Jim A. Youssef, MD; Revised January 2006 and May 2011
Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification Jim A. Youssef, M.D. Original Authors:Christopher Bono, MD and Mitch Harris, MD; March 2004 Jim A. Youssef, MD; Revised January 2006 and May 2011 Anatomy of Thoracic Spine
Kyphosis is natural alignment Narrow spinal canal Facet orientation Rib factor on stability Conus at T12-L1 Anatomy of Lumbar Spine
Lordosis is natural alignment Larger vertebral bodies Facet orientation Cauda equina Thoracolumbar Junction
Transition Zone Kyphosis Lordosis Mechanical Difference: Lumbar spine less stiff in flexion Transition Zone: Predisposed to Failure
Little opportunity for force dispersion Central loading of T-L junction Not anatomically disposed to transfer force Patient Evaluation Pre-hospital care EMT personnel Initial assessment
Transport and immobilization Patient Evaluation ABCs of Trauma History Physical Examination
Neurological Classification Clinical Assessment Inspection Palpation Neurological Evaluation
ASIA Impairment Scale Sensory Evaluation Motor Evaluation Reflex Evaluation Bulbocavernosus, Babinski Clinical Assessment Associated Injuries
Meyer, 1984 28% have other major organ system injuries Noncontiguous spine fractures 3-56% Always monitor Hematocrit GU: Foley recommended, check post-void residuals, if abnormal get cystometrogram GI: prepare for ileus. Radiographic Evaluation
Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P pelvis Obtunded patients require further skeletal survey Mackersie et al J Trauma 1988 Additional Imaging CT scan bony injuries
MRI images spinal cord, intervertebral discs, ligamentous structures CT Scan L3 unstable burst fracture MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris Thoracolumbar Fractures Controversies
CLASSIFICATION!!!!! Indications for surgery Optimal time for surgery Best approach for surgery Classifications Necessary for
Uniform method of description Directing treatment *** Facilitating outcome analysis Should be: Comprehensive Reproducible Usable Accurate Bhler 1930 Importance of injury mechanism
Determines proper reduction maneuver Evaluated fractures using: Plain roentgenograms, anatomic dissection of fatalities 6 types of spinal fractures included in system Compression Flexion Extension Lateral flexion Shear Torsional Bhler, Verlag von Wilhem Maudrich 1930 Bhler, Fractures and Dislocation of the Spine, 1956 Morphologic Classification Watson-Jones 38
Descriptive terms based on 252 films 7 types Examples: Wedge fracture (compression fx) Comminuted fracture (burst fx) Fracture dislocation CT evolved MRI evolved * 1930 40 50 60 70 80 90 2000 10 Morphologic Classification Morphologic Classification Stable vs. Unstable Nicoll 49
Based on review of 152 coal miners Recognized importance of posterior ligaments 4 fracture types: Stable = post ligaments intact Unstable = post elements disrupted CT evolved MRI evolved * 1930 40 50 60 70 80 90 2000 10 Morphologic Classification Post elements important Anatomic Classification
2 or 3 Columns Denis 83 McAfee 83 Ferguson & Allen84 Holdsworth62 Kelley & Whitesides 68 Anatomic Classification 2 Column Theory Holdsworth 62
Posterior Anterior Six types- Nicols +2 Reviewed 1,000 patients Anterior- vertebral body, ALL, PLL Supports compressive loads Posterior- facets, arch, Inter-spinous ligamentous complex Resists tensile stresses Stressed importance of posterior elements If destabilized, must consider surgery 2 1 1 2 Anatomic Classification 3 Column Theory Denis 83
Posterior Middle Anterior Based on radiographic review of 412 cases 5 types, 20 subtypes Anterior- ALL , anterior 2/3 body Middle - post 1/3 body, PLL Posterior- all structuresposterior to PLL Same as Holdsworth Posterior injury-not sufficient to cause instability 3 2 1 1 2 3 McAfee Classification
Sixtypes CT based-100 patients Middle column most important Load Sharing Classification McCormack, Spine 1994
Review of injuries fixed posteriorly (McCormack 94) Which failed? Could they be prevented? Suggests when to go anteriorly CT evolved MRI evolved * 1930 40 50 60 70 80 90 2000 10 3 column, McAfee Load Sharing Morphologic Classification Post elements important 2 column Mechanistic classifications Load Sharing Classification (McCormack 94)
Devised method of predicting posterior failure 1-3 points assigned to the variables below Sum the points for a 3-9 scale 6 points anterior 2mm 4-9 10 >60% Comminution Fragment Displacement Kyphosis correction Mechanistic Classification AO
Review of 1445 cases (Magerl, Gertzbein et al.European Spine Journal 1994) Based on direction of injury force 3 types,53 injury patterns Type A - Compression Type B - Distraction Type C - Rotational Increasing severity CT evolved MRI evolved * 1930 40 50 60 70 80 90 2000 10 AO 3 column, McAfee Load Sharing Morphologic Classification Post elements important 2 column Mechanistic classifications AO Mechanistic Classification Complex subdivisions to include most fractures Oner, European Spine Journal 2002 53 Patients
