and in general

we think of them as a very high-energy

injury this isn't something that

typically is happening in and young

people unless there is a really really

large amount of force and most commonly

would be a car crash it could be a

motorcycle crash a fall from height or

getting hit by a car it takes some kind

of a whole lot of energy generally

speaking to break the pelvis and how it

breaks in terms of whether you get a

fracture or ligament disruption and

exactly where it breaks actually depends

a lot on where the force comes from and

we actually classify them based on this

but typically if the force comes to the

pelvis directly from the front like what

might happen in a motorcycle crash or a

car crash that's when we would see that

open book type pelvic injury where you

have this symphysis pubic symphysis

disruption in the front and the ligament

injuries in the back and the pelvis just

opens up and rotates outward if the

force comes from the side like a car

hitting another car getting t-boned in a

car from the side or a high fall or

somebody lands on their side then we see

a different pattern of injury more

commonly

set of the ligament injuries and open

the open book injury we get what's

called a lateral compression injury

where the pelvis turns inward and you

get breaks in the front and in the back

and we hold a whole classification

system around this and I'm not going to

belabor this I think it's kind of beyond

the scope of this talk but this is how

we kind of classify within each category

of direction of force we think about

there's kind of a spectrum of injury we

see depending on how much force got

transmitted to the pelvis and this

dictates at the lowest end of the

spectrum are things that often aren't

compar aren't totally unstable and don't

even need surgery whereas the ones that

the at the higher energy end of the

spectrum are more often more likely to

be unstable and more commonly would

require surgery but we divide them into

the lateral compression which is the

force from the side the anterior post

your compression which is a force from

the front and then vertical shear which

is literally like in plane with your

body usually it would be something like

a fall from a really large height 30 or

40 feet and landing and directly and it

shifts the pelvis vertically instead of

in either of those other two directions

but it's it's the least common of the

three so those are kind of the

high-energy pelvic fractures that we

talk about but what happens as we get

older well basically the these same

injuries can happen but you don't need

nearly as much force as we you would

need as at a younger age so we can start

to see pelvic fractures even from Falls

from a stepladder or Falls even from

standing as as bone quality starts to

get really really poor so in severe

osteoporosis just a simple fall from

standing can lead to lead to a pelvic

fracture because the bone quality is so

poor usually the types of injuries that

we see are that lateral compression

variant because it's usually a you know

a fall from standing and landing on the

side of the hip and even though there's

lower kinetic energy that lower kinetic

energy combined with poor bone quality

can still lead to fairly severe

fractures in some cases

luckily the majority fall on the less

severe end of the spectrum and this when

it's just from a from a fall

but we still see the same spectrum of

injury even in older patients who have

it from a lower lower energy mechanism

this is just a graph from a study it was

actually in Europe but the bottom line

is it just shows that there's we would

consider it's a bimodal distribution so

pelvic fractures happen in you know

young crazy twenty-year-old guys who are

crashing their motorcycles but then it

Peaks again later in life as bone

quality becomes poor and this just shows

that in more common in women and men

just because osteoporosis is a little

bit more common in the most extreme case

when bone quality is so so poor you can

actually get what we call insufficiency

fractures are not even associated with a

fall it's literally that bone gets so

poor that you just spontaneously start

to develop like a stress fracture

essentially that most typically occurs

in the sacrum in that lowest part of the

spine at the back of the pelvis and

these can be a cause of really severe

lower back pain and sometimes it's easy

to miss actually because back pain is so

common that it's easy to chalk it up to

just run-of-the-mill back pain but it

can actually be this more severe problem

again because it's a bone quality

problem it does happen more commonly

with increasing age the good news is

that it usually gets better with

conservative treatment it's usually a

period of rest just ping control

physical therapy and early

immobilization is tends to be the

mainstay of treatment we rarely have to

do surgery for this but it is important

to identify early because it does it is

different than your typical lower back

pain so circling back to public ring

injuries and just shifting gears and

talking a little bit more about

treatment well the good news is that the

majority of Pellegrini's and especially

those that occur with older age can be

treated without surgery and usually it

would be something like even we even

allow people to wait bear right away but

probably with some kind of assistive

device like

Walker initially and then as the pain

settles down can return and wean back to

a cane or nothing but there are some

some subset where if the front of the

ring in the back of the ring remember

