Youmans

1. Thoracolumbar Trauma
319
25/10/59
Ryan Janicki
Alexander R. Vaccaro
Brian K. Kwon

2. Thoracolumbar Trauma
• The thoracolumbar spine is the transition point between the more
rigid thoracic spine and the more flexible lumbar spine
• Neurological injury
• Long-term pain and disability
• High-velocity deceleration mechanisms

3. Outline
• Anatomy
• Initial Assessment and Management
• Classification
• Management Considerations
• Complications

4. Anatomy

6. Posterior ligamentous complex(PLC)
Sprain during
flexion

9. Watershed zone
4-9 thoracic level

10. Initial Assessment and Management
• Clinical Evaluation
• Imaging

11. Clinical Evaluation : primary survey

12. Clinical Evaluation
secondary survey
• Complete neurological examination
• ASIA work sheet
• Risk factor for thoracolumbar injury
• A high-energy mechanism of injury
• Neurological signs or symptoms
• Pain or tenderness on clinical examination
• The presence of significant distracting injuries
that might make both the patient and physician
overlook a spinal injury
(particularly in the absence of neurological deficits)

13. Imaging
• Plain radiograph
• identifying the level of injury
• characterizing bony injuries
• the relationship of one vertebral body to another
• evaluating the overall alignment of the spine

15. Imaging
• Widening of the interpedicular distance relative to other levels
suggests failure of the posterior vertebral body (middle column)
• burst fractures
• Interspinous distances can sometimes also be appreciated, and
widening is suggestive of a flexion-distraction injury
• Radiographic signs that may indicate major ligamentous (including
PLC) disruption and instability
• displacement of bone
• widening of the interlaminar space, apophyseal joints
• widening of the vertebral canal
• disruption of the posterior vertebral body

16. Cobb method

17. Imaging
• CT
• Excellent bone
• Visualization in any plane
• Benefit of visceral imaging
• Once a spine injury is identified  CT scan or further radiographs of the
entire spine to rule out other noncontiguous fractures(4-28 %)

18. Imaging
• MRI
• T2-weighted fat suppression
• Diskoligamentous soft tissues
• Neurological structures(spinal cord, conus medullaris, cauda equina, and
nerve roots)
• Disruption of PLC
• The sensitivity and specificity of MRI in predicting a torn PLC are 90% and 100%,
respectively
• Discontinuity of the “black stripe” on T2-weighted MRI, which represents the posterior
longitudinal ligament, or SSL, is often used
• Tears of the facet capsule and the ISL result in accumulation of fluid and is represented
by high-intensity signal on T2-weighted imaging

19. Classification
• Minor injury
• Major injury

20. Denis and McAfee three column concept

21. Minor injuries
• Involve only a part of a column and do not lead to acute instability
• not accompanied by major injures
• 1. fracture of transverse process :usually neurologically intact except in two
areas:
a) L4–5 →lum bosacral plexus injuries (there m ay be associated renal injuries,
check U/A for blood)
b) T1–2 →brachial plexus injuries
• 2. fracture of articular process or pars interarticularis
• 3. isolated fractures of the spinous process: in the TL spine: these are usually
due to direct trauma. Often diffcult to detect on plain x-ray
• 4. isolated laminar fracture: rare,stable

22. Major injuries

23. Wedge compression
Type A
Fracture of both end plates
and separation of the anterior body.
Type C
Fracture of the inferior end plate
Type D
Fracture of the anterior vertebral body
without involvement of the end plates
Type B
Fracture of the superior end plate
Note the absence of middle column involvement in all types, act as fulcrum
Most common T6-T8, T12-L3

24. Burst Fractures
Type A
Fracture of both end plates
-axial load
Type C
Fracture of the inferior end plate
-rare
Type D
Burst rotation
-axial load with rotation
Type B
Fracture of the superior end plate
(note the retropulsed bony fragment
[shaded] at the level of the pedicles)
-most common
-axial load with flextion
Type E
Burst lateral flexion
-axial load with lateral flexion
Note
1.the increased interpediculate distance seen on the
anteroposterior views (types D and E)

25. Seat belt–Type
Type A
One-level seat belt–type injury through
bone
-Chance fracture
Type C
Two-level injuries
the injury to the middle column
involves bone
Type D
Two-level injuries
to the middle column
involves ligamentous
Type B
One-level seat belt–type injury through
the ligaments
-that only the anterior anulus and
anterior longitudinal ligament
are preserved
Note
1.Flucrun anterior to anterior column(seat-belt)

