Thoracolumbar fractures

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Thoraco- Lumbar Spine Fractures and Dislocations Assessment and Classification:

Thoraco- Lumbar Spine Fractures and Dislocations Assessment and Classification Hossam Gad, MD Tanta university

Anatomy of Thoracic Spine:

Anatomy of Thoracic Spine Kyphosis is a natural alignment. Narrow spinal canal. Facet orientation. Rib factor add on stability. Conus ends at T12-L1.

Anatomy of Lumbar Spine:

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

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The facet joints of the thoracic region are oriented in the coronal (frontal) plane, limiting flexion and extension while providing substantial resistance to anteroposterior translation .

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In the lumbosacral region, the facet joints are oriented in a more sagittal alignment, which increases the degree of potential flexion and extension at the expense of limiting lateral bending and rotation.

Thoracolumbar Junction:

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

Transition Zone: Predisposed to Failure:

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

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The dorsolumbar junction is a zone of structural and functional transition, which makes it vulnerable to injury, this transition zone between the rigid thoracic vertebral column and the relatively mobile lumbar column creates a fulcrum at the thoraco lumbar junction

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For this reason the 75% of fractures occurring between T12 and L2. And this fractures associated with neurological injury in up to 48% of cases ------ 19% presented with complete neurological deficit, 26% have incomplete deficit, and 55% are neurologically intact.

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Thoracolumbar fractures are more frequent in men (2/3) than in women (1/3) and peak between the ages of 20 and 40 years . Spinal injuries in 22% of poly- traumatized patients.

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A delay in the diagnosis of thoracolumbar fractures is frequently associated with an unstable patient condition that necessitates higher-priority procedures than thoracolumbar spine radiographs in the emergency department.

Pathogenesis:

Pathogenesis Axial load burst fracture; the posterior elements are usually intact. In F lexion/distraction injuries, the posterior ligamentous and osseous elements fail in tension; a wedge compression fracture of the vertebral body.

Pathogenesis:

Pathogenesis Hyperextension rupture of the anterior ligament and the disc as well as in compression injuries of the posterior elements, i.e., fracture of the facets, the laminae, or the spinous processes. Rotational injuries combine compressive forces and flexion/distraction mechanisms and are highly unstable injuries. Shear forces severe ligamentous disruption and usually result in complete spinal cord injury.

Patient Evaluation:

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

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The cardinal symptoms are: Pain, loss of function (inability to move), sensorimotor deficit, bowel and bladder dysfunction

Clinical Assessment:

Clinical Assessment The inspection and palpation of the spine should include the search for: ) skin bruises, lacerations, ecchymoses ) open wounds ) swellings ) hematoma ) spinal (mal)alignment ) gaps

Clinical Assessment:

Clinical Assessment Neurological Evaluation ASIA Impairment Scale Sensory Evaluation--- Sacral sparing indicates an incomplete lesion with a better prognosis. Motor Evaluation Reflex Evaluation Bulbocavernosus, Babinski

Dermatomal Sensory Testing :

Dermatomal Sensory Testing

Lumbar and Sacral Motor Root Function:

Lumbar and Sacral Motor Root Function

Lumbar and Sacral Motor Root Function :

Lumbar and Sacral Motor Root Function

Reflex Examination:

Reflex Examination

Spinal Shock:

Spinal Shock Physiologic disruption of all spinal cord function Present or not present Bulbocavernosus Reflex

Spinal Shock:

Spinal Shock No BCR Flaccid paralysis, hypotonia, areflexia Hours to days End of shock stage + BCR Hyper reflexia, spasticity, clonus

Neurogenic shock:

Neurogenic shock Disruption of descending sympathetic outflow No sympathetic response and unopposed vagal tone Cardiovascular instability

Classification of Spinal Cord injury:

Classification of Spinal Cord injury Many Grading Systems Impairment Based Frankel ASIA Yale Motor Index Function Based Modified Barthel Index

Grading of Spinal Cord Injury:

Grading of Spinal Cord Injury

Grading of Spinal Cord Injury:

Grading of Spinal Cord Injury

Complete VS Incomplete Cord lesion:

Complete VS Incomplete Cord lesion Complete No function below level of injury Absence of sensation and voluntary movement in S4/5 distribution Incomplete Preservation of sensation in S4/5 distribution and voluntary control of anal sphincter

Incomplete cord lesion:

Incomplete cord lesion Determined by anatomic location of tissue injury Must understand cord anatomy Predictably pattern based on involvement

Cauda Equina Syndrome:

Cauda Equina Syndrome Cord ends L1/2 disc space Lower motor neuron axons Perianal anesthesia, sphincter and bladder dysfunction

Clinical Assessment:

Clinical Assessment Thoracolumbar factures may damage the parasympathic centers located in the conus medullaris. This injury will lead to bladder dysfunction, bowel dysfunction as well as sexual dysfunction.