the pretzel analogy if this if there's

just enough energy and the bone quality

is bad enough then you can get an

unstable injury where both the front and

the back are broken then occasionally we

still would need to do surgery in those

scenarios but luckily it's a little bit

less common now acetabular fractures I

remember this is the other broad bucket

of pelvic injury that we see these are

the ones that are injury of the actual

hip socket

these mark more often than not do

require surgery if the pieces are not

quite lined up and it really doesn't

take much and studies have shown that

even even two millimeters which is but

you can just barely begin to see on an

x-ray but even two millimeters of the

hip socket not being perfectly round can

lead to a higher risk of arthritis down

the road and so we really have a lot our

tolerances for the bones being that

slightly out of place is a lot lower for

an acetabular fracture than it would be

for the pelvic ring injury because of

the fact that it's involving the joint

but the problem is the exposure is to

get to the pelvis are to that stab them

to fix it are very big requires these

big open exposures to get all that

Anatomy we talked about at the beginning

we have to get that out of the way and

so this is just a picture of one of the

common exposures that we would do to fix

one of these fractures it's an incision

that goes up from way up on the eighth

crest here all the way down to the pubic

symphysis a huge incision I mean a lot

of exposure to get access to to fix

these so that's a big distinguishing

feature between sort of the acetabular

fractures versus the pelvic ring

injuries

so public cranium injuries just in

review

the bony injuries are a little bit more

straightforward to fix first of all they

don't often don't even need to be fixed

but when they do we can often do it with

small incisions and more limited

exposure and as long as the bone heals

the bone itself tends not to cause

long-term problems for people

unlike the S tabular where you can

develop arthritis down the road but

there's bad news with the pelvic ring

injuries and especially with the higher

energy ones they tend to be associated

more commonly with other injuries there

can be head injuries abdominal injuries

there's a much higher risk of

significant bleeding because of all the

blood vessels are running right by the

pelvis so like we talked about and high

risk of injury to all these other

Strutters bladder injuries and and

things like that are actually quite

common also the major nerves can cause

foot drop or bowel and bladder problems

so there's a lot of the bony injury

itself for pelvic ring is less often

less worrisome than the associated

injuries in contrast for acetabular

fractures and here's an example again

they have the fracture itself tends not

to bleed so much they're rarely

life-threatening amount of bleeding that

occurs from an S type of a fracture

there's much lower risk of damage to the

surrounding structures it tends to be

most of the energy of whatever fall led

to this tin tends to go right into that

hip socket and just create lots of

pieces around the hip socket but it

doesn't tend to damage things around

that area so that's the good news but

the bad news is that they are very

complex to treat they require these

large incisions and surgical exposures

in many cases and there's a much higher

risk of arthritis in the long term due

to damage to the joint so just a couple

of examples to run through to talk a

little bit about just to show you what

the treatments kind of look like and

this is a 61 year old man who was riding

his motorcycle and he crashed and

sustained this injury and what we see

here is

in the front there's a big gap in here

between the two bones that's the injury

of the pubic symphysis the ligament that

attaches these two bones in the front in

the back on the left side there's a big

it's may be hard for you to appreciate

but there's a big gap between the iliac

bone over here and the sacral bone here

that indicates that there's been a tear

of the liggett the thick ligaments that

hold the sacroiliac joint together

normally and there's also actually is a

fracture over here that's very close to

the acetabulum though this one wasn't

totally in the joint even though it's

quite close to it and so the way we

treat this one so this patient was was

very sick when they came in with a lot

of bleeding they needed a lot of blood

transfusions had to go to the ICU

need a lot of close monitoring and to be

resuscitated and once resuscitated went

to the operating room and it was able to

fix the front just with a fairly small

incision that's a plate and screws in

the front there that's holding that

pubic symphysis back together where it

belongs

this is a long screw placed along that

fracture through an incision a tiny

incision of about a centimeter and then

these screws in the back hold the sacrum

there actually both sides were injured

as it turned out and so there's screws

in the back that are holding the those

sacroiliac joints back together again

and that's all done through just little

small incisions without white exposures

using an intraoperative fluoroscopy and

intraoperative x-ray machine to guide

and make sure that we have the pieces

lined up again and make sure that we've

safely placed the screws and not hit any

of those important blood vessels or

nerve structures or things like that

that's obviously very important

so this that's kind of the fun part on

top of agreeing edges we're able to do

