S4_Classification-Thoracolumar-Spine

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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