How is a broken pelvic bone treated
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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