Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and

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 alignment Narrow spinal canal Facet orientation Rib factor on stability Conus at T12-L1

Anatomy of Lumbar Spine Lordosis is natural alignment Larger vertebral bodies Facet orientation Cauda equina

Thoracolumbar Junction Transition Zone Kyphosis Lordosis Mechanical Difference: Lumbar spine less stiff in flexion

Transition Zone: Predisposed to Failure Little opportunity for force dispersion Central loading of T-L junction Not anatomically disposed to transfer force

Patient Evaluation Pre-hospital care EMT personnel – Initial assessment – Transport and immobilization

Patient Evaluation ABC’s of Trauma History Physical Examination Neurological Classification

Clinical Assessment Inspection Palpation Neurological Evaluation – ASIA Impairment Scale Sensory Evaluation Motor Evaluation Reflex Evaluation – Bulbocavernosus, Babinski

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.

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

Additional Imaging CT scan – bony injuries MRI – images spinal cord, intervertebral discs, ligamentous structures

CT Scan L3 unstable burst fracture

MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris

Thoracolumbar Fractures Controversies CLASSIFICATION!!!!! Indications for surgery Optimal time for surgery Best approach for surgery

Classifications Necessary for Uniform method of description Directing treatment *** Facilitating outcome analysis Should be: Comprehensive Reproducible Usable Accurate

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, Verlag von Wilhem Maudrich 1930 Böhler, Fractures and Dislocation of the Spine, 1956

Morphologic Classification Watson-Jones 38 Descriptive terms based on 252 films – 7 types Examples: – Wedge fracture (compression fx) – Comminuted fracture (burst fx) – Fracture dislocation CT evolved MRI evolved 1930 ‘40 Morphologic Classification ‘50 ‘60 ‘70 ‘80 ‘90 * 2000 ‘10

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 CT evolved MRI evolved 1930 ‘40 Morphologic Classification ‘50 Post elements important ‘60 ‘70 ‘80 ‘90 * 2000 ‘10

Anatomic Classification 2 or 3 Columns Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Holdsworth’62 Kelley & Whitesides ’68

Anatomic Classification 2 Column Theory Holdsworth 62 Posterior Anterior Six types- Nicols 2 – Reviewed 1,000 patients –1 Anterior- vertebral body, ALL, PLL Supports compressive loads –2 Posterior- facets, arch, Inter-spinous ligamentous complex Resists tensile stresses Stressed importance of posterior elements – If destabilized, must consider surgery 2 1

Anatomic Classification 3 Column Theory Denis 83 Posterior Middle Anterior Based on radiographic review of 412 cases 5 types, 20 subtypes –1 Anterior- ALL , anterior 2/3 body –2 Middle - post 1/3 body, PLL –3 Posterior- all structures posterior to PLL Same as Holdsworth Posterior injury-not sufficient to cause instability 3 2 1

McAfee Classification Six types CT based-100 patients Middle column most important

Load Sharing Classification McCormack, Spine 1994 Review of injuries fixed posteriorly (McCormack 94) – Which failed? – Could they be prevented? – Suggests when to go anteriorly CT evolved MRI evolved 1930 ‘40 Morphologic Classification ‘50 Post elements important ‘60 2 column ‘70 ‘80 3 column, McAfee Mechanistic classifications ‘90 Load Sharing * 2000 ‘10

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 30% 30-60% 0-1mm 1-2mm 2mm 4-9 10 60% Comminution 3 Fragment Displacement Kyphosis correction

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 Increasing severity CT evolved MRI evolved 1930 ‘40 Morphologic Classification ‘50 Post elements important ‘60 2 column ‘70 ‘80 3 column, McAfee Mechanistic classifications ‘90 Load Sharing * 2000 AO ‘10

AO Mechanistic Classification Complex subdivisions to include most fractures Types Groups A1 impaction A compression A2 split A3 burst B1 post ligamentous B distraction B2 post osseous B3 anterior C1 A with rotation B rotation C2 B with rotation C3 shear Subgroups Specificastions A1.1 A1.3 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2 A3.3 B1.1 B1.2 B2.1 B2.2 B2.3 B3.1 B3.2 B3.3 C1.1 C1.2 C2.1 C2.2 C2.3 C3.1 C3.2 A1.2.1, A1.2.2, A1.2.3 A3.1.1, A3.1.2, A3.1.3 A3.2.1, A3.2.2, A3.2.3 A3.3.1, A3.3.2, A3.3.3 B1.1.1, B1.1.2, B1.1.3 B1.2.1, B1.2.2, B1.2.3 B2.2.1, B2.2.2 B2.3.1, B2.3.2 B3.1.1, B3.1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4 C2.1.1, C2.1.2, C2.1.3, C2.1.4 C2.2.1, C2.2.2, C2.2.3 C2.3.1, C2.3.2, C2.3.3

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

Results AO Interobserver – CT 0.31 – MRI 0.28 – CT/MRI 0.47 Denis Interobserver – CT 0.60 – MRI 0.52

Vaccaro, A.R. et al, Spine 2005

Spine Trauma Study Group Thoracolumbar Injury Classification and Severity Scale (TLICS) Three Part Description Injury Morphology Integrity of PLC Neurologic Status

