Classification of spinal fracture

Classification of spinal fracture by Dr. B. Borthakur

1. CLASSIFICATION, EVALUATION AND MANAGEMENT OF SPINE FRACTURE DR. B. BORTHAKUR (PROF.) DEPT. OF ORTHOPAEDICS, SMCH

2. introduction There are so many classification for spine fracture. The classification of spine injuries is still evolving. None of the classification satisfy all aspect (prognosis, treatment modality etc )

3. Cervical spine Injuries mainly divided into two parts Supra-axial injury Injury to occiput-C1-C2 complex They are mostly ligamentous. Sub-axial injury Injury to C3-C7 vertebrae

4. Cervical spine Injuries to the Occiput-C1-C2 complex Occipital condyle fractures Three types: Type I: Impaction of condyle(usually stable) Type II : Shear injury associated with basilar or Skull fracture (potentially unstable) Type III : Condyle avulsion (unstable) Treatment Stable fracture - Rigid cervical collar immobilization Unstable fracture – halo immobilization or Occipital – cervical fusion

5. Occipitoatlantal dislocation Almost always fatal Resulting from a combination of Hyperextension, distraction and rotation at craniocervical junction Based on the position of occiput in relation to C1 Type I: Occiput condyles anterior to the atlas Type II: Condyle longitudinally dissociated from atlas Type III: Occiput condyles posterior to the atlas

6. Cervical spine HARBORVIEW CLASSIFICATION For quantification of stability of craniocervical junction Type I: Stable with displacement <2 mm Type II: Unstable with displacement < 2 mm Type III: Gross instability with Displacement >2 mm Treatment : Halo vest application with strict avoidance of traction

7. Atlas fracture Levine classification Isolated bony apophysis fracture Isolated posterior arch fracture Isolated anterior arch fracture Comminuted lateral arch fracture Burst fracture or Jefferson fracture Treatment Stable fracture – Rigid cervical orthosis Less stable fracture – Prolonged halo immobilization

8. Fracture of Odontoid process(DENS) Anderson and D‘Alonzo classification Type I: Oblique avulsion of apex Type II: Fracture at the junction of the body and neck Type III: Fracture extending into the cancellous body of C2

9. hangman’s fracture Levine and Edward classification Type I: Nondisplaced ,no angulation Translation <3 mm(stable) Type IA: Atypical unstable lateral bending Fracture that are obliquely displaced . Usually involves one parsinterarticularis , Extending anterior to the pars and into the Body on contralateral side Type II: Significant angulation at C2-C3 Translation >3 mm(unstable) Type IIA: Avulsion of entire C2-C3 intervertebral disc in flexion with injury to posterior longitudinal ligament Type III : Rare, Severe angulation and translation with unilateral or bilateral facet dislocation of C2- C3 (unstable)

10. Injuries to C3-c7(sub-axial) Allen – Ferguson classification 1) compressive flexion(tear drop fracture) Stage I: Blunting of anterior body Stage II: “ Beaking ” of anterior body Loss of anterior vertebral height Stage III: Fracture lien passing from anterior body through the inferior subchondral plate Stage IV: Inferior margin displaced <3 mm into neural canal Stage V: “Tear drop” fracture

11. Allen-Ferguson classification 2) Vertical compression (Burst fracture) Stage I : Fracture through superior or inferior endplate (no displacement) Stage II: Fracture through both endplates (minimal displacement) Stage III: Burst fracture 3) Distractive flexion (Dislocation) Stage I : Failure of posterior ligament facet subluxation Stage II: Unilateral facet dislocation Stage III: Bilateral facet dislocation Stage IV: Bilateral facet dislocation with 100% translation

12. Allen-Ferguson classification 4) Compressive extension Stage I: Unilateral vertebral arch fracture Stage II: Bilateral laminar fracture Stage III, IV: Theoretic continuum between stage II and V Stage V: Bilateral vertebral arch fracture with full vertebral body displacement anteriorly ,