things through relatively small

exposures this is just a contrast this

is a 71 year old man hanging Christmas

lights not an uncommon story

unfortunately and fell from a ladder

about five or six feet and has this

acetabular fracture so this is on the on

the right side right here and it maybe

shows better on this other images that

to rotate it slightly you can see that

the the the ball of the ball and socket

the femoral head has pushed up into that

hip socket and split the pieces apart

and that's led to the you know the

sockets not a nice round socket anymore

it's it's into its it's broken into into

some pieces and so this in this case I

had to do a much bigger exposure so it's

that same it's called we call it

ilioinguinal but it's this big long

incision that wraps almost halfway or

you know a quarter the way around your

body

big wide exposure we have to kind of

expose those big blood vessels that go

to the leg and make sure everything's

safe and protected and then we use these

plates and screws to put it back

together and so we are able to you know

very accurately reconstruct the hip

socket but it does require a lot more

exposure and the surgery is probably

more risky risky in many ways than the

fracture itself which is a big contrast

to the public surgery so what's on the

horizon things that are kind of new in

the field of pelvic surgery I think one

that's really exciting is the use of

intraoperative CT scans so I mentioned

that we use intra operative x-rays a lot

but that's a two-dimensional image now

we're we have these it's called the ORM

it's it's literally like a Big O so we

can do a three-dimensional scan of

someone's pelvis during surgery that

allows us to check and make sure that

things are back in place where they

belong check them make sure the hardware

is where we think it's supposed to be

and there's even thing a thing called

navigation where we can actually

register your instruments to a machine

using that three-dimensional CT scan and

it can help guide you with a computer

and make sure that you're placing

everything and very precisely in bone

where you'd like to put it so I think

that this is something in the future

that's going to allow us to increasingly

do less and less of these big exposures

and do more and more through smaller

incisions the other one and and maybe

it's crossed someone's mind is so when

we're talking about the acetabular

fracture as well why not just do a hip

replacement it sounds

very simple and if when we another

important distinction that hopefully has

been clear is that when we talk about

hip fractures this isn't the hip

fracture that we're talking about when

people talk about hip fractures in

general it's talking about a break in

the femur side of the ball and socket on

the ball side of the ball socket so

that's those are at least a hundred plus

times more common than these acetabular

fractures but these socket fractures are

much more complex because when the ball

when it breaks right below the ball

which is very comp though your typical

hip fracture it's very easy to just do a

replacement the hip replacement

essentially even for arthritis they just

take the ball out anyway so it's almost

like the fracture does the work for you

so it's very easy to use total hip

replacement for treatment for that for

ask the tiger they're fractures though

unfortunately it's much more difficult

because the way the hip replacements

work the socket replacement has to sit

into the bone and be able to get fixed

to the bone very well there's nothing

that you really not much that you cut

out it's almost like a resurfacing and

so if the socket is broken then the

pieces won't won't have anything to hold

on to and so there is but there is a

push now towards trying to combine since

there's such a high risk of arthritis

with these some of these fractures to

actually fix the bone and replace at the

same time and we're trying to combine

this with some of these more

percutaneous limited small incision

approaches to fix the bone and then do

the hip replacement and that can really

be a way of kind of dealing with all the

problems at once but these are kind of

things that are still still evolving but

things were thinking about for the

future

so in conclusion it's a really complex

anatomy that surrounds the pelvis which

leads to complicated multi system

injuries and complicated surgeries to

try and reconstruct they do increase

with age and that relates to

osteoporosis and poor bone quality

there's a big spectrum of injury and

luckily the majority especially among

all their patients the majority can be

treated non-operatively but there are a

subset that are unstable and may require

surgery and of course we talked about

the acetabular fractures that's a whole

different category that's a break of the

socket of the hip joint there are more

complex and have a higher risk of

arthritis that's all I have thank you so

I'm not just going to talk about

fractures I'm going to talk about this

is a potpourri of a lot of different

things related to the spine I trained at

Vanderbilt and went did my worth Phoenix

at the University of Michigan I did my

trauma fellowship here in my spine

fellowship down in Los Angeles I've done

one thing perfectly in the world and

when I was in the first grade I achieved

perfect attendance and at the end of

that year I said you know what I'm gonna

try to keep this record up as long as I

can and I've never missed a single day

of school her work in my entire life

I'll be 65 in January so I'm really

lucky very lucky and I just came across