Clinical Assessment:

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.

Clinical Assessment:

Clinical Assessment Associated Injuries About one-third of all spine injuries have concomitant injuries head injuries (26%) chest injuries (24%) long bone injuries (23%) Flexion injuries are frequently associated with abdominal injuries.

Radiographic Evaluation:

Radiographic Evaluation Trauma series includes: lateral cervical, chest, lateral thoracic, A/P and lateral lumbar and A/P pelvis Supine radiographs underestimate the kyphotic deformity. Emergency radiographs often do not suffice because of their poor quality. CT has replaced radiographs for the assessment of seriously injured patients

When analyzing plain films, the following signs and points have to be considered:

When analyzing plain films, the following signs and points have to be considered loss of lateral vertebral body height (i.e., scoliotic deformity) Changes in horizontal and vertical interpedicular distance.

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asymmetry of the posterior structures luxation of costotransverse articulations perpendicular or oblique fractures of the dorsal elements irregular distance between the spinous processes (equivocal sign)

In the lateral view, the following features should be investigated:

In the lateral view, the following features should be investigated sagittal profile degree of vertebral body compression

In the lateral view:

In the lateral view interruption or bulging of the posterior line of the vertebral body dislocation of a dorsoapical fragment height of the intervertebral space

Additional Imaging:

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

CT Scan:

CT Scan L3 unstable burst fracture

CT Scan:

CT Scan

MRI Scan:

MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris MRI is helpful in ruling out discoligamentous lesions

Thoracolumbar Fractures Controversies:

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

Classifications Necessary for……:

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

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Definition of spinal instability Loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve root and, in addition, there is no development of incapacitating deformity or pain from structural changes.

Böhler 1930:

B ö hler 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, Fractures and Dislocation of the Spine, 1956 B ö hler, Verlag von Wilhem Maudrich 1930  

Morphologic Classification Watson-Jones 38:

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

Morphologic Classification Stable vs. Unstable Nicoll 49:

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 this classification is insufficient to give detailed treatment recommendations. Morphologic Classification 1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10 CT evolved MRI evolved * Post elements important

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

Anatomic Classification 2 Column Theory - Holdsworth 62:

Anatomic Classification 2 Column Theory - Holdsworth 62 Holdsworth [54] was the first to stress the mechanism of injury to classify spinal injuries and described five different injury types . 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 Posterior Anterior 1 2 1 2

Anatomic Classification 3 Column Theory Denis 83:

Anatomic Classification 3 Column Theory Denis 83 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 Unstable (>50% height, >30% kyphosis, multi level) Anterior Middle Posterior 1 2 3 1 2 3

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Denis distinguished minor and major injuries: Minor injuries included- fractures of the articular, transverse, and spinous processes as well as the pars interarticularis. Major spinal injuries were divided into compression fractures, burst fractures, flexion-distraction (seat-belt) injuries, and fracture dislocations.

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

McAfee and Associates:

McAfee and Associates Based on the CT scan appearance of 100 fractures Six injury patterns: Wedge-compression fracture Stable burst Unstable burst Chance Flexion-distraction Translational McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

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Compression Fracture Classification McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

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Stable Burst Fracture Minimal Kyphosis < 50% Ht. Loss Moderate CC No Neuro Deficit No Posterior Inj. Classification McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

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Posterior element disruption Progressive neurological deficit Kyphosis of greater than 20º-30º Anterior height loss > 50% Canal compromise > 50% Unstable Burst Fracture Classification McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

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Flexion - Distraction Injury Classification McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

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Translational Shear Injury Classification McAfee PC, Yuan HA, et al. The value of CT in thoracolumbar fractures. JBJS 1993

Load Sharing Classification McCormack, Spine 1994:

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

Load Sharing Classification (McCormack 94):

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

Mechanistic Classification AO :

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

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The AO classification has gained widespread acceptance in Europe for the grading of thoracolumbar fractures: Type A: vertebral compression fractures; Type B: anterior and posterior column injuries with distraction; Type C: anterior and posterior element injury with rotation

AO Mechanistic Classification Complex subdivisions to include most fractures :