13. 5)Distractive extension Stage I: Failure of anterior Ligamentous complex or transverse fracture of the body Widening of disc space No posterior displacement Stage II: Failure of posterior ligamentous complex and superior displacement of the body into the canal 6) Lateral flexion Stage I: Asymmetric, Unilateral compression fracture of vertebral body Stage II: Displacement of the arch on AP view or failure of the ligaments on the contralateral side with articular process separation

14. Miscellaneous cervical spine fracture Clay shoveler’s fracture Avulsion of Spinous process of lower cervical or upper thoracic vertebrae Treatment- Restriction of movement and symptomatic treatment Sentinal fracture occurs through lamina on either side of Spinous process Treatment – Symptomatic

15. Thoracolumbar spine Classification: McAfee et al . Based on the failure mode of the middle osteoligamentous complex Axial compression Axial distraction Translation within the transverse plane

16. McCormack et al This is a Load sharing classification Thoracolumber Injury Classification System(TICS) Done for- Grade and predict acute spine stability Risk of future deformity Progressive neurologic compromise

17. Denis Minor Spinal Injuries Articular process fracture Transverse process fracture Spinous process fracture Pars interarticularis fracture Major Spinal Injuries Compression fracture Burst fracture Fractures- dislocation Sealt belt- type injuries

18. Compression fracture Can be anterior or lateral There are 4 subtypes based on endplate involvement TypeA : Fracture of both endplate TypeB : Fracture of superior endplate TypeC : Fracture of inferior endplate Type D: Both endplates are intact Treatment : Stable fracture : Extension orthosis with early ambulation Unstable fracture : Open reduction and internal fixation

19. Burst fracture Due to compression failure of the anterior and middle columns under an axial load. There is loss of Posterior vertebral body height and splaying of pedicle There are 5 Subtypes Type A: Fracture of both endplates Type B: Fracture of superior endplate Type C: Fracture of inferior endplate Type D: Burst rotation Type E: Burst lateral flexion

20. Treatment : Burst fracture No neurological deficit : Hyperextension casting or bracing Early stabilization required in case of Neurological deficit Loss of vertebral body height >50% Angulation >20 to 30 degrees Canal compromise of >50% Scoliosis >10 degrees

21. Fracture dislocation All three columns fail under compression, tension, rotation, or shear, with transnational deformity Three types Type A: Flexion-rotation: Posterior and middle column fail in tension and rotation Anterior column fails in compression 75% with neurological deficit Type B: Shear: Failure of all three columns Complete neurologic deficit Type C: Flexion-distraction: Tension failure of posterior and middle columns, anterior tear of annulus fibrosus and stripping of the anterior longitudinal ligament 75% with neurologic deficit

22. Treatment : Fracture dislocation These are highly unstable, require surgical stabilization Patients whose fracture are stabilized within 3 days of injury have a lowwr incidence of pneumonia and a shorter hospital stay than those with fracture stabilized more than 3 days after injury

23. Flexion-distraction injuries Chance fracture, seat belt-type injuries Patients are neurologically intact Four types: Type A: One level bony injury Type B: One level Ligamentous injury Type C: Two level injury through bony middle column Type D: Teo level injury through Ligamentous middle column Treatment Hyperextension casting for type A injuries Posterior spinal fusion with compression for Type B, C and D

24. Denis three- column model Denis three- column model for spinal stability as follows Instability exists with disruption of any two of the three columns. 1) Anterior column : contains Anterior longitudinal ligament Anterior half of the vertebral body Anterior anulus 2) Middle column : contains Posterior half of the vertebral body Posterior annulus Posterior longitudinal ligament 3) posterior column : contains Posterior neural arch( pedicles, facets and laminae) Posterior ligamentous complex(supraspinous ligament, interspinous ligament, ligamentum flavum and facet capsules)