a book that was that that I found very

interesting how do you live a long life

well you know people theorized and

there's a Stanford long longevity

project but really what the the

punchline here is that if you work

really hard and you engage in a pursuit

of a goal you'll live longer than if you

just dilly-dally around and don't do

anything and you're happy-go-lucky

so maybe I'll live a really long time

but this book is really good so I would

advise people to maybe get it and have a

read so I've got multiple passions that

I'm really excited about and that's I

work seven days a week one of my

passions is my ranch out in the Central

Valley and we have a bunch of horses out

there it's a commercial operation and

I'm pretty good stall cleaner which is

very hard work but I'm used to it

because I grew up on a farm

Tennessee I'm also one of the team

doctors for the pro rodeo cowboy

Association and the Professional Bull

Riders and they get injured every eight

seconds or less it's extreme sport it's

very popular it's a popular spectator

sport there's usually thirty or forty

thousand people in the audience but the

two the three the three roughstock

events are bull riding bareback and

saddle bronc and I'll show you what we

did in a study with these the bareback

riders which is the bottom right there

it's subjected to extreme whiplash

forces that you won't really even

believe there are three things this is

probably gonna get me a little choked up

what I wanted to do you know people you

often hear people say they want to make

a difference in the world and so I gave

a lot of thought to that how could I

make a difference in the world and you

know day to day we do orthopedics and

you affect people's lives on a day to

day basis but what happens when I'm not

here and so I wanted to create a

fellowship a Graduate Medical Education

fellowship and I named it after my

daughter's and Dave can maybe explain it

a little better but I created this

international research fellowship with

the purpose of training our future young

orthopedic surgeons so they could go out

and perform research projects teach

other orthopedic surgeons in these

under-resourced countries and make a

difference in the world and this this is

a sustaining thing that will be here

long hopefully long after I'm not here

and I've pledged $250,000 of my own

money and I'm gradually chipping away at

it and I've got some brochures here I'm

going to pass out if anybody wants to

put a dollar in there but this is

something that I'm very passionate about

and Dave I think is headed

ooh Tanzania tomorrow Friday we have

three of our the orthopedic depart the

orthopedic trauma Institute which is

part of UCSF has multiple outreach sites

so Dave and some more shed and aamir

Matityahu are on a plane to Tanzania for

ten days to do courses and and do some

really good stuff I'm very proud of

those guys for doing that and we have a

fellow every year we've done this since

2012 and the fellows that have gone

through this program have achieved a lot

and I'm really proud of them too and

hopefully this will continue forever so

what we're going to talk about is a

bunch of different things related to the

spine and we'll go through a little bit

of anatomy a little bit of biomechanics

what is an injury whiplash spinal cord

injury disk herniation because that's

you know a common problem as well as

some fractures so in the spine world

there's there are three things you have

to do you have to take a history you

have to perform an examination and you

have to do imaging studies you can't

make a diagnosis without all three of

those so people will come up and say hey

dr. McClellan can you look at my MRI and

tell me what you think well I need to

know what the history is and I need to

know what the examination shows you

can't really give them any information

based on just an imaging study the

physical exam is very important because

I know the wiring diagram there's

certain nerves that go to certain

distributions whether it's a sensory

nerve or a motor nerve and you can

examine those specific nerve roots to

determine if there's an injury to that

nerve so the anatomy of the spine is

repetitive there's vertebral body discs

small facet joints if you look at a

cross-section of the spinal cord at the

or the spine at the cervical level the

disc is made up of a nucleus which is

like a jelly the outer covering or the

fibrous ring the vertebral body and then

those holes on either side is where the

artery is that goes to the brain then

the nerve root comes out you

that little framing or hole the spinal

cord is in the middle there and then

there's an arch or a roof over the top

of the back of the spinal cord to

protect it the spinal cord ends at about

t12 l1 so there's no spinal cord below

l1 so the lumbar spine your lower spine

again is a disc vertebral body disc

vertebral body repetitively and then the

struck the nerve roots come out again as

paired structures at certain levels and

go into into a particular distribution

into your into your lower extremities

this just shows the ligaments in the

front and the ligaments in the back of

the spine that hold the vertebral bodies

together and they're very strong

ligaments it takes an incredible force

to tear them and then the spinal cord is

protected in the bony ligamentous bony

structure of the spinal column so what

it what is an injury an injury you need

to know what a clear definition of an

injury and it's sort of there's there

are multiple theories on what an injury

is like most diseases injury is defined

