Thoracolumbar fractures classification

Thoracolumbar fractures classification

1. Thoracolumbar Fractures Classification Dr. Yousef T. Khoja

2. ?? Classification ?? Indications for surgery Optimal time for surgery Best approach for surgery Should be : Comprehensive Reproducible Usable Accurate

3. Classification Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important 2 column 3 column Load Sharing AO TLICS

4. Holdsworth’62 Kelley & Whitesides ’68 Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Anatomic Classification

5. Anatomic Classification 2 Column Theory: Holdsworth 1962 Reviewed 1,000 patients: Separated spine into anterior weight-bearing column (a) and posterior tension-bearing column (b) Six types: simple wedge, dislocation, rotational fracture-dislocation , extension, burst , and shear. Stressed importance of posterior elements If destabilized, must consider surgery

6. Anatomic Classification 3 Column Theory: Denis 1983 Based on radiographic review of 412 cases Anterior : ALL , anterior 2/3 body Middle : post 1/3 body, PLL Posterior : all structures posterior to PLL Middle column Injury was necessary & create instability. Posterior injury not sufficient to cause instability

7. Denis Classification Divides spinal fractures into minor and major injuries Minor injuries: fractures of Transverse Process, Pars Interarticularis , Spinous Process. Major injuries : Wedge Compression , Burst, Seat-belt type & Fracture-Dislocation.

8. Denis Classification Wedge Compression Fracture: Isolated failure of the anterior column Result from forward flexion Rarely are associated with neurological deficit except in multiple adjacent vertebral fracture PLC may be disrupted in tension if there is loss of VB height >50%

9. Denis Classification Burst Fracture: The anterior and middle columns fail from axial load In stable Burst  PLC intact. In Unstable burst  PLC disrupted No relation between canal compromised & neurological defecit . Early Stabilization in: Neurologic Deficits Injury To The Posterior Ligament Complex > 30°kyphosis  > 50% loss of vertebral body height > 50% canal compromise 

10. Denis Classification Flexion-distraction injury (Chance, seat belt injury) 3-columns injury Anterior: Compression Middle & Posterior: Tension Abdominal visceral injuries are commonly associated ~ 50 % Bony vs Ligamentous

11. Denis Classification Fracture-dislocations All three columns have failed in compression, tension, rotation, shear with translation deformity. At the affected level, one part of the spinal canal has been displaced in the transverse plane

12. Load-Sharing Classification McCormack Classification: Designed specifically for thoracolumbar burst fracture (1994 ) Devised method of predicting posterior failure 1-3 points assigned grades to amount of VB comminution , displacement of fracture fragments, degree of kyphosis Sum the points for a 3-9 scale < 6 points posterior only > 6 points anterior <30% 30-60% >60% 0-1mm 1-2mm >2mm Comminution Fragment Displacement Kyphosis Correction <3° 4-9° >10°

13. AO Classification Review of 1445 cases ( Magerl , Gertzbein et al. European Spine Journal 1994) Based on direction of injury force 3 types , 53 injury patterns

14. Thoracolumbar Injury Classification & Severity Score (TLICS or TLISS) Introduced by the Spine Trauma Study Group in 2005. Three major injury characteristics: Injury morphology Neurologic status Integrity of the PLC

15. TLICS The total score used to guide treatment: ≤ 3 points  non-operatively ≥ 5 points  surgical intervention = 4 points  w / or w/o surgery

16. Example (1) Dx : Compression Fx TLICS Morphology: Compression Neurology: Intact PLC: Intact 1 + 0 + 0 = 1 point  Non-OP

17. Example (2) Dx : Stable Burst Fracture TLICS Morphology: Burst Neurology: Intact PLC: Intact 2 + 0 + 0 = 2 points  Non-OP

18. Example (3) Dx : Unstable Burst-Complete Neuro Injury TLICS Morphology: Burst Neurology: Complete PLC: Injury 2 + 2 + 3 = 7 points  OP

19. Example (4) Dx : Stable Burst-Complete injury TLICS Morphology: Burst Neurology: Complete PLC: Intact 2 + 2 + 0 = 4 points  Non-OP vs OP

20. Example (5) Dx : Fracture-Dislocation TLICS Morphology: Distraction Neurology: Complete PLC: Injury 4 + 2 + 3 = 9 points  OP

21. Example (6) 18-year-old woman presented with severe mid back pain following a rollover motor vehicle collision. Patient assessment revealed a normal neurologic examination with a palpable, tender gap in the thoracolumbar region .

