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
Anatomy of Thoracic Spine
• Kyphosis is natural
• Narrow spinal canal
• Facet orientation
• Rib factor on stability
• Conus at T12-L1
Anatomy of Lumbar Spine
• Lordosis is natural
• Larger vertebral bodies
• Facet orientation
• Cauda equina
2 Column Theory
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
3 Column Theory
• 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
Load Sharing Classification
McCormack, Spine 1994
• Review of injuries fixed posteriorly
– Which failed?
– Could they be prevented?
– Suggests when to go anteriorly
1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10
CT evolved MRI evolved
Load Sharing Classification
• 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
0-1mm 1-2mm >2mm <3° 4-9°
• 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
1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10
CT evolved MRI evolved
AO Mechanistic Classification
Complex subdivisions to include most fractures
Types Groups Subgroups Specificastions
A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3
A compression A2 split A2.2
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
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
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
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
0 = No Agreement
1.0 = Perfect Agreement
Posterior Soft Tissue Point System
(displaced in tension)
Evaluated by MRI, CT,
Plain X-rays, Exam
• AS/ DISH/Metabolic bone disease
• Sternal fracture
• Multiple rib fractures at same or adjacent levels as
• Multiple trauma
• Coronal plane deformity
• Burns at site of anticipated incision
The Journal of Spinal Disorders
Identifying objective findings on
imaging studies and clinical
examination instead of guessing
injury mechanisms provides more
valid understanding of injury
– 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
The Spine Journal, 2006
Most reliable indicators:
• Vertebral body translation on plain
• Disrupted PLC components on T1 sagittal
• Focal kyphosis in absence of vertebral body
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
- Disrupted PLC components i.e. ISL, SSL, LF;
black stripe on T1 sagittal MRI , most important
- Diastasis of the facet joints on CT
- Fat suppressed T2 sagittal MRI
• IMPACT OF EXPERIENCE
(attending surgeons, fellows,
residents, and non-surgeon health
• Most reliable among spine fellows,
followed by attending spine
Lim, Coluna/Columna Journal, 2006
• 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
Dramatic Reliability Increase in Latest Evaluation:
Inter-rater Reliability as Assessed by Cohen's Kappa
Mech PLC Total Management
TJU TLISS June
STSG TLISS July
Rothman/TJU Reliability Study, Fall 2005
TJU TLISS Dec
• DIFFERENCES BETWEEN SPECIALTIES
– Inter-rater reliability: “injury mechanism” higher in
– Assessment of PLC, neurological status- higher in
– Reliability total score/management recommendations similar
– Overall, differences subtle
J Spinal Disorders, 2006
• DIFFERENCES IN
• 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
85 pts reviewed to determine late outcome of non-
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
No correlation was found between radiological
Vertebral column deformity that occurred after the
injury was stable in 2-column; progressive in 3-
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
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
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
Dai, J Trauma, 2004
147 pts w/acute thoracolumbar fractures: 1988 to 1997
Min. 3yr f/u; 4 pts died during hospital stay
Lack of evidence demonstrating superiority of one
approach over the other
No evidence linking posttraumatic kyphosis to
Strong need for improved clinical research
methodology to be applied to this patient
Thomas, J Neurosurg Spine, 2006
Evaluated scientific literature on operative & non-op treatments
Reviewed 37 pts
Accuracy of plain radiographs improved
w/experience of observers
Impact of disagreement on treatment plan was
Plain radiography alone is not adequate
Dai, Spine, 2008
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
Acosta, J Neurosurg Spine, 2008
Biomechanical comparison of 3 fixation techniques for unstable
Induced at L1:
1) Short-segment anterolateral fixation
2) Circumferential fixation
3) Extended anterolateral fixation
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
Difficult to establish the ideal surgical approach
Anterior decompression assocd w/ recovery of motor
strength & bowel/bladder fxn; pain & improve
Stand-alone anterior constructs: complications &
likely to have revision
More definite evidence required to determine best
Whang, J Am Acad Orthop Surg, 2008
Conclusions on Treatment
• Surgically treating incomplete neuro
deficits potentiates improvement and
• Complete neuro deficits may benefit from
operative treatment to allow mobilization
• Little chance of developing neuro deficits
with nonoperative treatment
Anterior versus Posterior
– More predictable
– Saves levels
– Questionable improved
recovery of neuro
– Gertzbein,1992 – may be
indicated in bladder
– McAfee, 1985 – neuro
recovery in 70 patients
– Less morbidity
– Failures with short –
– Usually requires more
– Less blood loss
– Transpedicular anterior
column bone grafting may
protect posterior construct
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