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Slide 1-

Thoracic Spine Trauma Sunil Jeph MBBS, MD
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Biomechanics
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Stabilizing anatomy of thoracolumbar spine
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Mechanism of injury
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Intervertebral disks in load bearing and force distribution during axial compression.
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Normal anatomic configuration of the PLC (Posterior ligament complex)
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Anteriorly displaced center of gravity that creates a compressive force (dotted arrow) on the spinal vertebrae similar to the force on the crane lifting arm. The resulting baseline flexion force (solid arrow) on the PLC is similar to the tension on the crane’s lifting cable
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Critical factor for treatment decision making Mechanical stability Integrity of bone and ligamentous components. Objective of treatment: Prevent the development of neurologic injury Prevent the development of progressive deformity in response to physiologic loading and a normal range of movement.
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Thoracolumbar spine classification for clinical and surgical treatment.
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Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
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Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
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Based on Anatomic structures or proposed injury mechanism. Denis three-column classification system: This model is used to predict the soft tissue injury from bone injury Denis three-column classification system
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Denis three-column classification system: Emphasis on the fracture involvement of the “middle column,” (posterior half of the vertebral body and intervertebral disk and the posterior longitudinal ligament)
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Denis three-column classification system: Spinal stability is dependent on at least two intact columns. When two of the three columns are disrupted, it will allow abnormal segmental motion, i.e. instability. So a simple anterior wedge fracture or just sprain of the posterior ligaments is a stable injury. A wedge fracture with rupture of the interspinous ligaments is unstable, because the anterior and the posterior column are disrupted. A burst fracture is always unstable because at least the anterior and middle column are disrupted.
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Criteria to predict soft-tissue injury from bony injury are: Angulation greater than 20 degrees. Translation of 3.5 mm or more.
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Major injuries Compression fracture Burst fracture Seat belt injury Fracture-dislocation Minor injuries: Transverse process fracture articular process fracture pars interarticularis fracture spinous process fracture Denis three-column classification system Injury to the middle column renders the spine mechanically unstable
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Modifications of the Denis classification: Intact posterior ligamentous complex (PLC), two-column unstable injuries can be successfully treated nonsurgically - Unstable Stable. All based on the premise that a fracture caused by forward flexion should be treated by undoing the flexion by positioning the patient in an extension brace, or by surgical intervention correcting the spinal column in extension. Some of the injuries thought to be due to extension mechanisms, however, turn out to be due to flexion and vice versa. These descriptions may thus be misleading.
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Denis classification, Cons: Does not provide prognostic information or consider the patient’s neurologic status, and therefore it cannot adequately guide surgical intervention. Since it uses the terms stable and unstable. In many cases, however, there is no good correlation with the necessity for surgery
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Stability Ambiguous and may refer to: Direct osseous stability Neurological stability Long-term (ligamentous) stability.
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Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
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Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Types (9 subtypes in each) Group A: vertebral body compression Group B: anterior and posterior element injuries with distraction. Transverse disruption either anteriorly or posteriorly. Group C: anterior and posterior element injuries with rotation. axial torque.
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Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Pros: Highly detailed subclassifications, the AO system has shown limited inter-observer variability. Cons: Difficult to use. Does not incorporate the patient’s neurologic status.
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Thoracolumbar spine classification for clinical and surgical treatment. Denis three-column classification system Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification Thoracolumbar Injury Classification and Severity Score (TLICS)
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Thoracolumbar Injury Classification and Severity Score (TLICS) is a scoring and classification system developed by the Spine Trauma Study Group . Scoring and classification system. Decide surgery vs no surgery Based on 3 components: Injury morphology (not mechanism). Integrity of the posterior ligamentous complex. Neurologic status of the patient.
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Injury Morphology If more than one injury morphology exists, the single injury with the largest score is used. If multiple levels of injury are involved, each injury is assessed independently
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PLC Integrity SIGNS OF PLC DISRUPTION: Widening of the interspinous space. Avulsion fracture of the superior or inferior aspects of contiguous spinous processes, Facet joints: widening, empty (“naked”), perched or dislocated. Vertebral body translation or rotation.
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Normal PLC anatomy MR imaging is the standard of reference for detecting PLC injury.
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Except, vertebral body translation or interspinous widening, osseous findings such as a loss of vertebral body height and kyphosis have been found to be unreliable in assessing PLC integrity because of the inverse relationship between osseous destruction and ligamentous injury. Patients with severe osseous destruction may have less risk for PLC injury because the vertebral injury dissipates energy, thereby sparing adjacent soft tissues. Conversely, patients with a significant translation or rotation injury and less vertebral fragmentation may have a higher risk for PLC injury. PLC must be directly assessed at MR imaging regardless of the severity of vertebral body injury seen at CT
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PLC injury scenarios
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PLC injury scenario: 1
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Axial compression with mild flexion, which results in nearly asymmetric height loss of the anterior and middle columns and minimizes the risk of distraction injury to the PLC
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PLC injury scenario: 2
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Flexion-distraction mechanism and PLC injury should also be suspected if a superior or inferior posterior endplate fracture is seen because this likely reflects an avulsion fracture from the comparatively strong annulus fibrosus of the intervertebral disk. PLC injuries can occur in this setting with minimal kyphosis or vertebral body height loss, a fact that further underscores the importance of MR imaging in
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PLC injury scenario: 3
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Posterior endplate fracture with flexion-distraction mechanism and PLC injury.
