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

ABCs 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

Bhler 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

Bhler, Verlag von Wilhem Maudrich 1930

Bhler, 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

2or3
Columns

Denis83
McAfee83
Ferguson&
Allen84

Holdsworth62
Kelley&
Whitesides68

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

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

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

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
0.75

0.50

kappa

IMPACT OF TRAINING
Management component:
reliability rose from = 0.46
(r=0.47) on first assessment to
= 0.72 (r=0.91) on the 2nd
assessment.

TJU TLISS June

STSG TLISS July
TJU TLISS Dec

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 3column
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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Thank you

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