by or it's defined by the causative

event and what is the resulting

pathology the simple orthopedic

definition is a mechanical disrupt

disruption of a biological tissue

resulting in pain well what's Payne the

Marines say that pain is weakness

leaving the body and that's what the

Cowboys say they freaked if we tell the

bull riders you know if you didn't have

any pain you'd be lonesome so that's the

simple orthopedic definition but really

there's a very complex pain pathway the

epidermis has nociceptors in the skin

that are activated by some tissue injury

the signal travels through the

peripheral nerve it gets through

neurotransmitters it goes to the

thalamus and then in the Dallas it goes

to the somatosensory cortex the frontal

cortex in the limbic system and so pain

can be perceived you know there there's

anok pain is a very complex saying

there's an emotional piece there's a

century piece there's a thinking piece

so that's why chronic pain is a

difficult problem there are multiple

theories of injury these are just a few

of them and just to talk about the top

one the multivariate interaction theory

there's um

there the there's a bunch of stuff that

can happen both genetically

morphologically psycho socially as well

as bowel mechanically that can result in

you know injury causation so injuries

serious public health issue one person

dies of an injury every three minutes

there's more than two and a half million

people that are hospitalized with

injuries thirty one point six million

people are treated in the emergency room

and more than four hundred and sixty

five billion is spent annually in

medical costs in lost productivity so

what about whiplash whiplash everybody

is knows what rip whiplash is well is it

is it fake or real and it's not uncommon

for patients that are involved in a

rerender to get an MRI very quickly

after them after the accident and it

almost always shows something and then

there's the issue what was that caused

by the accident well there's a bunch of

studies that have been done that show

that probably those changes are not

related to the accident this is a study

that was done by radiologists it was

published it was a prospective study and

what they did they took a hundred

consecutive patients and they had an MRI

within 48 hours after the accident and

then they matched that to a hundred

match controls they had for people that

had no idea what whether it was a

whiplash cat person or an age match

control and there was really limited to

no evidence that the the findings on the

MRI were related to the whiplash there

was basically the the two MRIs were very

similar again this was a study that

looked at long lasting symptoms

following a whiplash it was a

prospective trial with a one-year

follow-up

and what they found was that preexisting

degenerative changes was not associated

with a prognosis MRI rarely gave you an

answer to a diagnosis getting early MRI

scans didn't predict the prognosis so

bottom line his bottom line with this

study and with multiple others is that

you know the MRI alone is not really

your answer for you know diagnosing what

might have happened with a whiplash this

was a study that actually won an award

it was done about 20 years ago they took

21 volunteers subjected them to a 14

point 2 kilometre rear-end accident

which is equivalent to 3.6 G's they

examined them and did MRIs before and

after this accident and there weren't

any symptoms or changes on the MRI now

obviously the volunteers knew that

something was coming

and that's 3.6 G's is not very much you

know that's less than 10 basically 10

miles an hour so what what I wanted to

do is say what would happen if I exposed

a human to ten times that force and

you're gonna say well who's gonna

volunteer to 36 Gees and and be happy

about that

well I got the rodeo guys we took the

bareback riders and I don't know if

you've ever seen a bareback rider but

they're laid out like this and the

horses butt so hard that they're

whiplashed like you're crazy this was an

IRB approved study we had volunteers it

was also a concussion study that's me

with some of the Cowboys you know

they're young and tough just like me we

actually did a lot of stuff before we

examined them we did had them fill out

surveys we did MRIs right before and

right after and the really cool thing is

we did g-force calculations with this

accelerometers so we put accelerometers

in their mouths so we could measure the

linear and the rotational g-forces while

they got bucked okay this is one of the

riders before he

before he actually got on a bucking

horse you can see has a very large

herniation at c6 7 he was totally

asymptomatic most surgeons most people

would say you better not get on this

horse if you've got that but he said you

know I've never had a problem with my

neck he had a here's his GeForce data he

he was exposed to a peak of 35 G's okay

here's his MRI right afterwards or the

next morning really no difference here

the two MRIs side-by-side this was read

by radiologists no difference in the two

MRIs despite a large herniation pre and

post ride so we had 21 guys that were

that we did this with the mean

acceleration was about 24 G's when one

of the riders peaked at 62 point 8 G's

really there was no real difference the

the post ride next scores were a little

bit higher but there was no arm pain no

radiculopathy no real change of than a

little bit of bulging in the disc before

and after so really that this study was

significantly more severe as far as the

g-forces in that other study so how do