Classification of thoracic and lumbar spine fractures: problems of reproducibility A study of 53 patients using CT and MRI Oner, European Spine Journal 2002 53 Patients AO & Denis Classifications 5 observers Cohen Test 0=No Agreement 1.0=Perfect Agreement Results AO Interobserver Denis Interobserver CT 0.31 MRI 0.28 Vaccaro, A.R. et al, Spine 2005 Spine Trauma Study Group Thoracolumbar Injury Classification and Severity Scale (TLICS) Three Part Description Injury Morphology Integrity of PLC Neurologic Status Compression: prefix-axial, lateral, flexion, postfix-burst
InjuryMorphology Compression: prefix-axial, lateral, flexion, postfix-burst Distraction: prefix-extension, flexion postfix-compression, burst Translation/Rotation: prefix-flexion Neurologic Status Intact Nerve Root Injury Cauda Equina Injury Cord Injury-Incomplete, Complete Posterior Ligamentous Complex
Not disrupted in tension Disrupted in tension Treatment Spine Trauma Severity Score Determined by:
Injury Morphology Neurology Ligamentous Integrity Vaccaro, A.R. et al., J. Spinal Disorders & Techniques 2005 Point System Translation / Rotation 3 Injury Morphology Select one
Compression fx Axial, Flexion1 Burst - add 1 Distraction injury 4 Neurology-Point System
Intact Nerve root Cauda equina 2 3 Cord And conus medullaris Incomplete Complete 3 2 Posterior Soft Tissue Point System
Intact 0 PLC (displaced in tension) Suspected/ Indeterminant 2 Injured 3 Evaluated by MRI, CT, Plain X-rays, Exam MODIFIERS AS/ DISH/Metabolic bone disease Nonbraceable
Sternal fracture Multiple rib fractures at same or adjacent levels as fracture Multiple trauma Coronal plane deformity Burns at site of anticipated incision Next Step - Direct TX Assign Points Conservative Surgery Treatment Injuries with 3 points or less = non operative
Injuries with 4 points=Nonop vs Op Injuries with 5 points or more = surgery Examples Flexion Compression Fx
Flexion compression (morphology)- 1 Intact (neurology) - 0 PLC (ligament) no injury - 0 Total 1 points- Non Op Compression Burst Fracture
Flexion compression burst- 2 Intact ( neurology) - 0 PLC (ligament) no injury (0) Total 2 points-Non Op Compression Burst-Complete Neuro Injury
Axial compression burst with distraction posterior ligamentous complex -4 Complete (neurology) - 2 PLC (ligament) injury - 3 Total 9 points-Surgery Compression Burst-Complete injury
Axial compression burst-2 Complete (neurology)-2 PLC (ligament) Intact-0 Points 4-Non Op vs Op Translational/Rotation Injury
Distraction, Translation/rotational, compression injury- 4 Complete (neurology) 2 PLC injury - 3 Total 9 points-Surgery Surgical Decision making based off tenets of classification system
Journal of Spinal Disorders & Techniques, 2006 Surgical Decision making based off tenets of classification system Injury morphology Neurological status PLC integrity/injury stability Reliability/treatment validity at single institution
Spine, 2006 Reliability/treatment validity at single institution Treatment validity exceptional- 96.4% Moderate agreement for PLC (66%) andmechanism (60%) Conflict: Mechanism vs Morphology The Journal of Spinal Disorders and Techniques
Identifying objective findings on imaging studies and clinical examination instead of guessing injury mechanisms provides more valid understanding of injury classification Problems Inter-rater agreement on sub-scores was:
J. Neurosurgery Spine, 2006 Problems Inter-rater agreement on sub-scores was: Lowest for mechanisms followed by PLC Highest for neurological status Substantial for the management recommendation The Spine Journal, 2006 Status PLC Most reliable indicators:
Vertebral body translation on plain radiographs Disrupted PLC components on T1 sagittal MRI Focal kyphosis in absence of vertebral body injury Assessment of Injury to the PLC in the Setting of on Normal Plain Radiographs Lee, J.,Vaccaro, A.R. et al. J Orthopaedic Trauma 2006 Validation Study J. Orthopaedic ResearchSubmitted 2006 STATUS PLC Disrupted PLC components i.e. ISL, SSL, LF; black stripe on T1 sagittal MRI , most important factor Diastasis of the facet joints on CT Fat suppressed T2 sagittal MRI Lim, Coluna/Columna Journal, 2006
IMPACT OF EXPERIENCE (attending surgeons, fellows, residents, and non-surgeon health care professionals). Most reliable among spine fellows, followed by attending spine surgeons. Spine, 2007 IMPACT OF TRAINING
Management component: reliability rose from = 0.46 (r=0.47) on first assessment to = 0.72 (r=0.91) on the 2nd assessment. DIFFERENCES BETWEEN SPECIALTIES
J Spinal Disorders, 2006 DIFFERENCES BETWEEN SPECIALTIES Inter-rater reliability: injury mechanism higher in neurosurgeons Assessment of PLC, neurological status- higher in orthopaedic surgeons Reliability total score/management recommendations similar Overall, differencessubtle DIFFERENCES IN NATIONALITIES
World J Emerg Surg, 2007 DIFFERENCES IN NATIONALITIES Inter-rater reliability for mechanism higher among non-US surgeons Reliability for PLC, neurological status,management higher among US surgeons Management of Thoracic and Lumbar Injuries
CONTROVERSIAL!!!! Non-Operative Treatment of Thoracic Spine Injuries
