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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
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Anatomy of Thoracic Spine Kyphosis is natural alignment Narrow spinal canal Facet orientation Rib factor on stability Conus at T12-L1
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Anatomy of Lumbar Spine Lordosis is natural alignment Larger vertebral bodies Facet orientation Cauda equina
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Thoracolumbar Junction Transition Zone Kyphosis Lordosis Mechanical Difference: Lumbar spine less stiff in flexion
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Transition Zone:Predisposed to Failure Little opportunity for force dispersion Central loading of T-L junction Not anatomically disposed to transfer force
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Patient Evaluation Pre-hospital care EMT personnel Initial assessment Transport and immobilization
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Patient Evaluation ABC’s of Trauma History Physical Examination Neurological Classification
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Clinical Assessment Inspection Palpation Neurological Evaluation ASIA Impairment Scale Sensory Evaluation Motor Evaluation Reflex Evaluation Bulbocavernosus, Babinski
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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.
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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
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Additional Imaging CT scan – bony injuries MRI – images spinal cord, intervertebral discs, ligamentous structures
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CT Scan L3 unstable burst fracture
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MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris
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Thoracolumbar Fractures Controversies CLASSIFICATION!!!!! Indications for surgery Optimal time for surgery Best approach for surgery
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Classifications Necessary for…… Uniform method of description Directing treatment *** Facilitating outcome analysis Should be: Comprehensive Reproducible Usable Accurate
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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, Fractures and Dislocation of the Spine, 1956 Böhler, Verlag von Wilhem Maudrich 1930
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Morphologic ClassificationWatson-Jones 38 Descriptive terms based on 252 films 7 types Examples: Wedge fracture (compression fx) Comminuted fracture (burst fx) Fracture dislocation Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved *
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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 Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important
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Holdsworth’62 Kelley & Whitesides ’68 Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Anatomic Classification 2 or 3 Columns
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Anatomic Classification2 Column Theory Holdsworth 62 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 Posterior Anterior
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Anatomic Classification3 Column TheoryDenis 83 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 Anterior Middle Posterior
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McAfee Classification Six types CT based-100 patients Middle column most important
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Load Sharing Classification McCormack, Spine 1994 Review of injuries fixed posteriorly (McCormack 94) Which failed? Could they be prevented? Suggests when to go anteriorly Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important 2 column 3 column, McAfee Mechanistic classifications Load Sharing
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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 posterior only >6 points anterior Comminution Fragment Displacement Kyphosis correction <30% 30-60% >60% 0-1mm 1-2mm >2mm <3° 4-9° >10°
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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 Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important 2 column 3 column, McAfee Mechanistic classifications Load Sharing AO Increasing severity
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AO Mechanistic ClassificationComplex subdivisions to include most fractures
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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
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Results AO Interobserver CT 0.31 MRI 0.28 CT/MRI 0.47 Denis Interobserver CT 0.60 MRI 0.52
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Vaccaro, A.R. et al, Spine 2005
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Spine Trauma Study Group Thoracolumbar Injury Classification and Severity Scale (TLICS)Three Part Description Injury Morphology Neurologic Status Integrity of PLC
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Injury Morphology Compression: prefix-axial, lateral, flexion, postfix-burst Distraction: prefix-extension, flexion postfix-compression, burst Translation/Rotation: prefix-flexion postfix-compression, burst
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Neurologic Status Intact Nerve Root Injury Cauda Equina Injury Cord Injury-Incomplete, Complete
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Posterior Ligamentous Complex Not disrupted in tension Disrupted in tension
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TreatmentSpine Trauma Severity ScoreDetermined by: Injury Morphology Neurology Ligamentous Integrity
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Vaccaro, A.R. et al., J. Spinal Disorders & Techniques 2005
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Point System Compression fx Axial, Flexion 1 Burst - add 1 Distraction injury 4 Translation / Rotation 3 Injury Morphology Select one
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Neurology-Point System Cauda equina Cord And conus medullaris Incomplete Complete Nerve root 3 3 2 2 Intact 0
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Posterior Soft Tissue Point System PLC (displaced in tension) Evaluated by MRI, CT, Plain X-rays, Exam Intact 0 Injured 3 Suspected/ Indeterminant 2
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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
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Next Step - Direct TX Assign Points Conservative Surgery
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Treatment Injuries with 3 points or less = non operative Injuries with 4 points=Nonop vs Op Injuries with 5 points or more = surgery