26. Fracture-dislocation
Type A
Flexion-rotation–type injuries
through bone (slice fracture)
Type B
Flexion-rotation–type injuries
through the disk
Note
All 3 column
the difference in rotation between involved spinal segments,
which is best appreciated on anteroposterior views

27. Moving Forward from Purely Morphologic
Classifications
previous classification systems
+
patient’s neurological status
+
guideline for whether surgical management
=
Thoracolumbar Injury Severity Score (TLISS)
Modified to
Thoracolumbar Injury Classification and Severity Score (TLICS)

29. Management Considerations
• Decision Making for Nonsurgical versus Surgical Treatment
• Treatment Based on Fracture Morphology

30. Decision Making for Nonsurgical versus
Surgical Treatment
• TLICS
• Goal of surgical management
• decompress neural structures
• correct deformity
• stabilize the spine
• Approach
• posterior
• anterior
• combined approach
• Clinical scenarios

31. Posterior approach
• Familiar and most common used
• Posterior pedicle screw instrumentation
• Correction of sagittal- and coronal-plane deformity is most easily
achieved with posterior instrumentation
• For flexion-distraction injuries : pure distraction and little to no
anterior column injury
• For burst fractures : burst fragment retropulse to spinal canal, ventral
decompression

32. Posterior approach
• Axial-loading injuries in which the PLC and posterior longitudinal
ligament are intact
• Shoud be wary : Posterior distraction across pedicle screw tend to
induce kyphosis
• bending the rods into a slight degree of lordosis
• using fixed-angle or side-loading screws : which allow one to lever down on
the proximal aspect of the cephalad screws

33. Anterior approach
• Burst fractures in which vertebrectomy and anterior reconstruction
are required either to
• decompress retropulsed fragments of bone directly off the ventral dura or
• provide immediate restoration of the anterior weight-bearing column for
reason of mechanical stability
• Severe neurological deficit as the result of a large retropulsed piece
of bones of mechanical stability
• Reconstructed with a cage implant (using autogenous bone graft
from the vertebrectomy) or structural allograft

34. Anterior approach
• Stabilized with a variety of different anterior fixation screw-plate
devices or rod-screw constructs
• If PLC are intact : fixation may suffice to provide stability to the injury.
• If PLC are disruption : anterior construct with posterior pedicle screw-
rod fixation
• Contraindication : Obesity, previous abdominal surgery, and severe
pulmonary, chest, and abdominal trauma

35. Combined approach(360-degree instrumentation)
• Burst fractures with significant PLC disruption
• Vertebrectomy and anterior reconstruction, followed by posterior
pedicle screw instrumentation
• Anterior column reconstruction can also be performed
posterolaterally from a costotransversectomy approach
• Lower lumbar spine

36. Clinical scenarios
Neurologial status Posterior ligamentous complex
• Intact
• Disrupted
• Intact
• Incomplete neurological
deficit or cauda equina injury
• Complete neurological deficit

37. Neurologically Intact/PLC Intact
• If surgery is chosen to promote early rehabilitation
• Anterior (41%) and posterior (59%) approaches
• Surgery not superior to conservative management
• Management : most case no surgical intervention

38. Neurologically Intact/PLC Disrupted
• Flexion-distraction and severe compression injuries
• Management
• stabilized from a posterior approach
• Combination approach is required if the anterior column is severely
comminuted

39. Incomplete Neurological Deficit or Cauda Equina
Injury/PLC Intact
• Burst fractures (with pure axial loading and no significant distraction
through the posterior elements)
• Rarely with extension-distraction injuries
• Management
• early surgical intervention to decompress the neural elements
• Stabilized posteriorly before anterior decompression
• Direct anterior approach and decompression followed
by arthrodesis with a strut graft/cage
and anterior instrumentation

40. Incomplete Neurological Deficit Or Cauda Equina
Injury/PLC Disrupted
• Burst fractures, flexion-distraction fractures, and translational injuries
• Management
• combined anterior and posterior approach
• Stabilized posteriorly before anterior decompression

41. Complete Neurological Deficit/PLC Intact
• Severe burst fractures and extension-distraction fractures
• Management
• posterior approach for stabilization
• anterior decompression to avoid posttraumatic syringomyelia plus
reconstruction of the anterior column was the optimal approach

42. Complete Neurological deficit / PLC Disrupted
• Management
• posterior approach for realignment and stabilization was required
• anterior approach : decrease the risk for posttraumatic syringomyelia