you treat a how do you treat a whiplash

well this was in 20 years ago really

it's minimal intervention reassurance

encouragement simple exercises you know

don't get an MRI every 2 or 3 weeks

because it's not going to make any

difference you've heard the phrase no

pain no gain well if you go back to work

early and you you you will tend to

maintain your treatment gains if you're

rehabbed on a following an injury to the

neck so this was a study with one-year

follow-up 73 had returned to work 37

were disabled the participants who

returned to work were more likely to

maintain their treatment gains and those

who remained work disabled so when

patients say well you know I can't go

back to work I just say well if you go

back to work you'll you'll maintain what

treatment goals you've realized if you

you know

if you get back to work sooner the

better just a couple comments about

impairment and disability this comes up

frequently with back injuries impairment

is actually a loss of physiologic or

functional or psychological function due

to injury disability is loss of

limitation of work or opportunity to

take part in society a judge makes a

disability determination a doctor makes

an impairment recommendation the reason

this is important because this is very

common in the spine world patients think

they're disabled when in fact they have

very little impairment lower back pain

again is the top cost for years loss due

to disability there are multiple studies

and in in many different countries that

show that the global burden of BAC

related issues is is humongous

Social Security receives more disability

applications for back problems in any

other physical illness or injury so

let's talk a little bit about

biomechanics so how do you evaluate

injuries we can do mathematical model

modeling we can do cadaver studies human

volunteers you've seen those studies you

can put you know the car dummies in

there if you look at the spine that

breaks down into several segments one is

the thoracic spine from t1 to t2 and

that's fairly rigid it's supported by

the rib cage there's a curve that is

called a kyphosis sort of a hunchback

and usually flexion injuries predominate

in the thoracic spine at the junction

between thoracic and lumbar there's a

transition between very stiff to very

mobile

so most injuries occur at the junction

between the thoracic and lumbar spine

and then there's the lower spine from l3

to the sacrum in the lower spine is very

mobile and usually axial loading

injuries predominate there

again this is just a biomechanical

testing machine that we can create

constructs in cadavers and test the the

loading and the structural rigidity of

our constructs this is an interesting

study and I don't know how many golfers

there are out there but we're gonna talk

about some what what happens to your

back when you play golf and we'll talk

about what Tiger Woods had but if you if

you lift a load of 20 kilograms bent

forward slightly there's a four and a

half increase in disc pressure in your

bag just lifting a 20 kilogram weight

bent forward a little bit four and a

half fold increase in disc pressure so

the pressure actually increased after

you'd been after that person was

replaced in the disc that pressure

actually increased after they've been

lying down for seven hours and that was

presumably due to rehydration of the

disc after they went to bed so this is a

dummy model we you know the cars do all

this testing with safety restraints and

headrests and stuff all the new cars

after 2012 required a head restraint or

2010 whatever it was so there's fewer

whiplashes so car crashes are are not

uncommon and this is some of the numbers

that it takes to to create an injury a

vertebral compression fracture can occur

or a fracture dislocation can occur with

a 20 to 40 G load you can have a pelvic

fracture with a 100 to 200 G load and

your body can fragment with 350 G's now

these are this is a little bit different

than the than the rodeo study that we

perform but this just gives you an idea

of what g-forces can happen what can

occur with certain levels of g-forces so

what why is back pain so common in in

certain athletes

golfers are the most notorious victims

of of back injuries and I'll tell you

why in just a minute but most of the

tour professionals will have a neck or a

back injury Tiger Woods was crippled

with his l5 s1 disk because the he in

fact he couldn't play anymore he had

multiple surgeries until he had a lumbar

interbody fusion and the reason the back

is subjected to so much load is there's

your bending forward there's torsion on

the disc and this repetitive loading

that's one of the theories of injury

this repetitive loading produces injury

to the disc this was a study that looked

at the compressive shear and lateral

bending and rotational loads at l3 l4

with one golf swing so with one golf

swing there's eight times body weight

through the l3 l4 disc so imagine a guy

like Tiger Woods who swings the golf

club hundreds and hundreds of times a

day and experiencing eight times his

body weight through the disc so you can

understand why that would produce an

injury so this goes to the cumulative

load theory so it's a repetitive

cumulative load to the to the lower

discs it results in this injury to that

to that disc that causes the pain

there's probably a good reason that

women live longer than men and you know

you'll frequently hear the term fracture

or broken it's really the same thing and

a fall from a height like this will

almost guaranteed result in a spinal

