Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification

1
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

2
Anatomy of Thoracic Spine

• Kyphosis is natural alignment
• Narrow spinal canal
• Facet orientation
• Rib factor on stability
• Conus at T12-L1

3
Anatomy of Lumbar Spine

• Lordosis is natural alignment
• Larger vertebral bodies
• Facet orientation
• Cauda equina

4
Thoracolumbar Junction

• Transition Zone
• Kyphosis Lordosis
• Mechanical Difference
• Lumbar spine less stiff in flexion

5
Transition ZonePredisposed to Failure

• Little opportunity for force dispersion
• Central loading
• of T-L junction
• Not anatomically disposed to transfer force

6
Patient Evaluation

• Pre-hospital care
• EMT personnel
• Initial assessment
• Transport and immobilization

7
Patient Evaluation

• ABCs of Trauma
• History
• Physical Examination
• Neurological Classification

8
Clinical Assessment

• Inspection
• Palpation
• Neurological Evaluation
• ASIA Impairment Scale
• Sensory Evaluation
• Motor Evaluation
• Reflex Evaluation
• Bulbocavernosus, Babinski

9
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.

10
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

11
Additional Imaging

• CT scan bony injuries
• MRI images spinal cord, intervertebral discs,
  ligamentous structures

12
CT Scan

• L3 unstable burst fracture

13
MRI Scan

• Thoracic fracture subluxation with increased
  signal in conus medullaris

14
Thoracolumbar Fractures Controversies

• CLASSIFICATION!!!!!
• Indications for surgery
• Optimal time for surgery
• Best approach for surgery

15
Classifications Necessary for

• Uniform method of description
• Directing treatment
• Facilitating outcome analysis
• Should be
• Comprehensive
• Reproducible
• Usable
• Accurate

16
Böhler 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

Böhler, Verlag von Wilhem Maudrich 1930 
Böhler, Fractures and Dislocation of the Spine,
1956
17
Morphologic ClassificationWatson-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
18
Morphologic Classification Stable vs.
UnstableNicoll 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
19
Anatomic Classification 2 or 3 Columns
Denis 83 McAfee 83 Ferguson Allen84
Holdsworth62 Kelley Whitesides 68
20
Anatomic Classification2 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

21
Anatomic Classification3 Column TheoryDenis 83
Anterior
Middle
Posterior

• 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 structures posterior to PLL
• Same as Holdsworth
• Posterior injury-not sufficient to cause
  instability

22

• McAfee Classification

• Six types
• CT based-100 patients
• Middle column most important

23
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
24
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
• lt6 points posterior only
• gt6 points anterior

lt3
4-9
0-1mm
1-2mm
gt2mm
lt30
30-60
gt10
gt60
Comminution
Fragment Displacement
Kyphosis correction
25
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
26
AO Mechanistic ClassificationComplex
subdivisions to include most fractures
27
Classification of thoracic and lumbar spine
fractures problems of reproducibilityA 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

28
Results

• AO Interobserver
• CT 0.31
• MRI 0.28
• CT/MRI 0.47
• Denis Interobserver
• CT 0.60
• MRI 0.52

29
Vaccaro, A.R. et al, Spine 2005
30
Spine Trauma Study Group Thoracolumbar Injury
Classification and Severity Scale (TLICS)Three
Part Description
Injury Morphology
Integrity of PLC
Neurologic Status
31
Injury Morphology

• Compression prefix-axial, lateral, flexion,
• postfix-burst
• Distraction prefix-extension, flexion
• postfix-compression,
  burst
• Translation/Rotation prefix-flexion
• 
  postfix-compression, burst

32
Neurologic Status

• Intact
• Nerve Root Injury
• Cauda Equina Injury
• Cord Injury-Incomplete, Complete

33
Posterior Ligamentous Complex

• Not disrupted in tension
• Disrupted in tension

34
TreatmentSpine Trauma Severity ScoreDetermined
by

• Injury Morphology
• Neurology
• Ligamentous Integrity

35
Vaccaro, A.R. et al., J. Spinal Disorders
Techniques 2005
36
Point System
Injury Morphology Select one
Translation /
Rotation 3
Compression fx Axial, Flexion 1 Burst - add 1
Distraction injury 4
37
Neurology-Point System
Intact 0
Nerve root
Cauda equina
2
3
Cord And conus medullaris
Incomplete
Complete
3
2
38
Posterior Soft Tissue Point System
Intact 0
PLC (displaced in tension)
Suspected/ Indeterminant 2
Injured 3
Evaluated by MRI, CT, Plain X-rays, Exam
39
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

40
Next Step - Direct TX
Assign Points
Conservative
Surgery
41
Treatment

• Injuries with 3 points or less non operative
• Injuries with 4 pointsNonop vs Op
• Injuries with 5 points or more surgery

42
ExamplesFlexion Compression Fx

• Flexion compression (morphology) - 1
• Intact (neurology) - 0
• PLC (ligament) no injury - 0

Total 1 points- Non Op
43
Compression Burst Fracture

• Flexion compression burst - 2
• Intact ( neurology) - 0
• PLC (ligament) no injury (0)

Total 2 points-Non Op
44
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
45
Compression Burst-Complete injury

• Axial compression burst-2
• Complete (neurology)-2
• PLC (ligament) Intact-0
• Points 4-Non Op vs Op

46
Translational/Rotation Injury

• Distraction, Translation/rotational, compression
  injury - 4
• Complete (neurology) 2
• PLC injury - 3

Total 9 points-Surgery
47
Journal of Spinal Disorders Techniques, 2006

• Surgical Decision making based off tenets of
  classification system
• Injury morphology
• Neurological status
• PLC integrity/injury stability

48
Spine, 2006

• Reliability/treatment validity at single
  institution
• Treatment validity exceptional- 96.4
• Moderate agreement for PLC (66) and mechanism
  (60)

49
Conflict Mechanism vs Morphology
50
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
51
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

52
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

53
Assessment of Injury to the PLC in the Setting of
on Normal Plain RadiographsLee, J., Vaccaro,
A.R. et al. J Orthopaedic Trauma 2006Validation
Study J. Orthopaedic Research Submitted 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

54
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.

55
Spine, 2007

• IMPACT OF TRAINING
• Management component reliability rose from ?
  0.46 (r0.47) on first assessment to ? 0.72
  (r0.91) on the 2nd assessment.

56
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, differences subtle

57
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

58
Management of Thoracic and Lumbar Injuries

• CONTROVERSIAL!!!!

59
Non-Operative Treatment of Thoracic Spine Injuries

• Brace or Cast Treatment
• Compression Fractures
• Stable Burst Fractures
• Pure Bony Flexion-Distraction Injury

60
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

61
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
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

63
Surgical Management of Thoracolumbar Injuries

• Unstable burst fractures
• Purely ligamentous
• Facet dislocations
• Translational injuries
• Neurologic deficit

64
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

65
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

66
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

67
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

68
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

69
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

70
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

71
SurgeryAnterior versus Posterior

• Anterior
• 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

72
Thank You
73
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74
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