AO Mechanistic Classification Complex subdivisions to include most fractures

AO fracture classification – fracture types and groups:

AO fracture classification – fracture types and groups

Vaccaro, A.R. et al, Spine 2005:

Vaccaro, A.R. et al, Spine 2005

Spine Trauma Study Group Thoracolumbar Injury Classification and Severity Scale (TLICS) Three Part Description:

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

Injury Morphology:

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:

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

Posterior Ligamentous Complex :

Posterior Ligamentous Complex Not disrupted in tension Disrupted in tension

Treatment Spine Trauma Severity Score Determined by::

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

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

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

Point System:

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

Neurology-Point System:

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

Posterior Soft Tissue Point System:

Posterior Soft Tissue Point System PLC (displaced in tension) Evaluated by MRI, CT, Plain X-rays, Exam Intact 0 Injured 3 Suspected / 1 Indeterminant 2

MODIFIERS:

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:

Next Step - Direct TX Assign Points Conservative Surgery

Treatment:

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:

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

Compression Burst Fracture :

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:

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:

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

Translational/Rotation Injury :

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

The Spine Journal, 2006:

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:

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

Management of Thoracic and Lumbar Injuries:

Management of Thoracic and Lumbar Injuries CONTROVERSIAL!!!!

General objectives of treatment:

General objectives of treatment restoration of spinal alignment preservation or improvement of neurological function restoration of spinal stability avoidance of collateral damage

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Primary goals of treatment are prevention and limitation of neurological injury as well as restoration of spinal stability, regardless of whether operative or non-operative therapy is Chosen. Secondary goals consist of correction of deformities, minimizing the loss of motion, and facilitating rapid rehabilitation.

Non operative TTT:

Non operative TTT Main advantage of non-operative treatment of thoracolumbar fracture is avoidance of surgery-related complications such as: ) infection ) iatrogenic neurological injury ) failure of instrumentation ) anesthesia-related complications

Non-Operative Treatment of Thoracic Spine Injuries:

Non-Operative Treatment of Thoracic Spine Injuries Favorable indications for non-operative treatment: pure osseous lesions - absence of malalignment absence of neurological deficits absence of gross bony destruction only mild to moderate pain on mobilization absence of osteopenia /osteoporosis

Non-Operative Treatment of Thoracic Spine Injuries:

Non-Operative Treatment of Thoracic Spine Injuries Three different methods of non-operative treatment: repositioning and cast stabilization functional treatment and bracing without repositioning functional treatment without bracing

PowerPoint Presentation:

According to Bohler, the time of immobilization in a cast is usually 3–5 months depending on the fracture type. Importantly, skillful physical therapy is paramount to achieve good results. Because thoracolumbar fractures are bound to return to the initial deformity. Functional bracing without repositioning is an alternative to Bohler’s concept of repositioning and stabilization with a cast if the initial deformity is acceptable.

Surgical Management of Thoracolumbar Injuries:

Surgical Management of Thoracolumbar Injuries Surgical stabilization allows for: early mobilization of the patient diminished pain facilitated nursing care (poly-traumatized patients) earlier return to work avoidance of late neurological complications

Indications of Surgical Management:

Indications of Surgical Management Absolute incomplete paraparesis progressive neurological deficit spinal cord compression w/o neurological deficit fracture dislocation severe segmental kyphosis (>30°) predominant ligamentous injuries Relative pure osseous le desire for early return to regular activities avoidance of secondary kyphosis concomitant injuries (thoracic, cerebral) facilitating nursing in paraplegic patients

Timing of Surgery :

Timing of Surgery The timing of surgery remains controversial. While one randomized controlled trial showed no benefit of early (<72 h) decompression , several recent prospective series suggest that early decompression (<12 h) can be performed safely and may improve neurological outcomes .

Surgery: Anterior versus Posterior:

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

Male 26 ys ,driver, car accident with intact neurology..:

Male 26 ys ,driver, car accident with intact neurology..

CT scanning:

CT scanning

Reconstr. CT:

Reconstr. CT

Female 45ys, falling from height, complete paraplegia:

Female 45ys, falling from height, complete paraplegia

CT scanning:

CT scanning

Female 22ys,falling from height, rt neurology.:

Female 22ys,falling from height, rt neurology.

Conclusions on Treatment:

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

PowerPoint Presentation:

Favorable outcome has been reported with conservative as well as operative treatment when applying the correct technique. The superiority of surgical fracture treatment is not well supported in the literature.

Thank You:

Thank You

PowerPoint Presentation:

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

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

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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 circumferential procedure 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