fracture and potentially a spinal cord

injury so spinal cord injuries are

pretty significant most are from

vehicular accidents and Falls we see a

few from gunshot wounds some from sports

I've seen bull riders with broken necks

and broken backs they're as of 2015

there are about 12,500 new spinal cord

injuries each year

and between 240 to 337 people are

currently living with a spinal cord

injury in the United States so just a

couple of examples of fracture types

this is a burst fracture which means the

vertebral body just explodes into many

pieces and we sort of classify burst

fractures as to whether they're stable

or unstable the ones that are stable can

be treated in a brace called a tlso

because they're not going to tend to

fall apart or cause neurologic damage

this is an example of a CT scan of

somebody within an l1 burst fracture he

was neurologically intact in other words

the the nerves were working totally

normally so we felt like he could be

treated in a tlso unfortunately in

follow-up he started to - or collapsed

the bone collapsed more and he developed

a deformity there so we ended up putting

in screws and rods to stabilize his

spine so that it wouldn't collapse

anymore so this is another type of

fracture called a flexion distraction

injury where it tears ligaments and

bones and the bone it goes all the way

through the spinal canal

many of these result in neurologic

deficits in this particular patient

right here this was a young girl who was

in a car accident and it looks really

bad on your the x-rays on the left but

amazingly she was neurologically intact

and we we simply fixed that with a with

two screws at each at the level above

and two screws at the level below some

rods this is an unfortunate young girl

who was sitting in the seat with her

boyfriend in the front seat and the car

flipped and she broke her back this is

at l3 I guess which is below the level

of the spinal cord but she had a

complete spinal cord injury because at

the time of impact when she was thrown

out of the car this is a static image so

there was probably way more

displacement of the bone and it just

shredded all the nerves from the lower

spinal cord so you know we still fixed

it so that she could rehab and and get

through that that as well as possible

with with this little pain as possible

but she ended up with a complete spinal

cord injury this is a fracture

dislocation again there's almost all of

these result in neurologic deficit if

they're at the spinal cord level almost

all require surgery and this is a lady

that actually we're getting ready to

operate on here at UCSF this is a lady I

treated 20 years ago and she was in the

back of a pickup truck fell asleep or

was in the back of the pickup truck and

the driver fell asleep the truck rolled

multiple times and she has a fracture

dislocation you can see the red lines

and the yellow arrows showed that the

the vertebral column isn't obviously not

very well lined up and tore her spinal

cord we still fixed her but she actually

has developed a problem below the the

rods and the hooks with severe

degeneration so we're gonna revise that

and this was done 20 years ago here's a

here's a person with an l3 burst

fracture this is the MRI showing the

spinal cord getting sort of pain or the

nerves getting pinched not the spinal

cord because there's no spinal cord and

then the bone fragments in the canal on

the on the far your far right and this

was fixed where we took the the

fractured vertebral body completely out

we put an expandable cage in and then

put screws and rods in the back to

stabilize that this is the vertebral

compression fractures which are common

in elderly they can result from almost

no injury just a call for a simple slip

and fall or they can even occur

spontaneously they are incredibly common

we see about 700,000 of these per year a

lot of them are not even diagnosed

because the the the person has back pain

but they don't even go to the hospital

they just assume that they're old and

they've got back pain but there are

quite a few hospitalizations related to

compression fractures every year there

are a lot of causes or risk factors to

vertebral compression fractures

including age osteoporosis steroid use

smoking and some of these other things

malnutrition alcohol use in a sedentary

lifestyle are all risk factors and in

fact if you look at vertebral

compression fractures if you have more

than they can frequently occur in and

greater than one or two so if you have

three or more that's equivalent to

having a stroke or cancer as fall as as

far as quality of life this was a study

of 334 people that were 65 that had more

than three VCFs and their quality of

life was was not good so if you look at

risk following a recent fracture 20%

will experience another fracture within

the first year so if you get one you

have a 20% chance of getting another one

within the first year we're gonna move

into the final topic here of pinched

nerves this was a large study out of the

Mayo Clinic that looked at cervical

radiculopathy or a pinched nerve in the

neck causing arm pain they looked at 561

patients and the interesting thing is

that most of these patients 14.8% could

only only 14% could recall any history

of exertion or trauma so the vast

majority of of patients with a cervical

radiculopathy or pinched nerve in the

neck causing arm pain the vast majority

had no history of trauma or any history

of exertion they're just they occur

spontaneously thank you

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you