22. Example (6) Dx : T11-12 fracture-dislocation with a Chance fracture at T12 TLICS Morphology: Translation Neurology: Intact PLC: Injury 3 + 0 + 3 = 6 points  OP

23. Example (7) A 63-year-old man sustained a 15- foot fall at work and reported severe back pain. Assessment revealed a normal neurologic examination with no posterior tenderness, gap, or step-off .

24. Example (6) Dx : L2 burst fracture TLICS Morphology: Burst Neurology: Intact PLC: Intact 3 + 0 + 0 = 3 points  Non- OP

25. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine This system is being subjected to a rigorous scientific assessment . Based on the evaluation of three basic parameters: Morphologic classification of the fracture Neurologic injury Clinical modifiers

26. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine Morphologic classification Type A: Compression injuries. Failure of anterior structures under compression Type B: Failure of the posterior or anterior tension band Type C: Failure of all elements leading to dislocation or displacement.

27. Morphologic classification Type A: Compression injuries. Five subtypes and no further sub-classification. A0 / minor, nonstructural fractures A1 / Wedge-compression A2 / Split A3 / Incomplete burst A4 / Complete burst

28. A0 / minor, nonstructural fractures Do not compromise the structural integrity of the spinal column

29. A1 / Wedge-compression Fracture of a single endplate without involvement of the posterior wall of the vertebral body.

30. A2 / Split Fracture of both endplates without involvement of the posterior wall of the vertebral body.

31. A3 / Incomplete burst Fracture with any involvement of the posterior wall; only a single endplate fractured.

32. A4 / Complete burst Fracture with any involvement of the posterior wall and both endplates.

33. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine Morphologic classification Type A: Compression injuries. Failure of anterior structures under compression Type B: Failure of the posterior or anterior tension band Type C: Failure of all elements leading to dislocation or displacement.

34. Morphologic classification Type B: Failure of the posterior or anterior tension band There are three subtypes: B1 / Transosseous tension band disruption / Chance fracture B2 / Posterior tension band disruption B3 / Hyperextension

35. B1 / Transosseous tension band disruption / Chance fracture Axial plane horizontal fracture of the anterior and posterior elements goes through the bone of a single vertebra before exiting into the soft tissues posteriorly.

36. B1 / Transosseous tension band disruption / Chance fracture

37. B2 / Posterior tension band disruption Bony and/or ligamentary failure of the posterior tension band together with a Type A fracture.

38. B3 / Hyperextension Injury through the disk or vertebral body leading to a hyperextended position of the spinal column . Anterior structures, especially the ALL are ruptured but there is a posterior hinge preventing further displacement.

39. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine Morphologic classification Type A: Compression injuries. Failure of anterior structures under compression Type B: Failure of the posterior or anterior tension band Type C: Failure of all elements leading to dislocation or displacement.

40. Morphologic classification Type C: Failure of all elements leading to dislocation or displacement. There are no subtypes The pattern of the failure of the tension band can be also specified using the Type B subclassification like B2-flexion distraction or B3 hyperextension.

41. Type C: Failure of all elements

42. Algorithm for Morphologic Classification

43. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine This system is being subjected to a rigorous scientific assessment . Based on the evaluation of three basic parameters: Morphologic classification of the fracture Neurologic injury Clinical modifiers

44. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine Neurologic injury Neurologic status at the moment of admission should be scored N0: Neurologically intact N1: Transient neurologic deficit, which is no longer present N2: Radicular symptoms N3: Incomplete spinal cord injury or any degree of cauda equina injury N4: Complete spinal cord injury NX: Neurologic status is unknown due to sedation or head injury

45. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine This system is being subjected to a rigorous scientific assessment . Based on the evaluation of three basic parameters: Morphologic classification of the fracture Neurologic injury Clinical modifiers

46. AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine Clinical modifiers There are two modifiers M1: is used to designate fractures with an indeterminate injury to the tension band based on spinal imaging with or without MRI. This modifier is important for designating those injuries with stable injuries from a bony standpoint for which ligamentous insufficiency may help determine whether operative stabilization is a consideration. M2: is used to designate a patient-specific comorbidity, which might argue either for or against surgery for patients with relative surgical indications. Examples of an M2 modifier include ankylosing spondylitis or burns affecting the skin overlying the injured spine.

47. Danke ^_^

48. References Thoracolumbar Spine Trauma Classification; J Am Acad Orthop Surg 2010;18:63-71 A Review of Thoracolumbar Spine Fracture Classifications: Journal of Orthopaedics and Trauma Vol . 1 (2011), Article ID 235406, 5 pages. Thoracolumbar Spinal Injuries: http:// www.springer.com/978-3-540-40511-5 Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification: Christopher Bono, MD and Mitch Harris, MD; March 2004: Jim A. Youssef, MD; Revised January 2006 and May 2011; OTA