Thoracolumbar Fractures

1. Thoracolumbar Fractures Classification Models Fracture Management Case Illustrations Kevin Chao, MD Stanford Neurosurgery

2. Classification Models Denis • Three-column ANATOMIC biomechanical model • Accounts for mechanism of injury • No rigid guidelines for treatment Magerl/ AO Spine • MECHANISTIC model • Detailed characterization of fracture subtypes Thoracolumbar Injury Classification and Severity Score (TLICS) • Accounts for 1) fracture morphology, 2) neurologic deficit, and 3) posterior complex status • Point-based system guides intervention (TLICS > 4)

4. Denis Three Column Model Posterior SSL/ISL Posterior arch Facet capsule Ligamentum flavum Anterior ALL Ant annulus Ant wall VB Middle PLL Post annulus Post wall VB

6. Seat belt-type injuries

7. Denis Series Outcomes(412 pts) !! Denis gives NO RIGID PARAMETERS for treatment

11. TLICS TOTAL ___

12. ASIA Scale Poor prognosis Good prognosis

13. Spine Fracture Approach • Management • Surgery vs no surgery • Goals? • Brace? • Activity restrictions • Follow up • Imaging • Rehab Assessment • Mechanism of injury • Neuro exam • Imaging • Levels • Bone vs soft tissue • Dynamic vs static • Vessels? • Degree of instability

14. Stable or Unstable? Overall degree of instability 1st degree: Mechanical instability 2nd degree: Neurological instability 3rd degree: Both

15. Stable or Unstable? STABLE Minimal anterior column wedge Above T8 if ribs and sternum intact Seat-belt type injuries without neurologic deficit UNSTABLE > 50% height loss > 20°angulation > 50% canal compromise* Neurologic deficit Progressive kyphosis

16. Fracture Management Goals: • Mechanical stabilization • Prevention of secondary neurologic injury • [ Decompression, if needed ] !! Instrumentation only serves as a bridge to fusion (or ligament healing)

17. Case files

18. 35M paragliding accident • Motor • Right hip flexion pain-limited weakness (otherwise full strength) • Normal rectal tone • Sensory • Right thigh to knee completely numb • Left knee and shin partly dumb • Saddle anesthesia • Reflexes • Diminished at knees and ankles • No clonus L2 3rd degree instability TLICS 5 (2+3+0) ASIA D

20. Two-stage procedure Stage 1 Segmental instrumentation T12-L4 Decompression Posterolateral fusion

21. Two-stage procedure Stage 2 Lateral corpectomy Interbody cage

22. Post op result • Motor • Improved hip flexion • Able to walk • Sensory • Unchanged • Bracing • TLSO • Follow up • - 4 week repeat X rays 

23. Teaching points • Recognize cauda equina syndrome • Define surgical goals • Many approach options (P, A/P, L/P) • Lateral approach technique • No abd surgery exposure needed • L3-T12 (below L3 often limited by iliac crest) • Rib resection +/- chest tube may be needed • Lumbar lordotic curve  significant load bearing in middle and posterior columns

24. 42M fell from tree • Motor • Full strength • Normal rectal tone • Sensory • Intact to LT, proprioception, pin prick • Reflexes • Normal at knees and ankles • No clonus T12 1st degree instability TLICS 7 (4+0+3) ASIA E

25. Sag CT recon Facet disruption MR Sag STIR Disc extrusion Ligament disruption MR Axial T2 FS Canal hematoma Facet disruption

26. Post op result • T11-L2 posterolateral fusion • Motor • Intact • Sensory • Intact • Bracing • TLSO • Follow up • - 6 week repeat X rays pending

27. Teaching points • Look beyond static image: What was the mechanism of injury? • Ligamentous injury >> bony injury • Ligamentous seat-belt-type fracture management options: • Open surgical instrumentation/fusion • Internal bracing (i.e. percutaneous instrumentation) • Bracing ?

28. 22M motorcycle crash • Motor • 2/5 hip flexion and knee extension • 0/5 below knee • diminished rectal tone • Sensory • Diminished sensation to light touch below knee • Reflexes • None at knees and patella • No clonus 3rd degree instability TLICS 9 (3+3+3) ASIA C

29. 1st attempt at surgery: Aborted due to sacral hemorrhage Wound packed Pelvic binder placed Sacral vessels embolized Transfused pRBC, FFP, plts Returned to OR 2 days later…

30. Post op result • L1-L5 segmental instrumentation and posterolateral fusion • Correction of fracture-dislocation using Wilson frame and reduction screws • Motor • unchanged • Sensory • some ROF below knees • Bracing • TLSO • Follow up • - 6 week repeat X rays  Not yet

31. Teaching points • Fracture-dislocations lead to majority of neurologic deficits from spine traumas (~50%) • Recognize other trauma injuries • Many spine fractures are URGENT (treat within 48 hours). Very few are EMERGENT (treat < 12 hours). • Wait for hemodynamically stability AMAP • Know fracture pattern/ anatomy preop • Be prepared for other injuries (thecal sac/ nerve roots, vascular, ureters, bowel, etc)

32. Teaching points • Can reduce some fractures with special OR tables (Wilson frame, Axis tilt, Jackson prone) • Reduction screws can be very helpful Axis-Jackson Table Reduction screw Wilson frame

33. Final point • TP fractures are not always benign • L4-5 TP fractures associated with lumbosacral plexus injury • T1-2 TP fractures associated with brachial plexus injury

34. References • Denis F. The Three Column Spine. Spine 1983; Vol. 8, No 8: 817-831 • Classic historic paper with simple classification system • No rigid parameters for treatment • Patel A, Vaccaro A. Thoracolumbar Spine Trauma Classification. J Am Acad Orthop Surg 2010;18: 63-71 • New TLICS classification point system to guide treatment • http://www.aospine.org/ • Pocket cards and protocols