25. sacrum Denis classification Zone 1: Fracture lateral to foramina Most common Zone 2: Fracture through foramina Zone 3: Fracture medial to foramina into spinal canal U type sacral fracture Results from axial loading

26. INITIAL MANAGEMENT TRANSPORT TOTAL SPINE IMMOBILAISATION HARD CERVICAL COLLAR SPINE BOARD 2-3cm OCCIPITAL PAD USED TO AVOID RELATIVE EXTENSION IN CHILDREN- OCCIPITAL RECESS USED TO AVOID RELATIVE FLEXION

27. INITIAL ASSESMENT ADVANCED TRAUMA LIFE SUPPORT AIRWAY BREATHING CIRCULATION

28. SPINE ASSESMENT MECHANISM OF INJURY PRE-INJURY FUNCTIONAL LEVEL WEAKNESS OR SENSORY CHANGES SIGNS OF BLUNT HEAD TRAUMA SPINA TENDERNESS SPINE STEP OFF INTERSPINOUS WIDENEING FLACCIDITY IN THE EXTREMITIES INCONTINENCE PENILE ERECTION

29. NEUROLOGICAL EXAMINATION RECORDED ON ASIA CHART

30. NATIONAL EMERGENCY X-RADIOGRAPHY UTILISATION STUDY (NEXUS) CRITERIA N – NEURODEFICIT S – SPINE TENDERNESS A – ALERTNESS I – INTOXICATION D – DISTRACTING INJURY USED IN ASYMPTOMATIC PATIENTS FOR CLINICALLY CLEARING CERVICAL SPINE

31. DIAGNOSTIC IMAGING CERVICAL SPINE AP VIEW LATERAL WITH B/L SHOULDER PULLED DOWN OR SWIMMER’S VIEW ODONTOID VIEW DORSO-LUMBAR SPINE AP VIEW LATERAL VIEW LUMBO-SACRAL SPINE AP VIEW LATERAL VIEW CT SCAN & MRI – MAY BE REQUIRED FOR FURTHER EVALUATION

32. TREATMENT CERVICAL SPINE NON OPERATIVE- SOFT COLLAR 2 PIECE RIGID COLLAR STERNAL OCCIPITAL MANDIBULAR IMMOBILISATION (SOMI) MINERVA HALO VEST

33. 2. OPERATIVE OCCIPITOCERVICAL FUSION USING MODULAR PLATE & ROD CONSTRUCT/WIRE & BONE GRAFT SEGMENTAL FIXATION WITH OCCIPITRAL PLATING C1 LATERAL MASS SCREW C2 ISTHMIC SCREW LATERAL MASS FIXATION POST. C1-C2 FUSION USING ROD & SCREW CONSTRUCT WITH C1 LATERAL MASS SCREW/MOD. GALLIE POST. WIRING TECHNIQUE ANTERIOR ODONTOID SCREW FIXATION POSTERIOR C1-C2 TRANSARTICULAR SCREW/TRANSLAMINAR SCREW

34. TREATMENT THORACOLUMBAR INJURIES COMPRESSION # EXTENSION ORTHOSIS – STABLE # HYPEREXTENSION CASTING/ORIF – UNSTABLE # BURST # HYPEREXTENSION CASTING/BRACING – NO NEURODEFICIT & STABLE# SURGICAL DECOMPRESSION – UNSTABLE # & NEURODEFICIT

35. FLEXION DISTRACTION INJURIES HYPEREXTENSION CASTING – FOR TYPE A POST. SPINAL FUSION WITH COMPRESSION – TYPE B, C & D FRACTURE DISLOCATION SURGICAL STABILISATION AS UNSTABLE

36. SACRAL FRACTURES NON OPERATIVE – UNDISPLACED WITH STABLE PELVIS OPERATIVE – DISPLACED, UNSTABLE WITH PELVIC/SPINAL INSTABILTY

37. THANK YOU