Injury Morphology Compression: prefix-axial, lateral, flexion, postfix-burst Distraction: prefix-extension, flexion postfix-compression, burst Translation/Rotation: prefix-flexion postfix-compression, burst

Neurologic Status Intact Nerve Root Injury Cauda Equina Injury Cord Injury-Incomplete, Complete

Posterior Ligamentous Complex Not disrupted in tension Disrupted in tension

Treatment Spine Trauma Severity Score Determined by: Injury Morphology Neurology Ligamentous Integrity

Vaccaro, A.R. et al., J. Spinal Disorders & Techniques 2005

Point System Injury Morphology Select one Translation / Compression fx Axial, Flexion 1 Burst - add 1 Rotation 3 Distraction injury 4

Neurology-Point System Intact 0 Nerve root Cauda equina 3 2 Cord And conus medullaris Incomplete 3 Complete 2

Posterior Soft Tissue Point System Intact 0 PLC (displaced in tension) Suspected/ Indeterminant 2 Injured 3 Evaluated by MRI, CT, Plain X-rays,

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

Next Step - Direct TX Assign Points Conservati ve Surgery

Treatment Injuries with 3 points or less non operative Injuries with 4 points Nonop vs Op Injuries with 5 points or more surgery

Examples Flexion Compression Fx Flexion compression (morphology) - 1 Intact (neurology) - 0 PLC (ligament) no injury - 0 Total 1 points- Non Op

Compression Burst Fracture Flexion compression burst - 2 Intact ( neurology) - 0 PLC (ligament) no injury (0) Total 2 points-Non Op

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

Compression Burst-Complete injury Axial compression burst-2 Complete (neurology)-2 PLC (ligament) Intact-0 Points 4-Non Op vs Op

Translational/Rotation Injury Distraction, Translation/rotational, compression injury - 4 Complete (neurology) – 2 PLC injury - 3 Total 9 pointsSurgery

Journal of Spinal Disorders & Techniques, 2006 Surgical Decision making based off tenets of classification system – Injury morphology – Neurological status – PLC integrity/injury stability

Spine, 2006 Reliability/treatment validity at single institution – Treatment validity exceptional- 96.4% – Moderate agreement for PLC (66%) and mechanism (60%)

Conflict: Mechanism vs Morphology

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

J. Neurosurgery Spine, 2006 Problems – Inter-rater agreement on sub-scores was: Lowest for mechanisms followed by PLC Highest for neurological status Substantial for the management recommendation

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

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

Lim, Coluna/Columna Journal, 2006 IMPACT OF EXPERIENCE (attending surgeons, fellows, residents, and non-surgeon health care professionals). Most reliable among spine fellows, followed by attending spine surgeons.

Spine, 2007 Dramatic Reliability Increase in Latest Evaluation: Inter-rater Reliability as Assessed by Cohen's Kappa TJU TLISS June STSG TLISS July TJU TLISS Dec 0.50 kappa 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. 0.75 0.25 0.00 Mech PLC Total Management Rothman/TJU Reliability Study, Fall 2005

J Spinal Disorders, 2006 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

World J Emerg Surg, 2007 DIFFERENCES IN NATIONALITIES Inter-rater reliability for mechanism higher among non-US surgeons Reliability for PLC, neurological status, management higher among US surgeons

Management of Thoracic and Lumbar Injuries CONTROVERSIAL!!!!

Non-Operative Treatment of Thoracic Spine Injuries Brace or Cast Treatment – Compression Fractures – Stable Burst Fractures – Pure Bony Flexion-Distraction Injury

Folman and Gepstein, J Orthop Trauma, 2003 85 pts reviewed to determine late outcome of nonop management Pain intensity correlated with angle of kyphosis Chronic pain predominant in 69.4% 25% of subjects had changed jobs (most full to part) 48% of subjects filed lawsuits concerning injury But not w/magnitude of anterior column deformity Bed rest alone adequately manages traumatic, uncomplicated thoracolumbar wedge fractures

Agus, Eur J Spine, 2005 Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst fractures 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

Koller, Eur Spine J, 2008 Evaluated 21 pts; 9.5 yr f/u 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

Surgical Management of Thoracolumbar Injuries Unstable burst fractures Purely ligamentous Facet dislocations Translational injuries Neurologic deficit

Dai, J Trauma, 2004 147 pts w/acute thoracolumbar fractures: 1988 to 1997 Min. 3yr f/u; 4 pts died during hospital stay 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

Thomas, J Neurosurg Spine, 2006 Evaluated scientific literature on operative & non-op treatments 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

Dai, Spine, 2008 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

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 Extended anterolateral fixation is biomechanically comparable to circumferential fusion Extension of anterior instrumentation & fusion 1level above and below the unstable segment can result in near equivalent stability to a 2-stage circumferential procedure

Disch, Spine, 2008 Angular stable plate system showed higher primary and secondary stability In specimens with lower BMD, the use of angular stable systems substantially increased stability

Whang, J Am Acad Orthop Surg, 2008 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

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

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

Thank You

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