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ExamplesFlexion Compression Fx Flexion compression (morphology) - 1 Intact (neurology) - 0 PLC (ligament) no injury - 0 Total 1 points- Non Op
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Compression Burst Fracture Flexion compression burst - 2 Intact ( neurology) - 0 PLC (ligament) no injury (0) Total 2 points-Non Op
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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
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Compression Burst-Complete injury Axial compression burst-2 Complete (neurology)-2 PLC (ligament) Intact-0 Points 4-Non Op vs Op
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Translational/Rotation Injury Distraction, Translation/rotational, compression injury - 4 Complete (neurology) – 2 PLC injury - 3 Total 9 points-Surgery
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Surgical Decision making based off tenets of classification system Injury morphology Neurological status PLC integrity/injury stability Journal of Spinal Disorders & Techniques, 2006
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Reliability/treatment validity at single institution Treatment validity exceptional- 96.4% Moderate agreement for PLC (66%) and mechanism (60%) Spine, 2006
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Conflict: Mechanism vs Morphology
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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
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Problems Inter-rater agreement on sub-scores was: Lowest for mechanisms followed by PLC Highest for neurological status Substantial for the management recommendation J. Neurosurgery Spine, 2006
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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
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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
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IMPACT OF EXPERIENCE (attending surgeons, fellows, residents, and non-surgeon health care professionals). Most reliable among spine fellows, followed by attending spine surgeons. Lim, Coluna/Columna Journal, 2006
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IMPACT OF TRAINING Management component: reliability rose from κ = 0.46 (r=0.47) on first assessment to κ = 0.72 (r=0.91) on the 2nd assessment. Spine, 2007
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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 J Spinal Disorders, 2006
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DIFFERENCES IN NATIONALITIES Inter-rater reliability for mechanism higher among non-US surgeons Reliability for PLC, neurological status, management higher among US surgeons World J Emerg Surg, 2007
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Management of Thoracic and Lumbar Injuries CONTROVERSIAL!!!!
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Non-Operative Treatment of Thoracic Spine Injuries Brace or Cast Treatment Compression Fractures Stable Burst Fractures Pure Bony Flexion-Distraction Injury
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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 Folman and Gepstein, J Orthop Trauma, 2003
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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 Agus, Eur J Spine, 2005 Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst fractures
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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 Koller, Eur Spine J, 2008 Evaluated 21 pts; 9.5 yr f/u
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Surgical Management of Thoracolumbar Injuries Unstable burst fractures Purely ligamentous Facet dislocations Translational injuries Neurologic deficit
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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 Dai, J Trauma, 2004 147 pts w/acute thoracolumbar fractures: 1988 to 1997 Min. 3yr f/u; 4 pts died during hospital stay
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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 Thomas, J Neurosurg Spine, 2006 Evaluated scientific literature on operative & non-op treatments
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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 Dai, Spine, 2008
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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 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
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Angular stable plate system showed higher primary and secondary stability In specimens with lower BMD, the use of angular stable systems substantially increased stability Disch, Spine, 2008
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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 Whang, J Am Acad Orthop Surg, 2008
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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
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Surgery:Anterior 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
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Thank You
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Eur Spine J. 2008 Aug;17(8):1073-95. Epub 2008 Jun 25. Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases. J Trauma. 2004 Feb;56(2):348-55. Thomas KC, Bailey CS, Dvorak MF, Kwon B, Fisher C. Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit: a systematic review. J Neurosurg Spine. 2006 May;4(5):351-8. Dai LY, Wang XY, Jiang LS, Jiang SD, Xu HZ. Plain radiography versus computed tomography scans in the diagnosis and management of thoracolumbar burst fractures. Spine. 2008 Jul 15;33(16):E548-52. Acosta FL Jr, Buckley JM, Xu Z, Lotz JC, Ames CP. Biomechanical comparison of three fixation techniques for unstable thoracolumbar burst fractures. Laboratory investigation. J Neurosurg Spine. 2008 Apr;8(4):341-6. Disch AC, Knop C, Schaser KD, Blauth M, Schmoelz W. Angular stable anterior plating following thoracolumbar corpectomy reveals superior segmental stability compared to conventional polyaxial plate fixation. Spine. 2008 Jun 1;33(13):1429-37. Whang PG, Vaccaro AR. Thoracolumbar fractures: anterior decompression and interbody fusion. J Am Acad Orthop Surg. 2008 Jul;16(7):424-31. Gertzbein SD, Crowe PJ, Fazl M, Schwartz M, Rowed D. Canal clearance in burst fractures using the AO internal fixator. Spine. 1992 May;17(5):558-60. McAfee PC, Bohlman HH. Complications following Harrington instrumentation for fractures of the thoracolumbar spine. J Bone Joint Surg Am. 1985 Jun;67(5):672-86.
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