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Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification

Anatomy of Thoracic Spine. Kyphosis is natural alignmentNarrow spinal canalFacet orientationRib factor on stabilityConus at T12-L1. Anatomy of Lumbar Spine. Lordosis is natural alignmentLarger vertebral bodiesFacet orientationCauda equina. Thoracolumbar Junction. Transition ZoneKyphosis Lordosis Mechanical Difference:Lumbar spine less stiff in flexion.

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Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification

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    1. Thoracic and Lumbar Spine Fractures and Dislocations: Assessment and Classification Jim A. Youssef, M.D. Durango Orthopedic Assoc., P.C. OTA Resident Education

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

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

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

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

    6. Patient Evaluation Pre-hospital care EMT personnel Initial assessment Transport and immobilization

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

    8. Clinical Assessment Inspection Palpation Neurological Evaluation ASIA Impairment Scale Sensory Evaluation Motor Evaluation Reflex Evaluation Bulbocavernosus, Babinski

    9. 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.

    10. 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

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

    12. CT Scan L3 unstable burst fracture

    13. MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris

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

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

    16. Böhler 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

    17. Morphologic Classification Watson-Jones 38 Descriptive terms based on 252 films 7 types Examples: Wedge fracture (compression fx) Comminuted fracture (burst fx) Fracture dislocation

    18. 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

    20. Anatomic Classification 2 Column Theory Holdsworth 62 Six types- Nicols +2 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

    21. 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

    22. McAfee Classification

    23. Load Sharing Classification McCormack, Spine 1994 Review of injuries fixed posteriorly (McCormack 94) Which failed? Could they be prevented? Suggests when to go anteriorly

    24. 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

    25. 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

    26. AO Mechanistic Classification Complex subdivisions to include most fractures

    27. 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

    28. Results AO Interobserver CT 0.31 MRI 0.28 CT/MRI 0.47 Denis Interobserver CT 0.60 MRI 0.52

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

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

    31. Injury Morphology Compression: prefix-axial, lateral, flexion, postfix-burst Distraction: prefix-extension, flexion postfix-compression, burst Translation/Rotation: prefix-flexion postfix-compression, burst

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

    33. Posterior Ligamentous Complex Not disrupted in tension Disrupted in tension

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

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

    36. Point System

    37. Neurology-Point System

    38. Posterior Soft Tissue Point System

    39. 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

    40. Next Step - Direct TX

    41. Treatment Injuries with 3 points or less = non operative Injuries with 4 points=Nonop vs Op Injuries with 5 points or more = surgery

    42. Examples Flexion Compression Fx Flexion compression (morphology) - 1 Intact (neurology) - 0 PLC (ligament) no injury - 0

    43. Compression Burst Fracture Flexion compression burst - 2 Intact ( neurology) - 0 PLC (ligament) no injury (0)

    44. Compression Burst-Complete Neuro Injury Axial compression burst with distraction posterior ligamentous complex -4 Complete (neurology) - 2 PLC (ligament) injury - 3

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

    46. Translational/Rotation Injury Distraction, Translation/rotational, compression injury - 4 Complete (neurology) – 2 PLC injury - 3

    47. Surgical Decision making based off tenets of classification system Injury morphology Neurological status PLC integrity/injury stability

    48. Reliability/treatment validity at single institution Treatment validity exceptional- 96.4% Moderate agreement for PLC (66%) and mechanism (60%)

    51. Problems Inter-rater agreement on sub-scores was: Lowest for mechanisms followed by PLC Highest for neurological status Substantial for the management recommendation

    52. The Spine Journal, 2006

    53. 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

    54. IMPACT OF EXPERIENCE (attending surgeons, fellows, residents, and non-surgeon health care professionals). Most reliable among spine fellows, followed by attending spine surgeons.

    55. 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.

    56. 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

    57. DIFFERENCES IN NATIONALITIES Inter-rater reliability for mechanism higher among non-US surgeons Reliability for PLC, neurological status, management higher among US surgeons

    58. Management of Thoracic and Lumbar Injuries CONTROVERSIAL!!!!

    59. Non-Operative Treatment of Thoracic Spine Injuries Brace or Cast Treatment Compression Fractures Stable Burst Fractures Pure Bony Flexion-Distraction Injury

    63. Surgical Management of Thoracolumbar Injuries Unstable burst fractures Purely ligamentous Facet dislocations Translational injuries Neurologic deficit

    70. 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

    71. 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

    72. Thank You

    73. Bibliography

    74. Thank you

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