Braceor Cast Treatment Compression Fractures Stable Burst Fractures Pure Bony Flexion-Distraction Injury 85 pts reviewed to determine late outcome of non-op management
Folman and Gepstein, J Orthop Trauma, 2003 85 pts reviewed to determine late outcome of non-op management Chronic pain predominant in 69.4% 25% of subjects had changed jobs (most full to part) 48% of subjects filed lawsuits concerning injury Pain intensity correlated with angle of kyphosis But not w/magnitude of anterior column deformity Bed rest alone adequately manages traumatic, uncomplicated thoracolumbar wedge fractures No correlation was found between radiological &functional parameters
Agus, Eur J Spine, 2005 Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst fractures No correlation was found between radiological &functional parameters Vertebral column deformity that occurred after the injury was stable in 2-column; progressive in 3-column Significant remodeling of canal encroachment (CE) proportional to initial amount of CE but not related to age & radiology 62% showing good or excellent outcome
Koller, Eur Spine J, 2008 Evaluated 21 pts; 9.5 yr f/u 62% showing good or excellent outcome 38% showing moderate or poor outcome Significant effects on clinical outcome: Load-sharing classification, posttraumatic kyphosis & overall lumbopelvic lordosis Surgical reconstruction appropriate treatment in more severe fractures Surgical Management of Thoracolumbar Injuries
Unstable burst fractures Purely ligamentous Facet dislocations Translational injuries Neurologic deficit Delayed diagnosis in 28 pts (19%) Differences b/w surgical & non:
Dai, J Trauma, 2004 147 pts w/acute thoracolumbar fractures: 1988 to 1997 Min. 3yr f/u; 4 pts died during hospital stay Delayed diagnosis in 28 pts (19%) Differences b/w surgical & non: in pulmonary complications & length of hospital stay in non-op pts. Surgical pts had highly significantly less pain Radiographic studies should be performed Choice of treatment in pts with multiple injuries is not different from that in pts with no asscd injuries Thomas, J Neurosurg Spine, 2006
Evaluated scientific literature on operative & non-op treatments Lack of evidence demonstrating superiority of one approach over the other No evidence linking posttraumatic kyphosis to clinical outcomes Strong need for improved clinical research methodology to be applied to this patient population Accuracy of plain radiographs improved w/experience of observers
Dai, Spine, 2008 Reviewed 37 pts Accuracy of plain radiographs improved w/experience of observers Impact of disagreement on treatment plan was significant Plain radiography alone is not adequate Acosta, J Neurosurg Spine, 2008
Biomechanical comparison of 3 fixation techniques for unstable thoracolumbar fractures. Induced at L1: 1) Short-segment anterolateral fixation 2) Circumferential fixation 3) Extended anterolateral fixation Extended anterolateral fixation is biomechanically comparable to circumferential fusion Extension of anterior instrumentation & fusion 1-level above and below the unstable segment can result in near equivalent stability to a 2-stage circumferential procedure Disch, Spine, 2008 Angular stable plate system showed higher primary and secondary stability In specimens with lower BMD, the use of angular stable systems substantially increased stability Whang, J Am Acad Orthop Surg, 2008
Difficult to establish the ideal surgical approach Anterior decompression assocd w/ recovery of motor strength & bowel/bladder fxn; pain & improve neuro status Stand-alone anterior constructs: complications & likely to have revision More definite evidence required to determine best surgical strategy Conclusions on Treatment
Surgically treating incomplete neuro deficits potentiates improvement and rehabilitation Complete neuro deficits may benefit from operative treatment to allow mobilization Little chance of developing neuro deficits with nonoperative treatment Surgery: Anterior versus Posterior
More predictable decompression Saves levels Questionable improved recovery of neuro function Gertzbein,1992 may be indicated in bladder dysfunction McAfee, 1985 neuro recovery in 70 patients Posterior Less morbidity Failures with short segment constructs Usually requires more levels Less blood loss Transpedicular anterior column bone grafting may protect posterior construct Thank You Bibliography Meyer PR Jr, Sullivan DE. Injuries to the spine. Emerg Med Clin North Am May;2(2): Mackersie RC, Shackford SR, Garfin SR, Hoyt DB. Major skeletal injuries in the obtunded blunt trauma patient: a case for routine radiologic survey J Trauma Oct;28(10): Bohler L. Die techniek de knochenbruchbehandlung imgrieden und im kriege. Verlag von Wilhelm Maudrich 1930 (in German) Bohler L. Mechanisms of fracture and dislocation of the spine in the treatment of fractures. 5 th English ed. Fractures and dislocation of the spine. Bohler L, editor. Vol. 1. Grune and Straton, Inc: New York; p Watson-Jones R. 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