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  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 Zone: Predisposed 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 • ABC’s 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, Fractures and Dislocation of the Spine, 1956 Böhler, Verlag von Wilhem Maudrich 1930
  17. Morphologic Classification Watson-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 *
  18. 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 Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important
  19. Holdsworth’62 Kelley & Whitesides ’68 Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Anatomic Classification 2 or 3 Columns
  20. Anatomic Classification 2 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 1 2 1 2
  21. Anatomic Classification 3 Column Theory Denis 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 1 2 3 1 2 3
  22. McAfee Classification COLUMNS Type Anterior Middle Posterior Mechanism Wedge Compression Compression None None Forward Flexion Stable Burst Compression Compression None Axial Compression Unstable Burst Compression Compression Comp, Lat Flex, Rot Comp,Lat Flex, Rot Flexion-Distraction Compression Tension Tension Anterior Fulcrum Chance Tension Tension Tension Anterior Fulcrum Translational Shear Shear Shear Shear • 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 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
  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 • <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°
  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 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
  26. AO Mechanistic Classification Complex subdivisions to include most fractures Types Groups Subgroups Specificastions A1.1 A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3 A1.3 A2.1 A compression A2 split A2.2 A2.3 A3.1 A3.1.1, A3.1.2, A3.1.3 A3 burst A3.2 A3.2.1, A3.2.2, A3.2.3 A3.3 A3.3.1, A3.3.2, A3.3.3 B1.1 B1.1.1, B1.1.2, B1.1.3 B1 post ligamentous B1.2 B1.2.1, B1.2.2, B1.2.3 B2.1 B distraction B2 post osseous B2.2 B2.2.1, B2.2.2 B2.3 B2.3.1, B2.3.2 B3.1 B3.1.1, B3.1.2 B3 anterior B3.2 B3.3 C1.1 C1 A with rotation C1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4 C2.1 C2.1.1, C2.1.2, C2.1.3, C2.1.4 B rotation C2 B with rotation C2.2 C2.2.1, C2.2.2, C2.2.3 C2.3 C2.3.1, C2.3.2, C2.3.3 C3 shear C3.1 C3.2
  27. 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
  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 Neurologic Status Integrity of PLC
  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. Treatment Spine Trauma Severity Score Determined by: • Injury Morphology • Neurology • Ligamentous Integrity
  35. Vaccaro, A.R. et al., J. Spinal Disorders & Techniques 2005
  36. Point System Compression fx Axial, Flexion 1 Burst - add 1 Distraction injury 4 Translation / Rotation 3 Injury Morphology Select one
  37. Neurology-Point System Cauda equina Cord And conus medullaris Incomplete Complete Nerve root 3 3 2 2 Intact 0
  38. Posterior Soft Tissue Point System PLC (displaced in tension) Evaluated by MRI, CT, Plain X-rays, Exam Intact 0 Injured 3 Suspected/ Indeterminant 2
  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 points=Nonop vs Op • Injuries with 5 points or more = surgery
  42. Examples Flexion 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. • Surgical Decision making based off tenets of classification system – Injury morphology – Neurological status – PLC integrity/injury stability Journal of Spinal Disorders & Techniques, 2006
  48. • Reliability/treatment validity at single institution –Treatment validity exceptional- 96.4% – Moderate agreement for PLC (66%) and mechanism (60%) Spine, 2006
  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. • 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
  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 Radiographs Lee, J., Vaccaro, A.R. et al. J Orthopaedic Trauma 2006 Validation 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. • 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
  55. • 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 Dramatic Reliability Increase in Latest Evaluation: Inter-rater Reliability as Assessed by Cohen's Kappa Mech PLC Total Management 0.00 0.25 0.50 0.75 TJU TLISS June STSG TLISS July Rothman/TJU Reliability Study, Fall 2005 TJU TLISS Dec kappa
  56. • 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
  57. • 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
  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.  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
  61.  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
  62.  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
  63. Surgical Management of Thoracolumbar Injuries • Unstable burst fractures • Purely ligamentous • Facet dislocations • Translational injuries • Neurologic deficit
  64.  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
  65.  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
  66.  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
  67.  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
  68.  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
  69.  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
  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. 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
  72. Thank You
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