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Neurologic Status Although clinical neurologic status cannot be directly determined at imaging, a cord or nerve root injury identified on MR images should be included in the imaging report with the percentage of spinal canal narrowing .
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Axial compression with significant burst fracture of the vertebral body, bone retropulsion into the spinal canal, and resultant risk of neurologic injury.
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Anterior vertebral body compression percentage: percentage of anterior vertebral body compression with respect to the average height of the anterior vertebral bodies immediately cephalad and caudad to the injury level . Retropulsion: distance of a line drawn between the posterior margins of the adjacent vertebral bodies and the most posterior margin of the bone fragment. Sagittal canal diameter: distance between the posterior canal border and the anterior canal border. Posterior canal border: convergence of the superior margins of the left and right laminae at the midline of the spinous process. Anterior canal border: posterior extent of the retropulsed midvertebral body.
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Treatment TLICS addresses three different categories of spine stability: Immediate mechanical stability, suggested by injury morphology Long-term stability, indicated by PLC status Neurologic stability, indicated by the presence or absence of a neurologic deficit
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Burst fracture, in the absence of a neurologic deficit is controversial Osseous retropulsion alone does not imply neurologic injury or indicate a need for surgical decompression. Thoracic spine injury with retropulsion may cause significant neurologic injury because the spinal canal in the thoracic area is narrow and blood supply to the cord is sparse. Lumbar spine fracture may result in marked displacement of the cauda equina but no neurologic deficit because of the wider canal and cord termination near L1 Highly comminuted vertebral body fracture is more likely to deform under physiologic loading and may require short-segment posterior fixation and anterior fusion or long-segment posterior fixation. In the absence of a neurologic deficit, PLC integrity should be confirmed at MR imaging, especially if conservative management of burst fracture is planned
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TLICS can help guide the surgical approach
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Case 1
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31 years old man: Trauma
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Jumper's fracture
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Case 2
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21-year-old female who presented after sustaining a seatbelt type injury. She had an exploratory laparotomy for repair of a ruptured duodenum. There was no neurologic deficit.
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Chance fracture
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Mechanism of chance fracture
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first described by G. Q. Chance in 1948 most common site: thoracolumbar junction (T12-L2) "seat belt injury" due to sudden forward flexion in a head-on automobile collision while being restrained by a lap belt. advent of both lap and shoulder belts in the 1980s, Chance fractures have become less common
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Chance variant
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Case 3
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31 year old male. He was working on a roof, fell approximately 5 meters landing on his feet. He complained of pain in left lower extremity and lower back.
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Case 4
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21-year-old woman presented with back pain after a motor vehicle collision in which she was an unrestrained passenger in the middle seat. CT and MR imaging findings are shown.
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Injury morphology (burst) = 2 PLC integrity (indeterminate) = 2 Neurologic status (normal) = 0 TOTAL=4 (Burst fracture PLC integrity indeterminate)
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Injury morphology (burst) = 2 PLC integrity (indeterminate) = 2 Neurologic status (normal) = 0 TOTAL=4 (Burst fracture PLC integrity indeterminate)
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Case 5
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21-year-old man presented with multiple injuries and lower extremity paralysis after a high-speed motor vehicle collision in which he was an unrestrained driver.
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Injury morphology (translation) = 3 PLC (disrupted) = 3, and Neurologic status (cord injury) = 3 TOTAL = 9
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Injury morphology (translation) = 3 PLC (disrupted) = 3, and Neurologic status (cord injury) = 3 TOTAL = 9
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Case 6
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29-year-old man presented with complete paralysis after he collided with a telephone pole while driving a motorcycle.
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Injury morphology (distraction) = 4 PLC (disrupted) = 3 Neurologic status (paralysis) = 2 Total = 9
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Injury morphology (distraction) = 4 PLC (disrupted) = 3 Neurologic status (paralysis) = 2 Total = 9
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Case 7
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17-year-old girl presented with right-sided radiculopathy after a motor vehicle collision in which she was an unrestrained backseat passenger.
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Injury morphology (translation) = 3 PLC (disrupted) = 3 Neurologic status (nerve root injury) = 2. TOTAL = 8
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Injury morphology (translation) = 3 PLC (disrupted) = 3 Neurologic status (nerve root injury) = 2. TOTAL = 8
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Checklist for Reporting Spine Injury: CT Indirect findings
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Checklist for Reporting Spine Injury: MR
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Radiology report may include the TLICS total score if there is clear imaging evidence of neurologic injury. Generally the report will not include the total score if the patient’s clinical neurologic status is unknown.
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References: Khurana B, Sheehan SE, Sodickson A, Bono CM, Harris MB. Traumatic thoracolumbar spine injuries: what the spine surgeon wants to know. Radiographics. 2013 Nov-Dec. Radiology assistant A Magerl F1, Aebi M, Gertzbein SD, Harms J, Nazarian S. comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994; Google images