43. Neurologial status Posterior ligamentous
complex
Management
Intact Intact Conservative
Intact Disrupted Posterior +/- anterior
Incomplete neurological deficit or
cauda equina injury
Intact Posterior + anterior
Incomplete neurological deficit or
cauda equina injury
Disrupted Posterior + anterior
Complete neurological deficit Intact Posterior +/- anterior
Avoid post-traumatic syringomyelia
Complete neurological deficit Disrupted Posterior +/- anterior
Avoid post-traumatic syringomyelia

44. Treatment Based on Fracture Morphology
• Wedge Compression Fractures
• Burst Fractures
• Flexion-Distraction Injuries
• Fracture-Dislocations

45. Wedge Compression Fractures
• Stable
• Anterior aspect of the vertebral body, with the posterior aspect of the
vertebral body and the PLC being left intact
• The greatest danger with this fracture morphology is misclassification
• Short-segment pedicle screw stabilization or cement augmentation
• Significant loss of vertebral height
• Kyphosis
• previous laminectomies
• persistent pain

46. Wedge Compression Fractures
• Unstable
• 1. a single compression fracture with:
a) loss of > 50% of height with angulation (particularly if the anterior part of
the wedge comes to a point)
b) excessive kyphotic angulation at one segment. : > 30°, > 40°)
• 2. 3 or more contiguous compression fractures
• 3. neurologic deficit (generally does not occur with pure compression
fracture)
• 4. disrupted posterior column or more than minimal middle column failure
• 5. progressive kyphosis: risk of progressive kyphosis is increased when loss of
height of anterior vertebral body is > 75%. Risk is higher for lumbar
compression fractures than thoracic

47. Burst Fractures
• Unstable fracture, neurological deficit or both
• Surgery
• Decompression of neural structures with stable internal fixation over the
fewest segments
• Neurologically intact patients,intact PLC, stable fracture
• Nonoperatively in the large majority of cases
• Bed rest followed by mobilization in a cast or thoracolumbar orthosis for up to
16 weeks

48. Burst Fractures
• Surgical indication
• 1.anterior vertebral body height ≤ 50% of the posterior height
• 2.residual canal diameter ≤ 50% of normal (note: retropulsed bone in the
canal is often resorbed with either bracing or surgery and is therefore
controversial as an isolated indication for surgery)
• 3.kyphotic angulation ≥ 20°
• 4.when the increased interpediculate distance usually present on the initial
film widens further on AP x-ray when standing in brace/cast
• 5.neurologic deficit (incomplete)
• 6.progressive kyphosis

49. Burst Fractures
Anterior approach
• maintain sagittal alignment
• posterior ligaments have been
disrupted : add posterior
approach
Posterior approach
• Familiarity
• direct decompression of the
neural elements is more difficult
• how far the instrumentation and
fusion construct need to extend
above and below the fracture

50. Common surgical options for burst or severe
compression fracture
• If instrumentation alone is needed
• a) 2 levels above and 2 levels below the fracture
• b) if the index level can be included (i.e. if the pedicles are intact enough to
accept shorter screws), similar biomechanical stability can be achieved by
placing screws at the index level (the fractured level) and then just 1 above
and 1 below
• If decompression of the spinal canal and/or anterior support is
needed, corpectomy and strut graft (e.g. with expandable cage) with
percutaneous pedicle screws may be used. Approaches:
• a) from posterior approach e.g. laminectomy with transpedicular approach
and impacting bone anteriorly out of canal with a mallet and reverse angled
Scoville curette
• b) lateral corpectomy and removal of bone from canal

51. Stable anterior or middle column

52. Seat belt–Type Injuries
• Disruption of the entire PLC,unstable
• Flexion with the axis of rotation is within the body : distractive disruption
of the PLC but compressive failure of the vertebral body anteriorly
• Failed posteriorly in tension + no anterior column failure
• posterior tension band with pedicle screws and single-level fusion
• Compromised the anterior column
• additional fixation points to share the axial loading
• Entire injury has gone through the bone (i.e., a bony “Chance” fracture)
• Simple restoration of the posterior tension band with a short-segment pedicle screw

53. Fracture-Dislocations
• Always unstable, significant neurological compromise
• Surgery
• reduction and stabilization
• A posterior approach usually achieves spinal alignment. A staged
anterior procedure may be required if there is persistent ventral
compression

54. Complication

55. Complication
• Complications associated with immobilization occur
• Infection
• S.aureus
• Implant failure